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►C)❑ U-Mlogy Nevada (Beatty) El US Ecology Texas (RobW) ' #; Fax (775) 553-2125 Fax (361) 387-0794 � C O O "— ❑ US Eca ogy Idaho (Grand View) D Foot (209) 834-2919 Pr:, €., Ci•3,$'_,Y,:X�S7. •(3 t14Ci#TId$!j r `i *Waste as shipped will be LJ Industrial NON - Industrial *(T r Generator. PickArPull Check If Billing is Same Facility Address: 3927 Clark Drive Billing Company: EWN% r Inc. (No PO Box) Stoclacm,C495205 Billing Address: 26FMA4U%RVQFJj7J01 5,226 Mailing Address Same City/State/Zip: Corona, CA 92882 City/State(Zip: Billing Contact: Doug Keeney Technical Contact; Don Grose Phone No.: 909-597-2999- Fax No.: 909-597-299S Phone: 916-240-3965 Fax: Email: dougQS6690wosle.com NAICS# ❑ CESQG 0 SQG 0 LQG EPA IDS CAL000269375 State IDH i. US DOT Shipping Name Non RCRA Hazardous Worte Solid . Hazard Class NA 3. UN/NA# NA 4. Packaging Group NA 5.RQ NA s. Container Type: ❑ Bulk ❑ Totes ❑ Pallet Size 44 7. Frequency: ❑ Year ❑ QTR ❑Month ❑ Boxes ❑ Bags ❑ Drums ❑ Other Q"nndry 8 ❑ 1 Time ❑ Other f R:.; • .QENk (fLt4iRTH1.AT.�3Crfisi(iiiiii:��i(iiiiii I�JA7' RiAT,.& Y .R�wws °• T.0 . '. 1. Common name for this waste Ot! Absorbent and Debris 2. Process generating the material Spills and clean up roan arta dismantling operation 3. Describe physical appearance of waste Solid Material 4. Describe odor of waste: Q None ❑ slight ❑ Strong Describe 5. Knowledge is from: ❑ Lab Analysis ❑ MSDS ED Process/Generator knowledge ❑ Yes ❑ No Is the waste restricted under EPA Land Disposal ❑� Yes ❑ No Is the material <500 PPMW VOC as generated? Restrictions (40 CFR 268) Ifya, please complete LDR form -1 Yes I No Is the waste, or generating facility, subject to regulation under 40 CFR Pan 61 Subpart FF (Benzene Rule) of NESHAPS? If`=, complete form "attachment 4". (Note: Waste generated from chemical manufacturing, coke-by-product recovery plants, petroleum refineries or treaters of such waste are subject to these requirements.) ❑ Wastewater ❑ Nan-wastewater 0 Debds 21 Yes ❑ No State waste codes 1 52 1 1 1 ❑ Yes ❑ No Alternative--vandards for Soil? ❑ Yes ENO CERCLA Regulated (Superfund) Waste 0 Yes ❑ No Contains UHCs/Constituents of Concern: List in section D ❑ Yes FZI No I EPA Haz. Waste (list codes) ❑ Yes R] No Has the waste been treated after the initial point of generation? ❑ Yes R1 No Subpart XX (40 CFR 63.1080) Controls Required? ❑ Yes .r❑ No Exempt Waste: If yes, list ref. 40 CFR Source Code G Form Code W Mba Method H TERIAI CfD :U 3 dIe iflCfibM `iii(Etz�i .(Range ..•"%2:$:i:ia:":i`.i9i:i:;yi:ia:i: i:i:::::: �::� ii::: tiiE9ii ' ira...... ::if`GEieii t3igri3tiel#t5llo4x Total> or= 100%) Veluesare❑ TCLPPI TOTALS LI Yes ❑4 No Oxidizer ❑Yes ❑No Rcact. Sulfides ppm (hzludeadditlonel sheets as necessary) typaleal value unit range ❑ Yes 0 No Explosive ❑ Yes Q No React. Cyanidesm PP ❑ Yes No Organic Peroxide ❑ Yes Q No Water/Air(Pyrophorie) React. ❑ Yes No Shock Sensitive ❑ Yes Q No Thermally Unstable ❑ Yes 2 No Tires ❑ Yes ❑� No TSCA Regulated PCB Waste ❑ Yes 0 No Pyrophodc ❑ Yes Q No Regulated Medical/Infectious Waste ❑ Yes ❑ No Radioactive* ❑ Yes Q No Compressed Gasses ❑ Yes Q No Exempt RAD" "Add a..al ae:6ol.Skal into 6 xvvl&d to fusel's WAC Addmd ❑ Yes ❑•r No Halogenated Organic Cam on ( r40 CFR 265, Appendix III) oil I-5.. I % Absorbent 3040 % 'Sail 6x-70 % Debris, Rack, paper, ppe 5-10.. % Car f(W iz I -V % :. .....:.....: Z<;,PH1lS AT $ tACTERI6 CC 'irl!'=':.....€iii: PH Range 5 to 9 I.Flmh Poi NAI °F(if<140"F) 2.Typical PH: NA pHRange:❑ 52 ❑ Yes No Passibility of incidental liquids from trdnsparmtion? ❑ -2,<12.50 ❑� Yes ❑ No ram waste pass the EPA specified paint filter test? ❑ >_ 12.5 (Pass is a solid) ..•r,.,.,.•i�,.'Q?., CEp,{,'A,',iIQ ;❑Yes ❑ No I certify this material may be disposed of without further treatment. Certification Statement I certify, under penalty arlaw that I am romiliar with this waste stream through analysis and/or process knowledge, and that all information provided is true, accurate, representative and complete, and that all known or suspected hazards have been disclosed. Furthermore, l certify that this form was completed in accordance with the instructions pravided. Print Name: Signature: Title: Date: EdCOhyaiSE" .