Request for Waste Material Analysis

List all detectable components by chemical name, including physical materials (e.g., sorbent, debris, etc.)

I hereby certify that I am an authorized agent of the generator, and warrant on behalf of the generator that the information supplied on this form and on any attachments or supplements hereto is complete and accurate, and that all known or suspected hazards of the material(s) described herein have been disclosed. I agree that if the sample test results indicate a discrepancy with any information supplied on this form, that either Geocycle or the generator may initiate further testing and evaluation in accordance with the terms and conditions of the contract between Geocycle and the generator and that this profile certification may be amended accordingly.