PROFILE SHEET Please Choose Who Will Receive Your Email:---Scott KohlerHeather WhiteMax McQuillanLauren AndersonJason Reed GENERATOR INFORMATION *Generator Name: *Address: *City: *State: *Zip: Site Location: (if different) *Email: *Contact Name: *Phone Number: Fax Number: EPA ID #: State ID Num.: CUSTOMER/BILLING INFORMATION Same Billing Name: Address: City: State: Zip: *Contact Name: *Phone Number: *Fax Number: TRANSPORTER INFORMATION IlliniOther Name: Address: City: State: Zip: Phone Number: US EPA ID Number: CHARACTERIZATION OF WASTE *Name of Waste: *Process Generating Waste: Physical State:LiquidSolidSludgePowder Viscosity:LowMedHighN/A Free Liquids:YesNo Layering:SingleBi-layerMulti 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 TCLP TOTALS Yes No 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 Packaging:DrumToteBulk Other: Volume: Frequency: *USDOT Hazardous Material:YesNo *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 represented by the profile an Illinois Special Waste?: YesNo (All Industrial Process Waste or Pollution Control Waste containing free liquids is an IL Special Waste) Are there any specific disposal restrictions/handling requirements/requests/exemptions? Explain *How the generator determined the waste is/ is nota RCRA hazardous waste? 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 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.. I also certify that the obtained sample (if necessary) is a representative of the material described above and give Illini Environmental, Inc. permission and consent to make amendments and corrections. I will notify Illini Environmental, Inc. of any waste generating process changes and/or changes to the above profiled material prior to shipment. ELECTRONIC SIGNATURE DATE COMPANY / TITLE
