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DEMENNO / KERDOON'S LABORATORY IS CERTIFIED BY THE CALIFORNIA DEPARTME4U8F HALTH4 <br />SERVICES ENVIRONMENTAL LABORATORY ACCREDITATION PROGRAM (ELAP) CERT. # 2037 <br />GENERATOR'S WASTE PROFILE ftfflftttrLTH <br />GENERATOR'S INFORMATION <br />A. GENERATOR'S NAME <br />QBR INC <br />C. GENERATOR'S ADDRESS 2325 W. CHARTER WAY <br />E. CITY, STATE, ZIP <br />F. GENERATOR CONTACT <br />H. CUSTOMER NAME <br />STOCKTON, CA 95206 <br />J. Pineda <br />Envirosery - C. Barnes <br />J. TRANSPORTER NAME Envirosery <br />L. TRANSPORTER EPA ID# CAR000188201 <br />B. EPA ID# CAL000388538 <br />X <br />PHONE ( ) 209-467-0490 <br />G. TITLE EH&S Manager <br />I. PHONE ( ) 562-427-7277 <br />K. PHONE ( ) 562-427-7277 <br />M. CONTACT <br />A. NAME OF WASTE BRAKE FLUID with RUSTARREST (NAPHTHA) <br />B. CALIFORNIA HAZARDOUS WASTE CODE NO. 343,223 <br />C. EPA HAZARDOUS WASTE CODE NO. NONE <br />D. DESCRIBE PROCESS GENERATING WASTE EQUIPMENT, VEHICLE, MACHINERY MAINTENANCE <br />IS THIS WASTE REGULATED UNDER THE BENZENE NESHAP RULES? yes ✓ no • <br />E. <br />DOES THIS WASTE CONTAIN PCB'S? <br />yes no <br />F. <br />DOES THIS WASTE CONTAIN DIOXIN? (F020-FO28) <br />�_ yes no <br />G. <br />DOES THIS WASTE CONTAIN SULFIDES OR CYANIDES? <br />yes �_ no <br />H. <br />DOES THIS WASTE CONTAIN PESTICIDES OR HERBICIDES? <br />yes _ �� no <br />(IF YES, IDENTIFY IN ITEMS A OR D ABOVE.) <br />I. <br />DOES THIS WASTE CONTAIN SOLVENTS? <br />�_ yes M7_ no <br />(IF YES, IDENTIFY IN ITEMS A OR D ABOVE.) <br />J. <br />DOES THIS WASTE CONTAIN PLATING WASTE? <br />❑ yes W1 no <br />K. <br />HAS THIS WASTE BEEN MIXED WITH RCRA LISTED WASTE? <br />(F, K, U OR P EPA WASTE CODES) <br />(F, <br />�yes 17 no <br />L. <br />IF YOU HAVE MSDS FOR COMPONENTS IN THIS WASTE, <br />PLEASE ATTACH .............. ......................................................................... <br />MSDS ATTACHED ❑ <br />M. <br />IF YOU HAVE CURRENT ANALYSIS OF THIS <br />N. <br />WASTE, PLEASE ATTACH.................................................................CHEMICAL ANALYSIS ATTACHED ❑ <br />PACKAGING / VOLUME ❑ ❑ ❑✓ TOTES 1,000 <br />BULK LIQUID DRUMS OTHER <br />p AMOUNT <br />❑ GALLONS ❑ LBS. ❑ CUBIC YARDS PER: ❑ DAY ❑ MONTH <br />❑ QUARTER m YEAR <br />GENERATOR'S CERTIFICATION <br />I HEREBY CERTIFY THAT THE INFORMATION PROVIDED ON THIS DOCUMENT, IS TRUE AND ACCURATE, AND NO INTENTIONAL MIS- <br />REPRESENTATION HAS BEEN COMMITTED BY ANYONE. I FURTHER CERTIFY THAT ANY SAMPLE(S) PROVIDED WITH THIS WASTE <br />PROFILE WERE TAKEN AND PRESERVED IN ACCORDANCE WITH 40 CFR 261, APPENDIX 1 AND ARE ACCURATE AND REPRESEN- <br />TATIVE OF MY ACTUAL WASTE STREAM. I HEREBY AGREE TO NOTIFY DEMENNO / KERDOON SHOULD THIS WASTE STREAM <br />CHANGE IN ANY WAY. <br />AUTHORIZED SIGNATURE _ _ DATE <br />PRINT NAME AND TITLE <br />FORM NO. 1001 REV. 4-15-08,5-25-10 • IS Denzene waste tram a chemical manpWturing, p4e by-product recovery, or <br />petroleum refinery process? -ILEI yes _L_j. no <br />