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TvI 1 ❑✓ i IC Ecology Nevada (Beatty) ❑ US Ecology Texas (Rnhstown) Profile #: 07-01 Fax (775) 553-2125 Fax (361) 387-0, El llt, Ecology Idaho (Grand View) an American FavdoKv comp.W Fax 208 834-2919 A. CUSTOMER INFORMATION *Waste as shipped will be : Ll Industrial NON - Industrial *(Teras customers only) Generator: QB REBUILDERS ❑ Check if Billing is Same Facility Address : 2325 W. CHARTER WAY Billing Company: ENVIROSERV (No PO Box) STOCKTON, CA 95206 Art dress: 2650 LIME AVE Mailing Addres +, '� /Zip: SIGNAL HILL, CA 90755 City/State/Zip:'El Billing Contact: J. INSCORE Technical Contact: K VONG / C. BARNES 6 ZU14 Phone No.: 562-427-7277 Fax No.: 562-490-7272 Phone: 209-467-0490 Fax: 209-467-100 cbames@enviroserv.net �Em�a�il: NAILS# 336211 ❑ CESQG ❑ SQG ❑ LQG FP� A*�7A�LhUZ-'/ State ID# B. SHIPPING INFORMATION US DOT Shipping Name NON RCRA HAZARDOUS WASTE, LIQUID , Hazard Class 3. UN/NA # 4 Packaging Group 5.RQ 6. Container Type: ❑ Bulk ❑ Totes ❑ Pallet Size 55 /30 Gal 7. Frequency: ❑ Year El QTR ❑ Month ❑ Boxes ❑ Bags E Drums ❑ Other Quantity 1 to 3 ❑ 1 Time ❑ Other C. GENERAL MATERIAL & REGULATORY INFORMATION i. Common name for this waste OILYSLUDGE 2. Process generating the material MACHINERY/EQUIPMENT MAINTENANCE (include additional sheets as necessary) 3. Describe Physical Appearance of Waste BLACK /GREY SLUDGE WITH SOME FREE LIQUIDS ON TOP 4. Describe odor of waste: ❑ None El Slight ❑ Strong Describe: OIL /GREASE 5. Knowledge is from: ❑ Lab Analysis ❑ MSDS ❑J Process/Generator knowledge ❑ Other (specify) 0 Yes ❑ No Is the material <500 PPMW VOC as generated ❑ Yes ❑ No Is the waste restricted under EPA Land Disposal Restrictions ❑ Yes ❑� No Waste Subject to Benzene NESHAP regulations (40 CFR 268), if yes please complete LDR form 0 Yes ❑ No State waste codes 1 223 ❑ wastewater ❑ Non-wastewater El Debris ❑ Yes 0 No CERCLA Regulated (Superfund) Waste ❑ Yes 2 No Exempt Waste: If yes, list ref. 40 CFR ❑ Yes Q No EPA Haz. Waste (list codes) NONE ❑ yes ❑✓ No Contains UHCs/Constituents of Concern: List in section D ❑ Yes 0 No Has the waste been treated after the initial point of generation? ❑ Yes 21 No Subpart XX ❑ Yes ❑✓ No Alternative standards for Soil ? Source Code G Pone Code W Mgt. Method H D. MATERIAL COMPOSITION (Physical/Chemical) E. Does the waste exhibit or contain the following: (Range Total > or= 100%) Values are ❑ TCLP ❑ TOTALS ❑ Yes ❑✓ No Oxidizer ❑ Yes ❑ NO React. Sulfides ppm (include additional sheets as necessary) typical value unit range ❑ Yes ❑., No Explosive ❑ Yes Q No React. Cyanides ppm ❑ Yes ❑✓ No Organic Peroxide ❑ Yes ❑✓ No Water/Air (Pyrophoric) React. ❑ Yes ❑✓ No Shock Sensitive ❑ Yes ❑✓ No Thermally Unstable ❑ Yes 21 No Tires ❑ Yes Q No TSCA Regulated PCB Waste ❑ Yes Q No Pyrophoric ❑ Yes ❑ No Regulated Medical/Infectious Waste ❑ Yes ❑/ No Radioactive** ❑ Yes Q No Compressed Gasses ❑ Yes Q No Exempt RAD** -Additional Radiological info is provided in USEI's WAC Addendum ❑ Yes ❑✓ No Halogenated Organic Compounds? (per 40 CFR 268, Appendix III) OIL 5 40 GREASE 10 50 WATER 0 10 DIRT 1 10 DEBRIS - RAGS/ WIPES 1 10 ABSORBENT- GRANULAR /MATS 1 10 F. PHYSICAL CHARACTERISTICS I .Flash Po >200 OF (if <140°F; 2.Typical pH: 7 - 9 pi 1 Range: ❑ < 2 ❑✓ Yes NO Possibility of incidental liquids from transportation? ❑✓ >2, <12.50 ❑ Yes El No Does waste pass the EPA specified paint filter test? ❑ > 12.5 G. GENERATOR'S CERTIFICATION: I IYes I I No I certify this material may be disposed of without further treatment. Certification Statement: I certify under penalty of law that I am familiar with this waste stream through analysis and/or process knowledge, and that all information provided is true, accurate, representitive and complete, and that all known or suspected hazards have been disclosed. Furthermore, I certify that this form was completed in accordance with the instructions provided. Print Name: Signature: Title: Date: Facility use only First review Second review Final review: Date approved: Date Denied: