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LIC <br /> SEf?VB SPECIAL WASTE PROFILE Page 1 of 2 <br /> Waste Profile # <br /> Requested Disposal Facility: 4204 Forward Inc. CA <br /> Saveable rill-In form. Restricad painting until all required (Vailovr) flelds aro ccm Sleted_ <br /> L 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: <br /> II . Billing Information <br /> Bill To: Generator Contact Name : <br /> Billing Address: I Email : <br /> City: State: Zip: Phone: <br /> 111 . Waste Stream Information <br /> Name of Waste: Diesel Impacted Soil <br /> Process Generating Waste : <br /> Spills and dripping from the diesel fueling area were cleaned up and placed into a plastic tote with metal cage. We <br /> propose to dispose of both the tote and soil combined , <br /> Type of Waste: ® INDUSTRIAL PROCESS WASTE ❑ POLLUTION CONTROL WASTE <br /> Physical State: ® SOLID ❑ SEMI-SOLID ❑ POWDER ❑ LIQUID <br /> Method of Shipment: ❑ BULK ❑ DRUM ❑ BAGGED ® OTHER: Tote <br /> Estimated Annual Volume: 1 Tons <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, <br /> collected in accordance with U . S. EPA 40 CFR 261 .20(c) guidelines or equivalent rules? ® YES or [:]NO <br /> Type of Sample : ❑COMPOSITE SAMPLE ® GRAB SAMPLE <br /> Sample Date: 9/26/18 <br /> Sample ID Numbers: Yard Soil <br /> © Republic Services, April 2013 <br />