Generators Waste Material Profile Sheet

Section A - General Information

Generator Name:   ____________________________________________________
Facility Address:    ____________________________________________________
Mailing Address:    ____________________________________________________
Technical Contact: ____________________________________________________
Name of Waste:    ____________________________________________________
Process Generating Waste: ______________________________________________
Nature of Business: ____________________________________________________
EPA Form Code:                     ___________________________ SIC Code: _______

Billing Information:

Name: _____________________________________________________________
Address: ___________________________________________________________
City:   State:  Zip Code: ________________________________________________
Phone Number: ______________________________________________________
E-Mail Address: ______________________________________________________

Section B - Generator Characteristics

Spill Cleanup: Yes No       Cercia Waste: Yes No
This Is  A: WW  NWW  Debris   Soil
Virgin Product or Chemical: Yes No  (If Yes, please mail MSDS)
Generated From A Planting Operation: Yes  No
Anticipated Volume: Gallons  Drums  Tons  Other 
Per: One Time Week Month Quarter Year Other
Drum Type       DOT Number       Drum Size 

IS THIS A HAZARDOUS WASTE AS DEFINED IN 40CFR261:  Yes  No
If No, sign your name:
___________________________________________

Section C - DOT and RCRA Characteristics

DOT Proper Shipping Name:____________________________________________
Hazard Class: Packing Group____________________________________________
UN or  NA: RQ: _____________________________________________________
US EPA Waste Codes: ________________________________________________
Note: If D001 (Except High TOC>10%), D002, or D002-D043 requires treatment of the characteristic, then the underlying hazardous constituent(s) present in the waste at the point of generation must be identified below:

Section D - Physical Characteristics

Chemical Composition (Totals MUST add up to 100%)

Component Range (%)
   
   
   
   
   
   
Totals  
   

Physical State:   Liquid       Semi-Solid         Solid
Viscosity:          Low          Medium             High
Layering:          Multi         Bi-Layered        Single
Odor:               None                  Mild      Strong
Color: ____________________________________________________
Free Liquids:  Yes No   Percent: ___________
Specific Gravity: ___________  Btu/Lb: ___________
Flash Point: ___________  Chlorides (%): ___________
PH: ___________  Water: ___________
Hazardous Characteristics as defined in 40CFR 261:
Reactivity:
None   Phrophoric    Shock Sensitive Explosive Water Reactive
Other: ___________
Corrosivity: Yes No   Ignitability: Yes No
Toxicity:
Yes No   Listed: Yes No
Other Hazardous Characteristics:   None   Radioactive Ethological
Pesticide/Herbicides Waste   Other ___________

Section E - TCLP (Indicate if the waste contains any of the following: Totals or TCLP
Waste   Regulatory Waste   Regulatory
# Constituent Level PPM   # Constituent Level PPM
D004 Arsenic 5.0     D024 M-Cresol 200.0  
D005 Barium 100.0     D025 P-Cresol 200.0  
D006 Cadmium 1.0     D026 Cresol 200.0  
D007 Chromium 5.0     D027 1, 4 Dichlorobenzene 7.5  
D008 Lead 5.0     D028 1, 2 Dichloromethane 0.5  
D009 Mercury 0.2     D029 1, 1 Dichloroethylene 0.7  
D010 Selenium 1.0     D030 2, 4 Dinitrotoluene 0.13  
D011 Silver 5.0     D031 Heptachlor 0.008  
D012 Endrin 0.02     D032 Hezachlorobenzene 0.13  
D013 Lindane 0.4     D033 Hexachlorobutadiene 0.5  
D014 Methoxychlor 10.0     D034 Hexachloroethane 3.0  
D015 Toxaphene 0.5     D035 Methyl Ethyl Ketone 200.0  
D016 2 4 D 10.0     D036 Nitrobenzene 2.0  
D017 2 4 5-TP 1.0     D037 Pentachlorophenol 100.0  
D018 Benzene 0.5     D038 Pyridine 5.0  
D019 Carbon Tetrachloride 0.5     D039 Tetrachloroethylene 0.7  
D020 Chlordane 0.03     D040 Trichloroethylene 0.5  
D021 Chlorobenzene 100.0     D041 2,4,5 Trichlorophenol 400.0  
D022 Chloroform 6.0     D042 2,4,6 Trichlorophenol 2.0  
D023 O-Cresol 200.0     D043 Vinyl Chloride 0.2  
                 

 
     PPM       PPM       PPM        PPM
PCB's Beryllium Cyanide Amenable Manganese
TOC Copper Cyanide Total Aluminum
Sulfides Zinc Thallium Nickel

 

Section F

The above information is true and accurate and is based on an analysis of a representative sample of this waste in accordance with EPA guidelines, documents SW-846--1980 and EPA-600/2-80-018, or on my thorough knowledge of the waste.

By: ________________________________________________________

Title: _______________________________________________________

Date: _______________________________________________________

I authorize Environmental Alternatives to act as my agent to make corrections to this profile. Such corrections being consistent with the results of sample characteristics and/or regulatory requirements of the Alabama Department of Environmental Management or USEPA.  I understand that a corrected copy will be sent to me by Environmental Alternatives.

Yes   No  Initials:  ___________