|
FEB-01-2008 FRI 04; 21 PM PAH
<br /> 91,/21!2008 11:213 177471° UNIVERSAL PAGE 02/03
<br /> Crosby &('Oveitori, Inc. krvbemal Use Only
<br /> Job Number-
<br /> w--waaem+v+�mr:mmww.on.�.n...:.<wna rnn we,catvaraaa'a r.r�.v:avvn<:n®ane�..mr. .aaa:mwm��
<br /> WASTE. PRODUCT QUESTIONNAIRE --_---
<br /> _ 6 ..527
<br /> 1. GENERAL INFf
<br /> Generator Natoe � � �t C-•%�� (ling IVamz �� �V gnu Gi'-'
<br /> Address���. /../�/l/�_ w�-' _ Address_/�',/O/
<br /> Ci taCity,S
<br /> te,Zi• '�' r ✓.._,_� _ ,
<br /> ty,Sf " �.� .x.11'.-....•--""'=_ •a^t _
<br /> Contact--��77/� Contact
<br /> pbonc i.:•_'.:.✓„f•_:lE,%'�r..• 'i ,.. ._.._y �:,,)
<br /> Phone
<br /> u, WASTE PRODIJC'i 1 GS
<br /> A, Waste Product Camnlon Nierie
<br /> t. ProrSaa GerIP.lAt m:�Waafy ............. .... .... ..._..- _. _1:.�..y
<br /> 13. Hazardous Properti..,;,.—'---_-_._..--_-.... _.._.,•------
<br /> 1. U.S.EPA Hezardous Wasie? C)vv:e14c: 2. State Code (s);
<br /> r' EPA Code(s): --
<br /> o.Is Waste Product: O Shock Sensitive O Re2clive U Radioactive ❑pyrophoric ❑Etiological ❑None
<br /> C. Physical Properties al 70°F:
<br /> 1. Physteal Stott! 2 Layen); 3, Flesh Point(Closed cup Only): 4, Hlscaslty,sirNi9r to:
<br /> olid O Sludge ❑Multilayered 01701F fD 140.200°F ❑Water
<br /> ❑Liquid O Empty Cnnloiner X1R-I_dyvred Cl 70-100'F Flesh ❑Motor oil
<br /> Any free liquids xl 70"F 'D Honey
<br /> D Ym, D hk> Cl usher
<br /> O. 1. benslty; ^•.:,oncma 3. Odor: 4. Ph,
<br /> Liquid O _.__......_._.,•lbs/(,anti:, 1 F,'+r!Ve�Pnl C None Lk, 0 9.1 . 12's
<br /> Solid ?..,ti.-._„,. Ibvwb;::(c T..i F.y t;�Mt/Fry'1 ( � C)Strang "D 2•S L`.>t7.5
<br /> Any de<)riyo w;aril.d: 't'iN ._%_._� r ri191d
<br /> MYds C1 Flo
<br /> ;G•P.
<br /> Explain ...._—•--.___...____ " li•..
<br /> E Chemical Composition (Accourn for i WWe of to'el)" , Fan > I Metal-� a:-- Postclldca.HOM1 des.PPM
<br /> Total (Paid)
<br /> Endrin . . . . .
<br /> __J�7_•S-� tP Toxicity irngrli
<br /> AMenlc(AS) - Metho�yChlpi
<br /> (9a)
<br /> •-�i4•Gr 5•--...------_...---..._..---.� D- �. % 7oxspirens __---
<br /> % Cadmium (Co) -- 111.4-1).
<br /> % Chromium (CO 24,r.7P _
<br /> �.-. % Copper(Cu) Other
<br /> lead (Pe) _
<br /> Mercury(H®)
<br /> - =,y Feaaivee&Other
<br /> - % Nickel (NI) Wastes(PPM):
<br /> ----- _ tb
<br /> Selenium(So) Cyanides ._— Oiouln
<br /> Sliver(Ag) Sulfido& ,__ PCBs _•_._
<br /> Phenols ._
<br /> w.. ..Idcpyertg mind
<br /> . 1, n;t2 s)tniWrn.r 1's:N- .
<br /> 1. D. . agpti:JV:;r,Aale rl rll?.....•.__.Yti:: ,..• fti0 2. rnrUUat 0.07, S)+gq;mg Name:
<br /> '-
<br /> 3. D.O.T. HarArC t7:cair __._....--. a U O.') 1p Number, hC, .
<br /> r nen ...._-...__._. ...- .__.__.__.._.._..._._.--.__7.-_..-......___.___
<br /> $. Mskhuoid.ilU -'..-''_- .."n i,n..> �<i:•.r'..-_._... BJk�__..._ _.%iJ.l?cr G, C.O.T. .`chipping Crnc:vu:: ..s..,� a/ �. ._..._.,�..
<br /> Per____. V-_One Yirrre�___-`-4Vvek=�_-,__.._._Month__�.-.._Ousner �Yaer -
<br /> n;. GENERA70P CERS4FCATICUd S1-A,TF;":Af;FJ7
<br /> I heresy CenfY ih^ .aorr.rvlyd r(:r rt'Ex:nrn;}tivR ,�f(nq�enerumr nom?d irt;ove. ,311 Iator:na G'sn %UnITd:led in Mln hind all tna atrnthnd dxvmants
<br /> is true, ta.Ane :as p!vte uvasta riaF tg?nd:wted in accorOvnce with the approved Nest methods in 40 GPN'aie;1 on a repiosenlaUve sampls
<br /> as defined i 0 CFR I6 .c0'. is(hs IySt of 3Rty knpwl6 go.all krw'-+n (d0 CFR[51) antl 9ut+pactee hazardous cpmlya^Cora have br en included in
<br /> this dpcu mztlon.All nalerlal cop pack6',m.!7 .vnl co I;I w{th au current ronulat)nns. 1 `
<br /> Sgneture .�'�'� � �„- Title GUFe_
<br /> FORM del(Rev.01 rot)
<br />
|