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�emical Waste Management, In�
<br /> .j Kettleman Hills Facility Proltle9
<br /> wnsr c a.nrviseraswrr� 35251 Old Skyline Rd.,PO Box 471,Kettleman City,CA 93239
<br /> (559)386-9711
<br /> Generator's Waste Profile SheetTracking N
<br /> (Please carefully read the instructions before completing this form Please print in ink or type) Sales 8
<br /> Sarv¢e Agreement on file? Yes❑X No a Classification: Class 1❑X Class II[] Daily Cover❑ Non HazD
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<br /> .1'r.:4 byre ri If s s a ear it-aU:n �u 'r,n..;±,.ii tldr:nl3 :iia 1 .. w Duo ai voiwra:i
<br /> GENERAL INFORMATION ...r.. �.---_/_�.. ._1.._�.^.....�.....a..^..,..^e.- __ /'y1':
<br /> I GENERATOR NAME e'w�:. ,�SL,�Nn l�',j 82� Generator USEPA ID. (� L[�� r)9 T
<br /> 2. Site Localion: /(� (% (.� • Ali ze /^'� Billing Address: ❑Same Ramos Env.S."CeIs
<br /> Acirzet , CA `75 Zf� � P.O Box 401
<br /> 3. Technical Contac(/Phone West Sacramento,CA.,95691 '
<br /> 4. Alternate ConlacVPhone Billing Contact/Phone Sally 916-371-5747 ext.228
<br /> Fax Number. Fax Number. 916.371-9312
<br /> PROPERTIES AND COMPOSITION
<br /> 5. A Process Generating Waste: Maintenance Shop Activities
<br /> B. Is-lke waste from a CERCLA or slate mandated cleanup? Yas0 N.FX Location Name:
<br /> C. Is your waste a result of a clean-up action and qualifies for reduced CA BOE Tax? Yeso NoFX
<br /> 6, Waste Name: Oily Solids
<br /> 7. A Is this a USEPA hazardous waste(40 CFR Pad 261)? Yes No
<br /> B. If D001,D002,DGG3,DOD4-DD43 do any underlying hazardous constituents(UHC'S)apply'? Yes NoX If
<br /> �( yes,agaW UHC(arm)
<br /> C. If using alternative LDR treatment standards for soil(40CFR 266.49),do any UH(7s appy? Yeso No Milt yes,attach UHC toren)
<br /> D. Does this weals contain debris(List size and type in chemical composition)? Yeso No F]
<br /> E. Idenlify ALL USEPA listed ands chamclerislic waste nide numbers (D,F,K P,U): NIA
<br /> Stale Waste Codas: 52
<br /> F. Doss this waste contain any Gass 1 or Class II ozone depleting substances? Yes❑(List in chemical compodtion) Not
<br /> 6. Physical stale®70°F: A.Solid"MX Liquid❑ BIGas❑ B.Single LayerrX MuIRlayerE]C.Free liquid range 10 0%
<br /> 9. A pH Range to or Not Applicable QX B.Strong Odor❑ describe C.Color Varies
<br /> 10. Liquid Flesh Point: <73°FEl 73-99F El IDO-139DFO 140-199eFF] >200-FEl N.A❑X
<br /> 11. CHEMICAL COMPOSITION:List ALL constituents(including halogenated organics and UHCs)pmsenl in any concenlretion and forward available
<br /> analysis.
<br /> Constituents Range Units Constituents Range Units
<br /> Absorben(s(clay based,non- 0-100 % Oil 0-20 %
<br /> biodegradable)Debris 0.100 % (Oil includes:motor oil,grease,
<br /> (Consisting of:rags,booms, lubricating oil,hydralic oil,
<br /> pads,paper,soil,cardboard) diesel fuel)
<br /> No PCB containing oils
<br /> TOTAL COMPOSITION MUST EQUAL OR EXCEED 100%
<br /> 12. OTHER: PCB's:Ryes,concentration(dry weight)_ppm, PCB's regulated by 40 CFR 761❑ Pyrophodc❑ Explosive Ra lkeeclNeE-1
<br /> Wale,Reactive El Shock SensBive0 Oxidizer❑ CarcinogenEl InfediousO Other
<br /> 13. If Benzene, concentration ppm. Is the waste subject to the Benzene Waste Operation NESHAP? Yes0 No ❑ Unknown❑
<br /> 14. Is the waste subject to RCRA Subpad CC controls? Yesr_J No[X • Volatile organic concentration,R known ppmw.
<br /> 15. If the waste is subject to the land ban and meds the treatment standards, check here❑and supply analytical results.
<br /> SHIPPING INFORMATION
<br /> 16 PACKAGING: Bulk Solid Type/Sae: Bulk Liquid TyWS": Dmm❑X Typa/S¢e: VarIOUS Other
<br /> 17. SHIPPING FREQUENCY: Units 10Per. L]Monih 00t, Year [__JOn9Time r-1 Other
<br /> 16. SHIPPING INFORMATION: US DOT Shipping Name: Non-RCRA Hazardous Waste Solid
<br /> Hazard Class: Packaging Group: Reportable Quantity(lbs,kg):
<br /> SAMPLING INFORMATION
<br /> 19. A. ❑ Sample(attach chain of custody) Sample source(drum,lagoon,pond,lank vat,etc.)
<br /> Dale Sampled Samplers NamWy ompany:
<br /> S. Generators Agent Supervision Sampling 20.❑No sample required lase instructions)
<br /> GENERATOR'S CERTIFICATION
<br /> 1 hereby cartity that atl mitirmdlon submitted In tNs and ed aaaehed decumenM comalne true and wourale deealptiom of tela wane.Any sample aubmllted is reprwMaWe es
<br /> de0ned In 40 CM 261-Appendx 1 or by uaing an equlvekrx meNOd.NI relevant Infamalm ngardrp known erampeded Nunnoe In IM pa session of iliagenerebrhas been
<br /> disclosed Ieulhalze CWM t°oblaln°sample fmm any waste aNpmenl for purpmee of racadlmeon It this arllwtlon Is made by a broker,the undersigned aigm as authorized
<br /> egenloflhe geamta en rmed Ne Information conlalmd In the Pic(le Sheet from information provided by the genersbr anC additional Information as It has deMoolmid to
<br /> be reasonably aassary. 0�11 1 /
<br /> ��1'1Fcc•, I�c -�-d�
<br /> re Printed(or typed)name and title C e Dale
<br /> 8 the waste profile is approved,Chemical Waste Management,Inc.has the appropriale permits and will accept the waste pursuant to our agreement.
<br /> CWM Form 601 replaces the following roans:CW M.51,CWM 6000,CWM 50-A-2,CWM 50.8,CWM 60000,and CWM Form 6000-D.WM101
<br /> CWM-KHF 2002
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