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Permian Environmental Solutions

1220 S. Faudree Road,

Odessa, TX 79766

PES Material Information Profile

Fill in as much information as possible. Not all fields are required currently.

Fields marked with an Asterix (*) Are Mandatory

Approval #:

Date:

Material Name/Description: *

Process Generating Material (Be Specific): *

Physical Description: *

Generator *

EPA ID#: *

Shipping Street Address

Shipping City

Shipping State

Shipping Country

Country

Shipping Postal Code

Generator Contact:

Phone

Fax:

Billing Street Address:

Billing City:

Billing State:

Billing Zip Code:

Billing Country:

Billing Contact:

Billing Email Address:

Billing Phone:

Billing Fax:

DOT/EPA Information

DOT Hazardous Material Basic Description: Specify the Identification Number, the Proper Shipping Name, the Hazard Class and the Packing Group | ISHP

RQ:

ERG#:

RCRA and/or State Materials Codes (Type N/A) if none apply:

Material Characterization Available

Chemical Composition
Low %
High %
Concentration

Material Characterization Available (01)

Chemical Composition
Low %
High %
Concentration

Material Characterization Available (02)

Chemical Composition
Low %
High %
Concentration

Material Characterization Available (03)

Chemical Composition
Low %
High %
Concentration

Material Characterization Available (04)

Chemical Composition
Low %
High %
Concentration

Material Characterization Available (05)

Chemical Composition
Low %
High %
Concentration

Material Characterization Available (06)

Chemical Composition
Low %
High %
Concentration

Material Characterization Available (07)

Chemical Composition
Low %
High %
Concentration

Halogens

<2 %

2-5%

5-10%

10-30%

>30%

Halogens Measured:

Layers

Multilayered

Bi-Layered

Single Phase

Layers Color:

Solids

Suspended %
Settleable %
Dissolved %

Solids Color:

Odor

None

Mild

Strong

Describe Odor

Physical State

Solid

Flowable Powder

Semisolid

Pumpable

Liquid

Gas

If Liquid Select Viscosity

High (Syrup)

Medium (Oil)

Low (Water)

<2%

2-5%

5-9%

9-12.5%

>12.5

N/A

Not Specified/Determined

Exact:

Specific Gravity:

<0.8

0.8-1.0

1.0-1.2

>1.2

Not Specified/Determined

Gravity Measured:

Flash Point

<80

80-100

101-140

141-200

>200

No Flash

Not Specified/Determined

Flash Point Measured

Hazardous Characteristics

Radioactive

Explosive

Biohazard (Certificate Required)

Reactive Material - Specify:

Water Solubility

% ASH

BTU/LB

Optional Information

(Known l Suspended l Estimated - ppm or mg/L)

Constituent l Concentration & UOM

Antimony
Arsenic
Barium
Beryllium
Cadmium
Chromium
Copper
Cyanide
Lead
Mercury

Constituent l Concentration & UOM Continued...

Nickel
Nitrates
Organics
Silver
Sulfates
Sulfates
Sulfide
Thallium
Vanadium

Container Information:

Packaging:

Present Container:

Shipping Container:

Size

Units:

UOM:

(e.g., Drums, Boxes, Totes, etc...)

Shipping Frequency (Check One)

One Time

Per Day

Per Week

Per Month

Per Quarter

Per Year

Additional Description:

Additional Information

Is this material subject to subpart CC regulations (i.e. contains >500 ppm volatile organic compounds)?

Yes

Are there underlying hazardous constituents, other than mercury listed in 40CFR268.48?

Yes

Does the material contain >500 ppm of any 40CFR Part 261 Appendix VIII Constituents?

Yes

If any of the above items were answered yes, explain below:

Addt’l Comments:

Generator Certification:

I hereby certify that I have personally examined and am familiar with the information submitted in this and all attached documents. Based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information is true, accurate, and complete to the best of my knowledge and ability and that all known and suspected hazards have been disclosed.

PRINT NAME & TITLE

TODAY'S DATE:

Signature

Clear

TSDF Notification to the Generator: If approved for management, Permian Evironmental Solutions, has all the appropriate permit(s) for, and will accept, the material that has been characterized and identified by the Generator within this profile document.

Qtrly | Annual Reporting Information:

NAICS l SIC CODE(S):

Source Code

Form Code

Mgmt Method Code:

Module #