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5/2/2019 <br />Applicable Exempt Waste Item <br />0 UST Corrective Action -40 CFR 261.4 (b)(10) 0 PCB Bulk Product Waste -40 CFR 761.62 0 Oil & Gas E&P Waste -40 CFR 261.4 (b)(5) <br />RCRA-Empty Containers -40 CFR 261.7 0 Other <br />If Other, Provided reference <br />State Hazardous Waste? 0 Yes • No <br />Is this material non-hazardous due to treatment, delisting, or exclusion? 0 Yes • No <br />From an industry regulated under Benzene NESHAP? 0 Yes • No <br />Facility remediation subject to 40 CFR 63 GGGGG? 0 Yes • No <br />CERCLA or State-Mandated clean-up? °Yes • No <br />Regulated, Licensed or NORM Radioactive Waste? 0 Yes • No <br />Contains PCBs? 0 Yes • No <br />Regulated and/or Untreated Medical/Infectious Waste? 0 Yes • No <br />Contains Asbestos? 0 Yes • No <br />Subject to RCRA Subpart CC controls? oYes • No <br />SHIPPING & DOT <br />Event Frequency •One Time 0 On-Going <br />Estimated Annual Qty 2 Unit of Measure Q Tons 0 Yards • Drums 0 Gallons 0 Other <br />Shipping Frequency <br />Once 0 Daily 0 VVeekly Q Monthly 0 Other <br />Container Type DM <br />USDOT Shipping Name " <br /> <br />Qty Per Shipment 2 <br />Container Size 55D <br /> <br />PROFILE CERTIFICATION <br />I hereby certify that (1) all information submitted on this form and on supplemental materials is complete and accurate to the best of my knowledge and ability to determine; (2) the information provided <br />herein, including any supplemental information, such as laboratory analytical, MSDS, etc., accurately describes the waste stream to be delivered to the facility and that all known or suspected hazards have <br />been disclosed. I understand that, once the waste stream is approved by Destination Facility based on this information, any deviation in the source, composition, constituents or characteristics of the waste <br />stream from the information described herein, may render the waste stream unacceptable for disposal, at the sole discretion of Destination Facility. I further understand that any deviation from the information <br />contained herein will require immediate notification to the Destination Facility and cessation of disposal. <br />Iqattilurraik afeAtior LIPRR <br />Certified on 4/25/19 by VVyatt Murray ass Authorized Agent of GHD Services, Inc. <br />C Environmental Data Systems LLC 2018 <br />2/2