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For Facility Use Only I.D. # RECO BIOTECHNOLOGY SOIL DATA AND CERTIFICATION SHEET Date: Generator Information “The name you know” Richmond, VA Customer Information Name: Address: Name: Address: Contact: Telephone: Contact: Telephone: Site History Physical Address: Soil Storage Method: Petroleum Type: Estimated Quantity in Tons: Business Activity: Source: Please fill out the applicable information below and sign the Certification. No soil may be delivered until facility approval and facility manifests are issued for soil shipment. Please attach the appropriate analysis for the selected source type and check all applicable boxes. Soil Contaminated From Leaking Petroleum Underground Storage Tanks (USTs): * Double click boxes to mark Sampling Protocol and Location: Soil Contaminated with Petroleum From Sources Other than USTs: EPA SW-846 *Total Petroleum Hydrocarbon (TPH) 418.1 or 8015 Required for Non-Virgin Petroleum or Optional: *Benzene, Toluene, Ethyl Benzene Method 5030/8020 and Xylene (BTEX) *Total Organic Halogens (TOX or EOX) Standard Methods *TCLP or Total RCRA Metals Standard Methods Virgin Petroleum Testing Laboratory: Telephone Number: Non-Virgin Petroleum Certification: This is a complete and accurate description of the soil; no willful omissions of information have been made and all known or suspected hazards have been disclosed. I/We further certify that the soil is contaminated only with petroleum or petroleum products from a known source and that the soil to be remediated does not meet the definition of a hazardous waste according to 40 CFR Part 261 and the Virginia Hazardous Waste Management Regulations. All required analysis reports are attached. Generator’s Authorized Signatory: Print Name: _______ ________ Date:____________________ Title: ____________________ P.O. Box 25189, Richmond, VA 23260 710 Hospital Street, Richmond, VA 23219 – PHONE (804) 644-2800 FAX (804) 644-1335