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VUX to(Mb) 327-4049 <br /> GlBffN LIQUID -4 1PROFIL .E'T <br /> Eff:wri e February 1, 199 <br /> Please fill in completely All sr k'ap ly to your material. This is an application, nc)t an app:u`al <br /> Generator I-At- <br /> Facility Address $ A1b► 6Z� — <br /> M- ailing Address Telephone �� _ <br /> UCA EPA ID# <br /> Technical Contact Title <br /> Transporter rEN <br /> state <br /> Contact WID SkC0 Title 5-joews <br /> Telephone 610 245 134�j EPA 1'):i# C*©'0c1Q' <br /> '.Name of Waste No" **? S Ui t <br /> Activity Producing Waste <br /> Does this waste contain Petroleum Hydrocarbons? Yep ::I No .2-" <br /> Approximate Concentxations (Accg&=for 100%) 45_100 <br /> Petroleurn Hydr ns — % Solids % Wa:er 07 Usher_ <br /> pH Flash Odor NCAJC <br /> Ls this waste a R.CRA T Yes No <br /> Is this, waste a RCRA F-, -,P-,or U-ListedWaste) Yes No <br /> Does this waste contain any Lead,Chmi ,or oi6r "C.A.A.M. 17°' me'als`' Yes !a Ne °— <br /> lf yes, what substances and at whar eoncentmdons(mg/L of g/k®)? <br /> Does this waste contain: <br /> Reactive Cyanides or Sulfides of 1 ppmor more? Yes l] Nc, <br /> PCH's of 2 ppm or snore? Yes D No a^ <br /> Total Ozganrc Halogens of 1000 ppm or more? `[et" Zi .2. <br /> How will this waste be manifested: <br /> ikon-1 azardous on.a Bill of Lading or Data Form? Yes'aNo <br /> On a Uniform Hazardous Waste MaAfest as: <br /> 1. Non-RCRA Hazardous Waste Liquid`' Yes u No 0' Wa-;te Code _ <br /> ?. RQ-Hazardous Waste Li tud N.O.S.flP?vl:E NA 4 189(tJ{}_ Yes r,J No.2' Waste Ccxie <br /> 3. <br /> T de <br /> o }mo led e,I certify that the above is ix'tae and correct- <br /> led <br /> e <br /> q. <br /> Signature Title Taate <br /> My sipmre indicates perm n for Hazardous Waste-NL-Wfests to be corrected by Gibson to conform with i4ormatiur: <br /> fumished on this profile:. pmn <br /> Facility Decision <br /> Accept 51MRIC# Rele Farility <br /> Manager Date <br /> Recycled Paper <br /> 200 ' 39dd 1400 iD I L3 bE :@ t-G ° 8 i5dO <br />