CO0006235 - Laserfiche WebLink

Home Browse Search

Q5Chemical Waste Management, Inc. BX 3607 WASTE PROFILE profile# (Please carefully read the instructions before completing this form) Sales# TSDF requested 4171-2 Az /-I/LL s Technology requested nk'5l l Lf9/✓O`1 L I/ ❑ Check here if this is a Recertification ❑ Check here if a Certificate of Destruction or Disposal is required GENERAL INFORMATION I. GENERATOR NAME: L?/ *,Ile 7' 1 of Generator USEPA ID: C/?< dOy X60 Sf� 2. Generator Address: 7 Nom/ /�P/Sf1 5_T. Billing Address: ❑ Same �P/9/YJdS �.(i1/i /�.fJiJftir.T/�! 3. Technical Contact/Phone: TakltJ 4. Alternate Contact/Phone: �Q�Y/ Ti, /_ Billing Conrict/Phone: PROPERTIES AND COMPOSITION S. A.Process Generating Waste: B.is the waste from a CERCLA or state mandated cleanup? Yes ❑ Nom!r Location name: 6. Waste Name: 4'141:4 ' 7. A.Is this a USEPA hazardous waste(40 CFR Part 261)? Yes ❑ N 01 B.If D001,D002,DO12- D043 do any underlying hazardous constituents (UHC's)apply? Yes ❑ Nq, 1 (If yes,attach UHC form) C.Does this waste contain debris (List size and type in chemical composition)? Yes ❑ No,X D.Identify ALL USEPA listed and characteristic waste code numbers(D,F,K,P,U): State Waste Codes: sd 8. Physical State @ 70'F: A.Solid ❑ Liquid❑ Both❑ Gas❑ B. Single Layer❑ Multilayer❑ C. Free liquid range to % 9. A. pH:Range to or Not applicable❑ B.Strong Odor Cl-describe 10.Liquid Flash Point:< 73°F ❑ 73-99'F ❑ 100-139'F ❑ 140-199°F ❑ >_ 200°F ❑ N A. ❑ 1 1.CHEMICAL COMPOSrrION:List ALL constituents(including halogenated organics and UHC's)present in arry concentration and forward available analysis Constituents Range Units Constituents Range Units 'ge5a'R/1c y 9 TOTAL COMPOSITION MUST EQUAL OR EXCEED 100-- 12.OTHER: 00%12.OTHER:PCBs if yes,concentration _ppm,PCBs regulated by 40 CFR 761 ❑ Pyrophoric❑ Explosive ❑ Radioactive❑ Water Reactive❑ Shock Sensitive ❑ Oxidizer❑ Carcinogen❑ Infectious❑ Other_ 13.If Benzene,concentration_ppm.Is the waste subject to the Benzene Waste Operations N ESHAP? Yes ❑ No❑ Unknown ❑ 14.Is the waste subject to RCRA subpart CC controls? Yes❑ No❑ Volatile organic concentration,if known ppmw. I S.If the waste is subject to the land ban and meets the treatment standards,check here: _and supply analytical results where applicable. SHIPPING INFORMATION 16.PACKAGING:Bulk Solid ❑ Type/Size: Bulk Liquid ❑Type/Size: Drum❑Type/Size: Other 17.SHIPPING FREQUENCY:Units Per: []Month ❑Qtr. ❑Year ❑One Time ❑Other SAMPLING INFORMATION 18.A. Sample source(drum,lagoon,pond,tank,vat,etc.) Date Sampled: Sampler's Name/Company: 18. B. Generator's Agent Supervising Sampling: 19. No sample required(See instructions.) ❑ GENERATOR'S CERTIFICATION I hereby certify that all information submitted in this and all attached documents contains we and accurate descriptions of this waste.Any sample submitted is representative as defined � in 40 CFR 261-Appendix I or by using an equivalent method.All relevant information regarding known or suspected hazards in the possession of the generator has been diisclosed.I authorize CWM to in a sample from any waste shipment for purposes of recertification. If this certification is made by a broker,the undersigned signs as authorized agent of the O generator and ha onfirrred the o ation conained in this Profile Sheet from information provided by the generator and additional information as it has determined to be reason- 0 ably necessa Signature Printed (or typed) name and title Date (� v a 0 If the waste profile is approved,Chemical Waste Management.Inc.has the appropriate permits and will accept the waste pursuant to our agreement. CWM Form 6000-D replaces the following forms: CWK51.CWM 6000.CWM 50-A-2.CWM 50-8 and CWM 60000.