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Name of Waste: Motor oil petroleum hydrocarbon impacted soil <br />Process Generating Waste: <br />Soil excavation as a result from a small leak from a piece of on site equipment. <br />Physical State: FA SOLID OSEMI-SOLID • POWDER •LIQUID <br />Method of Shipment: FA BULK ❑ DRUM • BAGGED ❑ OTHER: <br />Estimated Annual Volume: 5 Cubic Yards <br />Frequency: FA ONE TIME ❑ANNUAL <br />Disposal Consideration: FA LANDFILL ❑ SOLIDIFICATION ❑ BIOREMEDIATION <br />Is the representative sample collected to prepare this profile and laboratory <br />analysis, collected in accordance with U.S. EPA 40 CFR 261.20(c) guidelines or <br />equivalent rules? <br />[AYES or O10 <br />Sample Date: 8/31111 I Type of Sample :ICOMPOSITE SAMPLE ❑ GRAB SAMPLE <br />Sample ID Numbers: CS-1 <br />Transporter Name: Palmetto Environmental Group I <br />Contact Name: Nick Halm <br />Transporter Address: 899 Decatur Street <br />City: Denver <br />County: Denver <br />State: CO I Zip: 80204 <br />Phone Number. (303) 825-811j <br />Fax Number. (303) 534 -5049 <br />State Transportation Number. <br />• <br />Requested Disposal Facility: 5125 Foothills LF CO <br />Waste Profile # <br />Saveable fill in form. Restricted printing until all required (yellow) fields are completed. <br />I. Generator Information <br />Sales Rep #. <br />Generator Name: Lyons Sandstone <br />Generator Site Address: 2493 CR 37E <br />City: Lyons <br />County: Boulder <br />I State: Colorado <br />Zip: 80540 <br />State ID/Reg No: <br />State Approval/Waste Code: <br />(if applicable) <br />NAICS # : <br />Generator Mailing Address (if different): 2493 CR 37E <br />City: Lyons <br />I County: Boulder <br />I State: Colorado <br />I Zip: 80540 <br />Generator Contact Name: Mr. Bemerd Buster <br />I Email: stoneworks@greenspeedisp.net <br />Phone Number: (303) 823 -5659 I Ext: <br />I Fax Number (303) 823 -0173 <br />REPUBLIC SPECIAL WASTE PROFILE <br />SERVICES <br />er Information <br />lib. Billing Information <br />Bill To: Palmetto Environmental Group <br />I Contact Name: John Drafts <br />Billing Address: 899 Decatur Street <br />Email: palmettoenvironmental @comcast.® <br />City: Denver <br />State: CO <br />I Zip: 80204 <br />Phone: (303) 825 -8117 <br />n <br />IV. Representative Sample Certification <br />RFV,1 <br />ONO SAMPLE TAKEN <br />Page 1 of 2 <br />C. Republic Services, May 2009 <br />