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Oct -,-15-99 08:08A QB Rebuilder inc P.03 <br />!' <br />DeM%nno / K _ <br />UEIIENNU : K011)00( j g LABOPATORY IS CERTIFIED BY THE CALIForNIA DEPARTMENT OF HEALrH <br />SEMICES ENVIROXIENTAL LA5CRATORY ACCRi CITATION PROGRAM ( ELAO) CERT 1112031 <br />GENERATOR'S WASTE PROFILE WORKSHEET <br />FGENERAlUR'S INFOR1,IA [-IDN <br />A. <br />GENERATOR'S NAXIE_CZ Y. 1 1,.1. :.1•-<: <br />R <br />EPA 104 CAL(', - 1-4 <br />-- <br />C <br />GI=AJERArc)R'S ADDRESS 1 L h: c i,...r I, . <br />_ <br />':`,k. <br />— <br />PHONE(i �:` ( Lit � • C�+- ; c' <br />F <br />CITY. STATL=. Zip— /1 <br />F <br />GENERATOR CONTACT I'.- }: VQ1, -rcG. <br />TITLE <br />H- <br />CL)NAME NAM_F't ••� : �� d •'C_• , 0 L c. <br />I. <br />PHONE 1_ - ti''I�, -7 1 <br />( j,— <br />J. <br />TRANSPORTER NAME t" �•'I c.- <br />_ <br />K- <br />PHONE (`,�,, i. - y�;s 11 1 <br />L. <br />THAN ;PORTER EPA ID# C A L- <br />- - <br />til- <br />CONTACT <br />PLEASE ATTACH. (NISDS -MAY BE REQUIRED ON CERTAIN <br />A 14c, zc.:•c{c.+1� <br />WASTE STREAMS.)........ <br />A <br />NAMF OF WASTE- <br />S <br />CALIFORNIA HAZARDOUS WASTE CODE NO. 5 C. EPA HAZARDOUS WASTE CODE NU r=+: K_; t' <br />C <br />[.)ESCHISE PROCESS GENE9ATING WASTE v .c, �� ;' 4 cis;ti:.•, c I<c,.�, <br />,. <br />C'r {�'+•�+�' [:-�� G►ti- <br />C.. r <br />E. <br />_ <br />DOES THIS WASTE CONTAIN PCB'S? <br />F. <br />DOES THIS WASTE CONTAIN DIOXX? (F0020 -F0029) — - yes ►: <br />no <br />G. <br />— <br />HAS THIS __.�_ V</AS i E BEEN MIXED WITH RCRA LISTEDWASTE?TE� Yes <br />no <br />(P, K, U OR P EPA WASTE CODES) <br />H, <br />_ - yes �_ _no <br />IF YOU HAVE A CURRENT N1SDS REGARDING THIS WASTE, <br />PLEASE ATTACH. (NISDS -MAY BE REQUIRED ON CERTAIN <br />WASTE STREAMS.)........ <br />i. <br />........,,...-..._.............. . .,..... ..MSDS ATTACHED <br />IF YOU HAVE A CURP.ENT CHEMICAL ANALYSIS OF THIS <br />Ll <br />WASTE, PLLASE ATTACH .._........._.._,.............. CHEMICAL ANALYSIS ATTACHED <br />—I..AEORATOHY ANALIS REQUEST <br />PROFILE U OTHER J <br />APPROVED FjY -- PURCHASE GRUER OR JOB NUMBER <br />GENCHATOR'S CERTIFICATION <br />I HERESY CEr+TI-Y THAT THE INFOPMATIQN PROVIDED ON T! -!IS OOCUMFNT, IS TRUE AND ACCURATE, AND NO IN I ENTICNAI_ MIS• <br />RENRES£NTION HAS SEEN COMMITTED AY ANYONE. I FLIRT►TIER CERTIFY THAT ANY SAMPLE(.';) PROVIDeU WITI4 THIF: WASTE <br />PFf_1r:LE WERE TAKLN ANn PRESFRVED IN ACCORDANCE WITH 40 Cf H 261. APPENDIX 1 AND ARE ACCURATE AND REPREFE-%1 <br />TATLE QF MY ACTUAL WASTE STREAM I HEREBY AGREE ra NOTIFY DF_ MENNQ l KLROCON SHOUT is THIS WASTE STREAM <br />CHANGF IN ANY WAY <br />AUTHORIZED SIGNATURE I <br />� - - PATE ! O ! /„�/ 9.� <br />PRINT NAME AND TITLE <br />FOWA NO IC01 REV- 1-30-95 <br />