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Crosby &U' VeAon, Inc. Internal Use Only <br /> Job Number: <br /> WASTE PRODUCT QUESTIONNAIRE <br /> I. GENERAL RJFO RA N ' <br /> Generator Name BunngName MVERSAL ENVIRONMENTAL, INC. <br /> Address N.=` Address 4101 TNMgTRTA7 ]TAY <br /> city."State,Zip_ City,State,Zip RF.NTCTA CA- 94 510 <br /> contact Contact qANDY STAMM �7 <br /> PhoneFax Phone 707-747-6699 Fax 707-747-*;R <br /> EPA Number -.. <br /> A- WASTE PRODUCT DESCRIPTION 8 CHARACTERISTICS <br /> A <br /> Waste Product Common Name <br /> 1. Process Generating Waste. <br /> B. Hazardous Properties: <br /> 1. U.S.FPA Hazardous Waste9 Lly`!es ❑No 2 State Code(a): <br /> EPA Code(s): <br /> c.Is Waste Produce ❑Shock Sensitive ❑Reactive ❑Radioactive ❑Pyrophoric ❑Etiological ❑None <br /> C. Physical Properties at 701 R <br /> 1. Physical State: 2. Layers: 3. Flash Point(Closed Cup Only): 4. Yascosity,similar to: <br /> 5`'lid 11 Sludge ❑Multilayered (3-1:70-F 0 140-270°F ❑Water <br /> /O Liquid 0 Empty Container s-layered X7i 0-100°F ❑No Flash ❑Motor Oil <br /> Any free liquids at 70°F ❑Homogenous ❑101-139'F ❑Exact 17 Honey <br /> ❑Yes ❑No ❑Other <br /> D. 1. Density: 2 %Solids 3. Odor. 4. Ph. <br /> Liquid <br /> 111111.....❑,.._..,,,,,,��-��- lbs/gallon Weight ❑None Qct ❑9.1-125 <br /> Solid lbs/cubic ft. y VolurPg.�," ❑Strong ❑2-5 m1U <br /> Any ebris in waste: Total 77 id 9 ❑Exact <br /> ❑Yes ❑No Describe: f;7 <br /> Explain <br /> E Cha nical Composition(Account for 100%of total): R�[a aage Metals: Pestc(ides,Herbicides:PPM <br /> Total (PPM) . , <br /> Endrin . . . , <br /> EP Toxicity(mgA) Lindane. . . . . . <br /> LArsenic(As) <br /> % Methoxychlor <br /> - Barium(Be) <br /> % Toxaphene <br /> Cadmium(Cd) <br /> % 2,4-D. <br /> % Chromium(Cr) Z4,5-TP <br /> _ % Copper(Cu) Other <br /> _ % Lead(Pb) <br /> .% Mercury(H9) Reactives&Other <br /> _ Nickel(Ni) Wastes(PPM): <br /> % Selenium(Be) Cyanides Dioxin _ <br /> Silver(Ag) Sulfides _PCBs <br /> Zinc(Zn) HOC Phenols <br /> F. Shipping and Handling Information; <br /> . . dais .rC '1 <br /> 3. D.O.T. Hazard Class, 4. D.O.T. ID Number. UNr P&':2= N U� <br /> T. Projected Volume: Tons Gallons Cubic Yards Other 8. RD Amount <br /> _ftr One Time Week Month Quarter Year <br /> _-- - Comments: <br /> III. GENERATOR CERTIFICATION STATEMENT <br /> I hereby certify that as an authorized representative of the generator named above, all information submitted in this and all the attached documents <br /> i5 true and/accurate.Analysis of the waste was conducted in accordance with the approved test methods in 40 CFA 261 on a representative sample <br /> as defined in 40 CFR 261.24.To the best of m knowletlge,all known (40 CFR 261)and suspected hazardous components have been included in <br /> l � i r <br /> Signature Title ,I Date 3 JI2'1 OJ <br /> FORM 402(Rev.01/01) <br />