WASTE STREAM CONTAINS TOXIC RELEASE INVENTORY (COMMUNITY RIGHT-TO-KNOW)

HAZARDOUS CLASS: ID#: PG: RQ: lb

METHOD OF SHIPMENT: BULK LIQUID

DRUM (TYPE SIZE)

GALLONS

GALLONS

DRUMS

TRI?

TRI?

TRI?

TRI?

TRI?

TRI?

TRI?

TRI?

TRI?

TRI?

TRI?

SOLID

LIQUID

LIQUID/SOLID MIXTURE

SLUDGE

MULTILAYERED

BI-LAYERED COLOR % VOLUME

pH

CERT. LAB REF:

ACCEPTED OR REJECTED

APPROVAL NO.CODE NO.BY:

B. PHYSICALCHARACTERISTICS

C. CHEMICAL COMPOSITION

Total of Maximum concentration must be >100%

D. METALS TOTAL (PPM)

E. OTHER COMPONENTS TOTAL (PPM)

F. SHIPPING NAME:

PER ONE TIME

QUARTER

PHONE

THE ABOVE INFORMATION WAS OBTAINED FROM THE FOLLOWING SOURCE(S): MSDS

SIGNED ON BEHALF OF GENERATOR

A. GENERAL INFORMATION

FLASHPOINT

Subject to Benzene NESHAP (40 CFR 61 Subpart FF)?

3150 East Pico Blvd. Los Angeles, CA 90023Phone (800) 499-7145

Fax (323) 780-0078

%

%

%

%

%

%

%

%

%

%

%

–

–

–

–

–

–

–

–

–

–

–

"TRI" means a chemical that needs to be reported pursuant to EPCRA Section 313, the Community Right-To-Know Act. TRI stands for Toxic Release Inventory, submitted on Form R.

I HEREBY CERTIFY THAT ALL INFORMATION SUBMITTED IN THIS AND ALL ATTACHED DOCUMENTS IS COMPLETE AND ACCURATE AND THAT ALL KNOWN OR SUSPECTED HAZARDS HAVE BEEN DISCLOSED. I ALSO CERTIFY THAT THE OBTAINED SAMPLE IS REPRESENTATIVE OF THE WASTE MATERIALS DESCRIBED ABOVE.

CYANIDES

SULFIDES

AMINES

PCBs

PHENOLICS

ARSENIC (As)

BARIUM (Ba)

CADMIUM (Cd)

CHROMIUM (Cr)

CHROMIUM HEX (Cr+6)

NICKEL (Ni)

ZINC (Zn)

THALLIUM (Ti)

OTHER:

MERCURY (Hg)

LEAD (Pb)

SELENIUM (Se)

SILVER (Ag)

COPPER (Cu)

G. HAZARDOUS PROPERTIES

GENERATOR NAME

FACILITY ADDRESS

PHONE

BILLING NAME

BILLING ADDRESS

BILLING PHONE

NAME OF WASTE

PROCESS GENERATING WASTE (be specific)

GENERATOR EPA ID#

TRANSPORTER

TRANSPORTER PHONE

TRANSPORTER EPA ID#

TECHNICAL CONTACT

TITLE

TCLP (mg/L)

REPORTABLE CHEMICALS?

USEPA (RCRA) HAZARDOUS WASTE?

USEPA HAZARDOUS WASTE CODE(S):

STATE HAZARDOUS WASTE?

STATE CODE:

PHYSICAL STATE @ 70°F LAYERS FREE LIQUIDS

BY ISSUANCE OF THE APPROVAL NUMBER BELOW AND IN ACCORDANCE WITH CALIFORNIA CODE OF REGULATIONS, TITLE 22, SECTION 66 264.12, PRR HEREBY CERTIFIES THAT IT HAS THE REQUISITE AUTHORIZATION AND PERMITS FOR THE WASTE DESCRIBED ON THIS CHEMICAL SAMPLE PROFILE SHEET, AND IST PROVIDED HEREIN THAT IT WILL ACCEPT SUCH WASTE FROM YOU FOR MANAGEMENT AT ITS FACILITY IN LOS ANGELES. APPROVAL NUMBER IS GOOD FOR ONE YEAR COMMENCING ON THE DATE BELOW.

(List Hazardous as well as Non-Hazardous components and corresponding ranges).

140°F-200°F

>200°F

NO FLASH

<70°F

70°F-100°F

101°F-139°F

EXACT

N.A.

1.3-1.4

1.5-1.7

>1.7

<0.8

0.8-1.0

1.1-1.2

>12.5

EXACT

N.A.

7

7.1-10

10.1-12.5

≤2

2.1-3.9

4-6.9

EXACT

CLOSED CUP

OPEN CUP

SINGLE PHASED

WEEK

YEAR

MONTH

AIR REACTIVE

PYROPHORIC

PESTICIDE RESIDUALS

ETIOLOGICAL

COMBUSTIBLE

EXPLOSIVE

POLYMERIZABLE

PATHOGEN

BIOLOGICAL

FLAMMABLE

VOC > 500ppm?

VOLUME TO SHIP NOW:

H. OTHER REGULATORY STATUS

ANTICIPATED VOLUME:

PRINTED NAME:

AUTHORIZED SIGNATURE:

PRODUCT INFO DATA PERSONAL KNOWLEDGE CERTIFIED LAB ANALYSIS

TITLE: DATE:

CHEMICAL SAMPLE PROFILE SHEETwww.pacificresourcerecovery.com

WATER REACTIVE

SHOCK SENSITIVE

RADIOACTIVE

CORROSIVE

OTHER:

BULK (GALLONS)

DRUMS

_____________

YES NO

YES NO

YES NO

YES NO YES NO

Y N

SPECIFICGRAVITY

NONE