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Waste Material Profile Sheet

Please fill out the form information below. We will evaluate your submission and contact you. Should you have any questions, feel free to call us, or contact us using our general online contact form.

GENERAL INFORMATION

Company:    
Facility Address: 
Facility City:       
Facility State:   
Facility Zip Code: 
Telephone Number
Fax Number
Generator  USEPA/Federal ID#    Not/Applicable:   

      

BILLING INFORMATION:    Please check here if billing information is same as above:      
Billing Name: 
Billing Address:  
Facility City:      
Facility State: 
Facility Zip Code:  
Biling Telephone Number:  
Billing Fax Number: 

         
                 

WASTE STREAM INFORMATION

Name of Waste:     
Process Generation Waste: 
Can A Representative Sample Be Provided?       Yes     No
Is a MSDS attached?         Yes       No
Is there any analytical attached?      Yes     No

                                                    

GENERAL CHARACTERISTICS:
 

Color:                Odor:   
Physical State @ 70 F:   % Liquid  % Sludge   %Solid     
  %Powder  % Gas         %Gas (0ther)       % Other  
Phases:         Single Layer    Multi Layer      How Many?   
Btu/lb    <3,000        3,000-5,000    5,000-10,000        >10,000   
PH     <2.0         2.0 to 4.0    4.0 to 10.0    10.0 to 12.5       >12.5  
Liquid Flash Point:  <73F 73 to 99F  100 to 139F 140 to 200F    >200  None 
Specific Gravity:      %  Total Halogens:   

       
     

CHEMICAL COMPOSITION    (Total of Maximum Concentration must be greater than or equal to 100%)
Constiutents
Name                                                                            Percent

           
           
           
           
           
           

 

OTHER WASTE STREAM INFORMATION

Does this Waste have any of the following characteristics? (Please check all that apply.)

Oxidizer Organic Peroxide Water Reactive Air Reactive Pyrophoric Dioxin
Radioactive Infectious Pathogen Carcinogen Etiological Aerosols
Explosive Shock Sensitive Undergo Hazardous Polymerization Cylinder    

Does this waste contain any of the following?

Name None Less Than <50 ppm Actual (ppm)
PCB's
Cyanides
Sulfides
Phenolics

SHIPPING INFORMATION

Liquid                        Bulk Solid                Cubic Yard Boxes            Totes   

Drums Select:                      Other:  

Shipping Frequency

Number of Units:        Year            One Time   

R.C.R.A. Characterization

If this an "F" or "K" waste or mixed with one? If "No," please skip to next section.
Is this a "Universal Waste" per 40CFR part 273?  
Is this a "Characteristic Waste?"  

If "Yes," is  it

D001 Ignitable D002 Corrosive D003 Reactive
Characteristic for Toxic Metals DOO4 D005 D006 D007 D008 D009 D010 D011
Characteristics for Toxic Organics: d012 through D043 (List all that apply.):
 

Is this a state regulated waste?
If "Yes," above, please list all codes:  

GENERATOR CERTIFICATION:

I hereby certify that the above and attached description is complete and accurate to the best of my knowledge and ability. No deliberate or willful omissions of composition or properties exist and that all known or suspected hazards have been disclosed. I also certify that the obtained sample is representative of the waste material described above and give Sierra Chemical Corporation permission and consent to make amendments and corrections.

Name:
Title: 
Date: 

By checking this box, you acknowledge that the above information serves as an online signature.