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0 <br /> tX <br /> US�� Naassistance8InCOmplebngthis}orm? <br /> Call <br /> ll Tell Frees 0�6g'&716O <br /> v Mail completed form 10: <br /> V ASTE DISPOSAL INFORMATION P.O.Box 7248 <br /> (See Spewai Instructions on Reverse Sida) Loutsvlae,KY 40257-0246 <br /> Attach any applicable/atwrarlo�ry an¢ta��lygsis as required by Beatty Part 8 Permit <br /> EPA GenaratW lDa. �+--,..7-Sr ::i'$i`• g. --*4 State Genarstora(Mapp/ieable) <br /> ❑Check If axampt go$mall quarmty� CFR 261.5) <br /> Generator Name: 54 a �8 ^^" <br /> Generator Facility Addrase: 140 (yrriE�.r a C:)A" <br /> Contact Name: — 71tle: Mexxrr-4 Phone COW) <br /> BrokK Name: t '^F'' Contact: Phone e: <br /> Broker Address: 5 1v - ,,.v.er 4`148O) <br /> WASTVWASn STREAM NAYS: NO lJ IZZLA <br /> Describe the Prones Generar)ng Waste: PP04 r 1u � Go.Ylrw.w'Y IR3•"'I' C-��-.a r Gpc���.y <br /> EPA HAZARDOUS WASTE COMM' (40 CFR 261.21-261-33) <br /> A Check it waste is NOT hazardous per RCRA. <br /> ❑Check if waste is ex~par 40 CFR 261.4. <br /> Describe appearance(e.g. brown Powder,ate.) ir�{7 <br /> Is the waste state SOLID per RCRA? 19 Yes ❑ No <br /> Distinctive Odor? ❑Yes ❑No If yes,despite rpt <br /> Density: IED 13Itili it ❑lbs./go. Gkovg. les.l55-gal. drum <br /> WASTE PROPERTIES <br /> IGNITABILITY(40 CFR 261.21) <br /> Flash Point(for liquids 8 sludges) ` F. (Closed Cup) Range: ' F. to ° F. <br /> Cheek box if waste ignites when exposed to: ❑Air ❑Water ❑ Friction <br /> CORROSIVITY —is waste corrosive per 40 CFR 261.221. ®Yes ❑ No <br /> Enter pH(for solids,pH or a 1%solutioh� 1 Range: fir'.._— to <br /> REACTIVITY—Is waste resctrw per 40 CFR 26123? Yes yILNO <br /> TOXICITY—DOW the waste meet the toxicity Charsebtriatie6 for 40 CFA 261.24? Yes *No <br /> N EP Toxicity test was performed, Olson a copy of the test results. <br /> COMPONENTS — Specific chemical names of components are required, Do NOT use generic names. Account for 100%of the waste. <br /> Attach additional pages, 0 neciesesry. <br /> Am,."ar Areraoa or <br /> Component sueye As" ftrw Component -amPw Aefua Rogge <br /> '�i4♦•n�na wf.J,� Go.r-ILt �l0 16 _ 91 % <br /> Analytical Technique: <br /> Check box it waste contains: ❑siologiCMaYls. ❑Pathogens ❑Etiological Agents ❑Infectious Agents ❑Carcinogens ❑Radioactive Mat'Is. <br /> ❑ PCB's (as defined by 40 CFA 761) ❑ Dioxins. If yes. has a notice of disposal leen filed(40 CFR 775)? _ <br /> U.S.DOT Proper Shipping Name Hazard Class UN/NA Coda <br /> NoN -tZc�A �ttazAaus t��ss� Sax,l] <br /> Proposed Shipping Method- Morums ❑Bulk ❑Other; Describe: <br /> EstimatedOuantity: '15 a4yO.4 Frequency: Oa°e— I�.,,a_ <br /> Special or Unique Handling Instructions: <br /> 1 certify and warrant that theabove waatestfesm identification forthe materials oHared for disposal ss appears on this form,and the rnfdrmation <br /> contained on any attachments oraupplements,is trueand OOrrlot.MY certification is based on personal examination of the information submitted, <br /> or is based upon my inquiries of those individuals reapotlsiWefer obtskling the information.)further certify and warrant that the identification lithe <br /> result of an analysis of a repressntativesamplsobtainad and analyzed in accordance with testing procedures apeCified by the U.S.Environmental <br /> Protection Agency or by applying knowledge of the process generating the specific waste being offered for disposal. <br /> #!' Managq-Fit i,�gnrr+entai and <br /> Signature:- <br /> --,+-. Title:° ata: <br /> NOTE:Prashipment representative Sampling ue required for disposal of material in bulk form. <br /> Ansch XWM Copy of this farm to ae 211IMP141.Can aOMW71401x malanp InarNalWns' <br /> 200 ' 39t+d DNI—NOSM31213 WOM3 IVrZ1 EIS. 9 NtIC <br />