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Twin Enviro Services <br />Milner LandRll (Twin Landfill Corporatlon) • P.O. Box 774362 • Avenue <br />Steamboat Springs, Colorado 80477, vo/oe 97OM75-0355 r 8151377-24 olfic 61Whenvlro.com <br />Phantom Landoll (Twin Landfill Corporation o/ Fremont Coun - remont County Road 67 <br />Penrose, Colorado 81240 • voice 719/372-6671 - fax 815/377-2495 • phanfornCt winenviro.com <br />Trinidad (Twin Landfill Corporation of Fremont County) P.O_ Box 267, Trinidad. Colorado 81082 <br />voice 71"464030 • rox 8151377-2495 • trinldedQtwinenviro.com <br />Disposal Site Destination (check one) Milner Phantom Other rev OM <br />WASTE PROFILE FORM <br />In order for Twin to decide whether we con lawfully and safely accept your waste for delivery, we must obtain the following information about your w4ste. <br />The form shoutd be tilled out completely by son eons kn?eabb about the waste and hazardous waste rinses- The Generator makes a hazardous waste <br />determination and is reaponsible for its waste from cradle to grave, All related analysis must be included with this form, and If future analysis ditrs from <br />what was s bvftad, the analytical results must be sent to TGwin immediately. AN Womwk n on this form must be typed or printed In black Ink <br />1. Generator Information (NOT Consultant, Contractor or Abatement Firm) <br />1. Generator Name:- _ ICU, i) A trs d / <br />2. Address: Z `) 5'/ S ??, R Z Z <br />Da k ec% G2 So Y6 7 <br />3. Contact: &Mr4 1/1/A doer Phone: $76 Z7.5" b <br />Fax: Email: Zwa 7?io emti ( ^a Tenze <br />?h <br />4. Location of Waste Generation: arule?ro I-idd???k-rd S- <br />L/ II. Waste Information /? <br />1. Common Name of Waste, as ?/hG« iN r fl 51r noL,21 tr ne..r Ll rl d CA I Gf V ?Pl <br />2. Detailed Description of Process Generating Waste <br />C -e <br />3. Is This a Hazardous Waste as Defined by Federal, State or Local Laws or Regulations? [ ] Yes [>I No <br />Ili. Physical Characteristics of Waste <br />1. Color. 014(x. ?a <br />2. Odor: [ None (] Mild [ ] Strong Describe <br />3. Physical State*[ ] Solid [R Semi-Solid(sludge) [ ) Liquid (j Other <br />4. Percent Solids (if known): % <br />5. Waste will be delivered to the site in, [413ulk [ } Drum [ ] Other <br />6. Anticipated Volume: (lam/KaiWZh_[ ] Tons [ ] Yards [ ] Drums [ ] Gallons [ j other <br />7. Frequency: [ j One-time [ } Weekly [ ] Monthly [ ] Other AS ?-Ca? <br />IV. Consultant or Abatement Firm Information <br />1. Consultant/Abatement Firm: & der 6'a _SAeur Ara, <br />2. Address: <br />3. Contact: 09 J &h/Pr Phone: 3C.0 "*? Fax: Email: <br />V. Laboratory Information <br />1. Laboratory Name. <br />2. Contact: Phone: Fax: Email: