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ewREPUBLIC SPECIAL WASTE PROFILE PRINT Page 1 of 2 <br /> ZIAA SERVICES <br /> Waste Profile# <br /> Requested Disposal Facility:4204 Forward Inc. CA <br /> Saveable fill-in form. Restricted printing until all required(yellow)fields are completed. <br /> 1. Generator Information Sales Rep#: <br /> Generator Name: Kent's Oil Service, Inc. dba Pacific Northwest Oil <br /> Generator Site Address: 3310 E Miner Ave. <br /> City: Stockton County: San Joaquin State:California Zip: 95205 <br /> State ID/Reg No: State Approval/Waste Code: (if applicable) NAICS# : <br /> Generator Mailing Address (if different):❑✓ PO Box 6930 <br /> City: Stockton County: San Joaquin State: California Zip: 95206 <br /> Generator Contact Name: Steve Azevedo Email: steve.azevedo@kniferiver.com <br /> Phone Number: (209)948-0302 Ext: Fax Number: (209)466-2756 <br /> 11. Billing Information <br /> Bill To: Same as Generator Contact Name: <br /> Billing Address: Email: <br /> City: State: Zip: Phone: <br /> 111. Waste Stream Information <br /> Name of Waste: ButonaINX4190 (Latex)-Solidified <br /> Process Generating Waste: <br /> Expired product in tanks and totes is shoveled and stockpiled for disposal. The composition of the product at this point is <br /> a solid and contains no free liquids. <br /> Type of Waste: ✓❑INDUSTRIAL PROCESS WASTE ❑POLLUTION CONTROL WASTE <br /> Physical State: ✓❑SOLID ❑SEMI-SOLID ❑POWDER ❑LIQUID <br /> Method of Shipment: [Z]BULK ❑DRUM ❑BAGGED ❑OTHER: <br /> Estimated Annual Volume: 2 Cubic Yards <br /> Frequency: []ONETIME ❑✓ ONGOING <br /> Disposal Consideration: [Z]LANDFILL [—]SOLIDIFICATION [_]BIOREMEDIATION <br /> IV. Representative Sample Certification ❑✓ NO SAMPLE TAKEN <br /> Is the representative sample collected to prepare this profile and laboratory analysis, ❑YES or[—]NO <br /> collected in accordance with U.S. EPA 40 CFR 261.20(c)guidelines orequivalent rules? <br /> Type of Sample: ❑COMPOSITE SAMPLE ❑GRAB SAMPLE <br /> Sample Date: <br /> ©Republic Services,April 2013 <br />