Environmental :: WASTE PROFILE FORM

WASTE PROFILE FORM

(For HELP completing the fields on this form, click HERE.)

SECTION 1: GENERAL INFORMATION

WASTE GENERATOR:

COMPANY NAME:		EPA ID #:
ADDRESS:		STATE:
CITY:		ZIP:
PHONE #:	FAX #:
CONTACT PERSON:

BILLING IF DIFFERENT FROM ABOVE:

Address:	City:
State:	Zip:
Phone #		Fax #
Contact Person:

SECTION 2: WASTE DESCRIPTION

Common Name:		Waste Code:
Please provide detailed description of process generating this waste stream. Process Generating Waste

Ship Volume:	Frequency:	Bulk:	Drums:

PHYSICAL DESCRIPTION

Color

Odor:

None

Mild

Strong

Physical State:

Liquid

Solid

Sludge

Layers:

Single Phase

By-Phase

Multi Phase

Density

Free Liquid Range:

C/CC

LB/GAL

Flashpoint:

< 140 F

140-200 F

> 200 F

pH:

2-4

4.1 - 6

7 - 10

10.1 12.5

>12.5

SECTION 3: WASTE CHARACTERIZATION

ATTACHED LABORATORY ANALYSIS, MSDS, OR OTHER SUPPORTING DOCUMENTATION
		Waste Code
1. Does the waste meet any F,K,P, or U listing Description?	[ No] [ Yes]
2. Does the waste exhibit the characteristic of ignitability?	[ No] [ Yes]
3. Does the waste exhibit characteristic of corrosivity?	[ No] [ Yes]
4. Does the waste exhibit TCLP constituents Above: Characteristic Limits? (See section 4 for waste oil see section 5.)	[ No] [ Yes]
5. Is the waste Michigan Hazardous Waste?	[ No] [ Yes]
6. Is the waste a Non-Hazardous liquid?	[ No] [ Yes]
7. Does the waste contain reactive cyanide greater than 250 PPM?	[ No] [ Yes]
8. Does the waste contain sulfide greater than 500 PPM?	[ No] [ Yes]
9. Does the waste contain HOC greater than 1000 PPM?	[ No] [ Yes]
10. Does the waste contain an PCB's > 1PPM?	[ No] [ Yes]
11. Does the waste contain VOC's above 100PPM/W?	[ No] [ Yes]

SECTION 4: TCLP CERTIFICATION

Mark the "YES" column to indicate which TCLP testing has been conducted. (Attach lab results)
For those constituents not tested mark "NO" and sign certification provided either "YES" or "NO" must be checked for each constituent.

TCLP REGULATORY ACTION LEVELS		CONSTITUENT TESTING CONDUCTED OR CERTIFICATION
		Yes	No
ZHF Organic	MG/L		Based on my knowledge of the waste
1. DO28 1, 2 - Dichloroethane	0.5		and the process generating the waste,
2. DO29 1,1 - Dichloroethylen	0.7		these constituents are not present in
3. D01 Benzene	0.5		the waste above hazardous
4. 9 Carbon Tetrachloride	0.5		classification levels.
5. 021 Chlorobenzene	100.0
6. D022 Chloroform	6.0
7. D035 Methyl Ethyl Ketone	200.0
8. D039 Tetrachloroethylene	0.7
9. D040 Trichloroethylene	0.5
10. D043 Vinyl Chloride	0.2		Signed

TCLP REGULATORY ACTION LEVELS		CONSTITUENT TESTING CONDUCTED OR CERTIFICATION
METALS	MG/L	Yes	No
1. DOO4 ARSENIC	5.0		Based on my knowledge of the waste
2. DOO5 BARIUM	100.0		and the process generating the waste,
3. DOO6 CADIUM	1.0		these constituents are not present in
4. DOO7 CHROMIUM	5.0		the waste above hazardous
5. DOO8 LEAD	5.0		classification levels.
6. DOO9 MERCURY	0.2
7. DOO10 SELENIUM	1.0
8. DOO11 SILVER	5.0
9. DOO1D COPPER	100.0
10. DOO3D ZINC	500.0		Signed

TCLP REGULATORY ACTION LEVELS		CONSTITUENT TESTING CONDUCTED OR CERTIFICATION
ACID EXTRACTABLES	MG/L	Yes	No
1. DO23 o-CRESOL	200.0		Based on my knowledge of the waste
2. DO24 m-CRESOL	200.0		and the process generating the waste,
3. DO25 p-CRESOL	200.0		these constituents are not present in
4. DO26 CRESOL	200.0		the waste above hazardous
5. DO37 PENTACHLOROPHENOL	100.0		classification levels.
6. DO41 2,4,5-TRICHOROPHENOL hazardous	400.0
7. DO42 2,4,6-TRICHOROPHENOL	2.0		Signed

TCLP REGULATORY ACTION LEVELS		CONSTITUENT TESTING CONDUCTED OR CERTIFICATION
BASE NEUTRALEXTRACTIBLES	MG/L	Yes	No
1. DO27 1,4-DECHLOROBENXENE	7.5		Based on my knowledge of the waste
2. D30 2,4-DINITROTOLUENE	0.13		and the process generating the waste,
3. DO32 HEXACHLOROBENZENE	0.13		these constituents are not present in
4. DO33 HEXACHLOROBUTADIENE	0.5		the waste above hazardous
5. DO34 HEXACHLOROETHANE	3.0		classification levels.
6. DO36 NITROBENZENE	2.0
7. DO38 PYRIDINE	5.0		Signed

TCLP REGULATORY ACTION LEVELS		CONSTITUENT TESTING CONDUCTED OR CERTIFICATION
PESTICIDES	MG/L	Yes	No
1. DO20 CHLORDANE	0.03		Based on my knowledge of the waste
2. DO12 ENDRIN	0.02		and the process generating the waste,
3. DO31 HEPTACHLOR (&ITS HYDROXIDE)	0.008		these constituents are not present in
4. DO13 LINDANE	0.4		the waste above hazardous
5. DO14 METHOXYCHLOR	10.0		classification levels.
6. DO15 TOXAPHENE	0.5

HERICIDES	MG/L	Yes	No
1. DO16 2,4-D	10.0
2. DO172,45-TP (SIL VEX)	1.0		Signed

SECTION 5: USED OIL RECLAMATION

Is this material a "USED OIL" as defined by CFR 40 260.10?	NO	YES
Is this oil exempt from hazardous waste regulation per CFR 261.6?	NO	YES

PCB'S PPM	SULFUR %				ARSENIC PPM
CADIUM PPM	CHROMIUM PPM				LEAD PPM
Certification of waste oil stream (please check all that apply)
1. This oil stream has been mixed with hazardous waste which was generated by a conditionally exempt small quantity generator.
2. The waste oil stream has been mixed with a characteristic hazardous waste.
3. The waste oil stream contains chlorinated paraffins.
4. The oil stream contains halogenated chemicals which are not hazardous wastes, please specify:
I HEAR BY CERTIFY THAT THIS WASTE STREAM HAS NOT BEEN MIXED WITH OR DOES NOT CONTAIN HAZARDOUS WASTE REGULATED UNDER THE FEDERAL CONSERVATION AND RECOVERY ACT OF MICHIGAN AND REGULATIONS PROMULGATED UNDER THE AUTHORITY OF THOSE ACTS.
Signature			Date
Print Name			Title

SECTION 6: SHIPPING INFORMATION
Proper DOT shipping description
Hazardous class		UN/NA #		Packing group
Waste Code			Emergency response guide #

SECTION 7: GENERATOR CERTIFICATION
I CERTIFY UNDER PENALTY OF LAW THAT I AM FAMILIAR WITH THIS WASTE STREAM THROUGH ANALYSIS AND/OR KNOWLEDGE AND THAT ALL INFORMATION SUBMITTED IS TRUE, ACCURATE AND COMPLETE AND THAT ALL KNOW OR SUSPECTED HAZARDS HAVE BEEN DISCLOSED.

Signature		Title		Date