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4/26/2019 <br /> i If Other,Provided re[erenee <br /> 'SWOH"ordous Wasto? QYfa ONO - <br /> i <br /> Is this nutorlal n0n•hazardous duo 10lrsalmenl,dellating,oroxdusron? Oyes ONO <br /> From an Industry regulated under BanzonoNESHAP? OYos (ONO <br /> 1 Faeflty remediation subject to 40 CFR 63 GGGGG? o Yas a No <br /> i CERCLAOIStala•Mendateddeae.up? OYes ONO <br /> !Ragulatsd,llconeadatNORM RadioactivaWa;ts? QYec ONO <br /> 1 Conletns PCBs? OYU ONO <br /> I RogWated*rWorUntreatedMadicavinreedousWaste? OYas ®No <br /> Contains Asbestos? OYas (DNo <br /> I Subject to RCRA Subpart CC conuors? ©YO] ()No <br /> SH[PPING i DOT <br /> i Event Frequency QOno nmo 0On4dng <br /> ECUmatedAnnuslOy 400 UnhofMsasure OTons Yards oDrumc 00allons QOthar <br /> Shipping Frequency <br /> { 0Onco QDaily OWaoky emonWy 00ther Qty PorShipmenl 15 <br /> i Container Type Sin40CY I <br /> Container Size <br /> USOOT Shipping Nome WA <br /> 1 PROFILE CERTIFICATION _...._......_... .. . <br /> I14mbyeoniythal(1)Wl Inlomnatlon submitted on this form and en aupPlemental material$Is complete and accurate to she best of my knaw[edge and ability to determine:(2)the Inrormation provldod ! . <br /> twoln.IncludkV anysvpplamantal Information,such as kawatoryanalyticAt MSDS'etc,accW3161Y dssct%Ot the waste stroom to bo dolivo(ed to thafacifity end thatailknown orsuipocAed hazards have } <br /> been dr3e101ed.I understand[hal,Once th0 Wada stroom is approved by Destination Fadily based on this Information,any doviallon in the source,composivon,constituents orcharactorlairos ortha Was <br /> lo <br /> 1 stream fromtho tnformallon described herein,mayrendar tho waste sboam unaccoplablo for dispose?,aT tho sole discretion o(Oestlnatlon FacIG•ty.I further understand that any deviation from moteto <br /> eons ln0al herein wit t#Quiro 1`111111061M1`111111061Mnob Retort to the Destination Faa'6y and cessation oldlepo"L <br /> tion <br /> Conrncd On <br /> Csrtined By <br /> Coffiriad As <br /> OErtYkOnmentalnote SystamsLLC 2018 ........_._.._.................____..,.....,,... <br /> i <br /> I <br /> 1 <br /> i <br /> t <br /> I <br /> 2a <br />