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Oct -15-99 08:08A QB Rebuilder inc P_03 <br />DeWenno / Ke?doon <br />UELIENNO : KEF7I70OFJ 5 LAf3OPA70RY IS CERTIFIED By THE CALIFORNIA DEPARTMENT 017 HEALTH <br />SERVICES ENVIHOMENTAL LA5E?RATORY ACCRE OITATION FF;GGRAM ( ELA115) CERT It 2031 <br />GENERATOR'S WASTE PROFILE WORKSHEET <br />GENERAJOR'S INFOR-MATION <br />A. GENERATCR'-; NAME�►:.,,; I, <br />---_ -- B EPA IDtt Cl1Li,•(. f,4 ;s. ; <br />C GE=NF_RAfCIR'S ADDHF-SS . 1 Z �; c i,..;- 41.,/- <br />- PHONE <br />F. CITY. STAT C. Z;P <br />F GENERATCR CON1ACT I'r. }: �'.;,, -rc <br />G. TITLE 67. P A <br />H. CUSTONIErtI NAME_ H •,ter l .►1..'�.. ;,r <br />—.. I PRONE 2` <br />J. TRANSPORTER NAME f,. , •� I c K. PHONE <br />L. THANSPORTER FPA IDs AL �� ' I C.� 7 `� G , Z 4 <br />!41 CONTACT <br />A. NAN1F OF WASTE <br />B. CAI/IFOHNlA HAZARDOUS WASTE CODE NO � � � C. EPA HAZARDOUS WASTE CODE NO <br />D OESCHIBE PROCE5S GENE9ATING WASTE V -.C, i:. <br />F-. DOES THIS WASTE CONTAIN PCB -Sl— <br />_ <br />F. DOES THIS WASTE CONTAIN DIOXIN' (FOO20-F0029yesrl�.� <br />) — yrs ro <br />G HAS THIS WASTE BEEN MIXED WITH RCRA LISTED WASTE <br />(F, K. U OR P EPA WA$TE CODES) _ yes V �Q <br />H. IF YOU HAVE A CURRENT M1SDS REGARDING THIS WASTE, <br />PLEASE ATTACH (NISDS -MAY BE REQUIRED ON CE=RTAIN <br />Y'1ASTE STREAMS) ..........MSDS ATTACHED J <br />...................... <br />...................... <br />E. IF YOU HAVE A CURRENT CHEMICAL ANALYSIS OF THIS <br />WAgTE, PLLASE ATTACH _ ........... CHEMICAL ANALYSIS ATTACHED C�/ <br />L,AEOPANTOHY ANALIS REQUEST <br />PROFILE 0 OTHER O <br />APPROVED BY — PURCHASE ORDER OR JOB NUME3ER <br />GENCHATOk'S CERTIFICATION <br />1 <br />I NERE'JY CEWi -Y ThAT THE INFORMATION PRO`1IUF-D ON T1 -;IS DOCUMFNT. IS TRUE Ai 10 ACCURATE, AND NO IN I ENTI ,NAI_ MIS <br />REYRESENTQN HAS, SEEN COMMITTED BY ANYONE i FUr1THER CERTIFY THAT ANY SAMPLE(s) PROVIDED WIT14 THIS WASTE <br />WFOr':LS'01FRE TAKLN ANE) PREFFRVE•D IN ACCORDANCE WITH 40 CCH 261. APPENDIX 1 AND ARE ACCURATE AND REPRE SEN <br />TATI4E QF MY ACTUAL WASTE SrRk :AM I HEREBY AGREE r() NOTIFY OF MENNO / KERDOON SHOULD THIS WASTE STREAM <br />CHANGE IN ANY WAY <br />AUTHORIZED SIGNATURE Y <br />—�,- fr— f - DATE <br />PRINT NAME AND TITLE <br />FORM NO. ICd1 REV 1.30-55 <br />I <br />