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Page 2 of 2 <br /> If No,Attached Non-Hazardous Determination Document(s)(Check all that apply) <br /> ❑ Process Knowledge Process Details <br /> ❑ SDS <br /> Certified Analytical Sample <br /> Is the data derived from testing a representative sample in accordance with 40 CFR 261 and/or other applicable laws? •Yes O No <br /> If Yes,Type of Analytical Sample *Composite O Grab Sample ID# 248216-2,248216-1 <br /> ❑ Exempt Waste <br /> Applicable Exempt Waste Item <br /> OUST Corrective Action-40 CFR 261.4(b)(10) O PCB Bulk Product Waste-40 CFR 761.62 0 Oil&Gas E&P Waste-40 CFR 261.4(b)(5) <br /> Q RCRA-Empty Containers-40 CFR 261.7 Q Other <br /> If Other,Provided reference <br /> State Hazardous Waste? O Yes s No <br /> Is this material non-hazardous due to treatment,delisting,or exclusion? d Yes •No <br /> From an industry regulated under Benzene NESHAP? O Yes *No <br /> Facility remediation subject to 40 CFR 63 GGGGG? O Yes *No <br /> CERCLA or State-Mandated clean-up? O Yes *No <br /> Regulated,Licensed or NORM Radioactive Waste? O Yes O No <br /> Contains PCBs? O Yes *No <br /> Regulated and/or Untreated Medical/Infectious Waste? O Yes *No <br /> Contains Asbestos? O Yes *No <br /> Subject to RCRA Subpart CC controls? O Yes *No <br /> SHIPPING&DOT <br /> Event Frequency •One Time O On-Going <br /> Unit of Measure Q Tons 0 Yards Q Drums Q Gallons Q Other <br /> Estimated Annual Qty 25 <br /> Shipping Frequency <br /> 0 Once Q Daily 4 Weekly d Monthly 0 Other Qty Per Shipment 1 <br /> Container Type Dewatering Bin Container Size 25 yard metal bin <br /> USDOT Shipping Name Non-DOT Regulated Waste,Liquid(Sludge) <br /> PROFILE CERTIFICATION <br /> hereby certify that(1)all information submitted on this form and on supplemental materials is complete and accurate to the best of my knowledge and ability to determine;(2)the <br /> information provided herein,including any supplemental information,such as laboratory analytical,MSDS,etc.,accurately describes the waste stream to be delivered to the facility and <br /> that all known or suspected hazards have been disclosed.I understand that,once the waste stream is approved by Destination Facility based on this information,any deviation in the <br /> source,composition,constituents or characteristics of the waste stream from the information described herein,may render the waste stream unacceptable for disposal,at the sole <br /> discretion of Destination Facility.I further understand that any deviation from the information contained herein will require immediate notification to the Destination Facility and cessation of <br /> disposal. <br /> /yl�PiSsa/645011 <br /> Certified on 9/30/19 by Melissa Ibison as a Authorized Agent of American Integrated Services,Inc. <br /> ©Environmental Data Systems LLC 2018 <br /> https://wasteconnections.wastebits.com/companies/2816182/profiles/64b05395-2f7a-41 fa-... 10/1/2019 <br />