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RECLr.1 V EDO. 1242 <br /> e�,.2�1. <br /> F 2015 11 :04RM VGE W LOWRV, INC <br /> FEB 2 4 2015 <br /> iREPUSLIC Page 1 oft <br /> • SERVICES SPECIAL WASTE PROFILE <br /> 1iEV'rp a M <br /> Waste Profile# <br /> Requested Disposal Facility:---Select a Facility--- <br /> SeveaCl^CIFla rornt. RaattltA^o pdieng naN dl ra�uieG(Yae^r✓)i:91•Je an n,aipl^;^a. <br /> 1. Generator Information Sales Rep#: <br /> Generator Name: <br /> Generator Site Address: 3.72 -5. <br /> City: AGI( County: State: Select a State =' Zip: <br /> State ID/Reg No: State Approval/Waste Code: (ii applicable) NAI. )# <br /> Generator Mailing Address(if different): <br /> County: State: - Select a State Zip: <br /> City: <br /> E all: C(pK <br /> Generator Conte Name: CY M <br /> Phone Number: ' $ —U7 q 1 Ext: Fax Numberr <br /> 11. Billing Information <br /> Contact Name: <br /> Bill To: <br /> Email: CP ( . M <br /> Billing Address: U (� phone o1 Jrtl fJ7`(I <br /> City: State: Zip: <br /> Ill. Waste Stieam Information 1 I <br /> SUl �o �' eFrole�.M t Se lUr <br /> • Name of Waste: uvt In 1•(/ <br /> Process Generating Waste: <br /> Type of Waste: ❑INDUSTRIAL PROCESS WASTE PKPOLLUTION CONTROL WASTE <br /> Physical State: ZSOLID ❑SEMI-SOLID ❑POWDER ❑LIQUID <br /> Method of Shipment: <br /> BULK LJDRUM BAGGED ❑OTHER: <br /> Estimated Annual Volume: wt- ID Co. u --Select Volume Type-- <br /> Frequency: ONETIME ❑ONGOING <br /> Disposal Consideration: LANDFILL ❑SOLIDIFICATION ❑BIOREMEDIATION { <br /> IV. Representative Sample Certification E]NO SAMPLE TAKEN <br /> Is the representative sample collected to prepare this profile and laboratory analysis, ryyES or[]NO <br /> Collected in accordance with U.S. EPA 40 CFR 261.20 c uidelines ore uivalent rules? <br /> Type of Sample:DKCOMPOSITE SAMPLE ❑GRAB SAMPLE <br /> Sample Date: — I <br /> Sample ID Numbers: <br /> PILGi,}rG S�ri� atliln <br /> Re ere�re 150Xodj�- <br /> ®Republic Servlgps.April 2013 <br />