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PETROLEUM WASTE, _INC . <br /> Predis osal Iatormation Form for Material <br /> Contaminated with Petroleum Products <br /> GENERAL DIRECTIONS : In order for Petroleum Waste, Inc. to determine <br /> wftether we can lawtully and safely dispose of your waste, certain <br /> information about the waste is required and a sample of the waste may also <br /> oe required. Information will oe conridential . Leave no blanks, of not <br /> appiicable, indicate as 'NA" . For any responses , use additional paper. <br /> ,ve suggest the generator maintain a copy of the completed form on file. <br /> THIS FORM AND SUPPLEMENTAL !NFORMATION SHOULD BE RETURNED TO: <br /> �lotxoleua Gla��a , It..E T1L . 3 , ..,. y� V.ZL , aA $8188 . <br /> 1 Generating Facilit Name : / S <br /> Address ' �. Za2 <br /> US EPA I D# g?nE SS_ Phone <br /> 2 Company Contacts <br /> Name GT i t le Phone <br /> 3 a) Description of Waste - <br /> b) Petroleum Product present - Leaded Gasoline <br /> Unleaded Gasoline I Diesel <br /> Fuel Oil Other (please list ) <br /> 4 Expected Volume r 2 S <br /> 5 Physical Characteristics- <br /> a) Physical description. Solid ✓ Liquid Sludge <br /> o ) Are free liqu.fds Present (paint filter test) ? Yes Nn L <br /> 5 Waste Parameters pH -'<-IP Flashpoint (closed cup) * y2�P F= <br /> *only if free liquids are present <br /> - <br /> 7 Required Testing <br /> a) If petroleum contaminant is diesel , fuel oil, or kerosene: <br /> Total petroleum hydrocarbons ppm <br /> b) If petroleum contaminant is gasoline: <br /> Total petroleum hydrocarbonsppm <br /> Benzene .'"`- Pm G Gt Cr C <br /> Toluene ppm a-*40 <br /> Xylene pm <br /> OL yai,i` Dead ppm <br /> c ) If petroleum contaminant is other that diesel , fuel oil , kerosene <br /> or gasoline- <br /> Required testing to be determined by PWI personnel . Contact PWI <br /> personnel at (805 ) 762-7341 Ella Chipponeri or (805 ) 763-4171 John <br /> Farmer. <br />*5 - Does this waste contain Pesticide/herbicide products: Yes No �/ <br /> Halogenated Organic Compounds: Yes No <br />