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Rio Blanco County - D [ L ry} (A?;' <br />Solid Waste Facilities <br />570 Second Street Phone (970) 878-9590 <br />Meeker, CO 81641 Fax (970) 878-3.396 <br />SPECIAL WASTE CHARACTERIZATION FORM <br />In order for Rio Blanco County to decide whether we can lawfully and safely accept your waste for delivery, we must obtain the following <br />Information about your waste. The form should be filled out completely by someone knowledgeable about the waste and hazardous waste <br />rules. The Generator makes a hazardous waste determination and is responsible for their waste from cradle to grave. All related analysis <br />must be included with this form, and If future analysis differs from what was submitted, the analytical results must be sent to Rio Blanco <br />County Immediately. All information on this form must be typed or printed in Ink. <br />1. Generator Information <br />1. Generator Name: American Shale Oil LLC (AMSO) <br />2. Generator Address: 110 East 3rd Street, suite 201, PO Box 1470, Rifle CO 81650 <br />3. Contact: Roger L. Day Phone: 970/625-4324 <br />Fax: 970/625-4318 Email: <br />Billing Address if not the same as above: <br />4. Location of Waste Generation: AMSO RD&D Oil Shale Lease Tract; off Rio Blanco County Rd 85 <br />It. Waste Information <br />1. Common Name of Waste: drill cuttings <br />2. Detailed Description of Process Generating Waste: drill cuttings from installation of monitoring wells <br />3. Is This a Hazardous Waste as Defined by Federal, State or Local Laws or Regulations? [ ] Yes [ X ] No <br />Ill. Physical Characteristics of Waste <br />1. Color: Gray <br />2. Odor: [ X ] None [ ] Mild [ ] Strong Describe <br />3. Physical State: ] X ] Solid [ ] Semi-Solid(sludge) [ J Liquid [ J Other <br />4. Percent Solids (if known): <br />5. Waste will be delivered to the site in: [ X ] Bulk [ ] Drum [ ] Other <br />6. Anticipated Volume:100 f ] Tons [ X ] Yards [ ] Drums [ ] Gallons [ ] <br />Other <br />7. Frequency: [ ] One-time [ X ] Other Sufficient truck trips to transport over 5 - 10 days <br />W. Consultant Information <br />1. Consultant Name: <br />2. Consultant Address: <br />3. Contact Person: Phone: Fax: Email: