PROFILE SHEET

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GENERATOR INFORMATION

*Generator Name:

*Address:

*City:

*State:

*Zip:

*Was waste generated at above address?YesNo

Site Location: (if different)

*Email:

*Contact Name:

*Phone Number:

Fax Number:

US EPA ID Number:

State ID Number:

Site Location ID (If different from above:

Hours of Operation:

CUSTOMER/BILLING INFORMATION

Same

Billing Name:

Address:

City:

State:

Zip:

*Contact Name:

*Phone Number:

*Fax Number:

*Billing Email:

PO Number (If applicable):

TRANSPORTER INFORMATION

IlliniOther

Name:

Address:

City:

State:

Zip:

Phone Number:

US EPA Hauler ID Number:

IL SWH ID Number:

Sales Representative:

Sales Rep. Phone:

Sales Rep. Email:

CHARACTERIZATION OF MATERIAL

*Name of Material:

*Process Generating Material:

ANTICIPATED VOLUME

5-Gal. Drum:

15-Gal. Drum:

30-Gal. Drum:

55-Gal. Drum:

85-Gal. Drum:

Cubic Yard Box:

Super Sack:

Roll-Off / Vacuum Box:

Dump Trailer:

Tanker:

Other:

*USDOT Hazardous Material:YesNo

*Federal EPA Waste Codes:

none

*DOT Shipping Name:

*Hazard Class/ID Number/Packing Group/ERG:

*Is the waste a RCRA Hazardous Waste?:

YesNo

*Is the waste represented by the profile an Illinois Special Waste?:

YesNo

(All Industrial Process Waste or Pollution Control Waste containing free liquids is an Illinois Special Waste)

Has the waste stream been declassified by the EPA?:

YesNo

If "No," please complete the non-hazardous waste code section.
If "Yes," please skip the non-hazardous waste code section.

Are there any specific disposal restrictions/handling requirements/requests/exemptions? Explain

*How has the generator determined this waste material? (Check all that apply)

Generator KnowledgeMSDS (attach)Analytical (attach)

MSDS/ANALYTICS

I understand and agree that by typing my name above, I am signing this form electronically. I further understand and agree that this electronic signature is the legally binding equivalent to my handwritten signature. I hereby confirm that I am familiar with the information contained in this and attached documents. The information contained herein is true, accurate and complete. No material fact has been omitted as to make this information misleading. I understand that others may rely on these representations for the safe and legal handling and processing of the materials described herein. I certify that the sample (if submitted) is representative of the actual material in all respects. I will notify Illini Environmental, Inc. in writing, of any waste generating process changes and/or changes to the above profiled material prior to shipment. As Generator or Generator's representative I understand that there may be significant penalties for misrepresenting or failure to correctly identify a waste's characteristics. I hereby attest to the completeness and accuracy of the information contained in and attached to this form.I hereby certify that the above and attached description is complete and accurate to the best of my knowledge and ability. I certify that all relevant information within the possession of the Generator regarding known or suspected hazards associated with the material described above have been disclosed to Illini Environmental, Inc..

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PROFILE SHEET

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