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Feb, 25. 2015 4:32PM G*E W LOWRY, INC No. 1294 P. 1 <br /> REPUBLIC SPECIAL WASTE PROFILE <br /> Page 1 oft <br /> Requested Disposal Facility.—.Select a Facility-- Waste Profile <br /> IVED/CCD <br /> 5d 01 AMin(en,,:, ftQi0i6dpd,8l-.y uwjj Bit MUred zpftb .If rds u,e m:rdie:ea. <br /> I. Generator Information Sates Rep#: 2015 <br /> Generator Name: p as <br /> Generator Site Address: 3 K <br /> ENTAL <br /> HFA'3ti�r ARTMFNT <br /> County: State;– SelectaStale Zp: <br /> State ID/Reg No: State ApprovallWaste Code: (inapplicable) NAICS#: <br /> Generator Mailing Address(if different):Q <br /> City: County: Sfate: _Seigel a State Zip: <br /> Generator Contact Name: I <br /> EI EnI G'f�1CcY <br /> Phone Number: ' S" –o qt Ext. Fax Numbe .dz _ r✓t <br /> 11. Billing Information <br /> Bill To: Contact Name: jt <br /> Billing Address: p • / Email: Cp- ( � M <br /> City: state: Phone 2� 545--o 7 e(t <br /> Ill. Waste Stream Information <br /> . Name of Waste: !j {u rt rnrx e id/ a4r–,4 �M f✓C r�J �- <br /> Process Generating Waste: <br /> r�:a;t7s: ; _. ,. . . � - .. �• . <br /> ~ L1 �ian f�i0 eir'f <br /> 's _$icer(:" '.' f •; _ -- <br /> t ' <br /> Type of Waste: ❑INDUSTRIAL PROCESS WASTE POLLUTION CONTROL WASTE <br /> Physical State: SOLID ❑SEMI-SOLID ❑POWDER ❑LIQUID <br /> Method of Shipment: IDC BULK ' : DRUM ❑BAGGED OTHER: <br /> Estimated Annual Volume; out- 10 Gu._Y,,I =-Select Volume Type-- <br /> Frequency: 21ONETIME []ONGOING <br /> Disposal Consideration: LANDFILL ❑SOLIDIFICATION OBIOREMEDIATION <br /> V. Representative Sample Certification ONO SAMPLE TAKEN <br /> Is the representative sample collected to prepare this profile and laboratory analysis, f,� <br /> collected in accordance with U.S. EPA 40 CFR 261.20 c uidelines ore uivalent rules? 5� ES or❑NO . <br /> Type of Sampfe: COMPOSITE SAMPLE ❑GRAB SAMPLE <br /> Sample Date: _ L5, <br /> Sample ID Numbers: 1P <br /> TrUG1.4tLJdih L1U25� rMr�atlu� . : <br /> n'B 'erenc� iS D a U[)5" <br /> O Republic Services,April 2013 ' <br />