PROFILE SHEET Please Choose Who Will Receive Your Email:—Please choose an option—Scott KohlerHeather WhiteMax McQuillanLauren AndersonCrystal Jones 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: Physical State:LiquidSolidSludgePowder Viscosity:LowMedHighN/A Layering:SingleBi-layerMulti Free Liquids:YesNo Total Liquids: Total Solids: Specific Gravity: pH (exact or range): Exact: ≤22.1-12.4≥12.5 Flash Point: Exact: <73°73°-140°>140° Color: Odor: *Chemical Composition: (Range) Total ANALYTICAL DATA *Do you have any analytical data for the waste stream?YesNo TCLP TOTALS BTEX OTHER Name Other: Arsenic >5.0 ppm YesNo Barium >100 ppm YesNo Cadmium >1.0 ppm YesNo Chromium >5.0 ppm YesNo Lead >5.0 ppm YesNo Mercury >0.2 ppm YesNo Selenium >1.0 ppm YesNo Silver >5.0 ppm YesNo 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: GENERATOR CERTIFICATION *Does this waste contain any of the following?:PCBsRadioactiveBenzeneAsbestosListed WasteDe-listed WasteExplosivesPesticideInfectious/Sanitation WasteHalogensHerbicideReactive Cyanide/SulfidePhenolicsTCLP ToxicsNone *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?: label> YesNo If "No," please complete the non-hazardous waste code section. If "Yes," please skip the non-hazardous waste code section. NON-HAZARDOUS WASTE CODES Each waste stream itemized on the e-manifest is to be accompanied by a waste code. Non-hazardous special waste codes to be used are identified below. Please check which code applies to the waste stream being identified above. label> IL01 - Leaking underground storage tank contaminated soil, sand and clay: label> NoYes IL02 - Other contaminated soil, sand and clay: NoYes IL03 - Other contaminated materials: NoYes IL04 - PCB solids such as capacitors/carcasses: NoYes IL05 - PCB liquids such as transformer & capacitor oils: NoYes IL06 - Lab packs: NoYes IL07 - Leachate: NoYes IL08 - Ashes, incinerator or boiler: NoYes IL09 - Municipal WW treatment sludges: NoYes IL10 - Industrial WW treatment sludges: NoYes IL11 - Food processing waste, off-spec food products: NoYes IL12 - Antifreeze: NoYes IL13 - Waste / Used oil: NoYes IL14 - Other organic liquids: NoYes IL15 - Other organic solids or sludges: NoYes IL16 - Solids or sludges with other metals: NoYes IL17 - Solids or sludges with other metals: NoYes IL18 - Other inorganic liquids: NoYes IL19 - Other inorganic solids or sludges: NoYes IL20 - Containerized gas: NoYes IL21 - Household hazardous waste from collections: NoYes 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.. label> ELECTRONIC SIGNATURE DATE COMPANY / TITLE Δ