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Generator Information

Site Information

Waste Information

Analytical data attached (file limit: 1.5MB): YesNo

MSDS attached (file limit: 1.5MB): YesNo

Waste Characteristics

IndustrialCommercialMunicipalFood ProcessingGray WaterGround WaterRain WaterHolding TankGrease (Food Svc.)Septage (Domestic)Oily Waste WaterResidualSlurrySpent Filter MediaSludgeOther

Physical State

Oil SheenLiquidSludgeSolid

Quantity of Waste:

Shipping Information

VacuumVacuum TankerVacuum ContainerDewatering BoxRoll Off ContainerJet Vac

Size of bulk: 5,0006,0007,000Other

Shipping Frequency


MonthQuarterYearDayOne TimeOther

Was this waste stream previously transported for disposal at an approved facility?
YesNoIf yes, please provide the facility's name and the proper shipping name under which the waste was classified

Generator Certification

1. Is this waste RCRA nonhazardous?
YesNo If no, please attach details & description below

2. Is the waste generated as CERCLA/Superfund Site?

3. Is the waste represented by this waste profile a categorial waste as defined in 40 CFR 439?

4. Does the waste represented by this waste profile contain concentrations of Polychlorinated Biphenyls (PCBS) regulated by 40 CFR 761?

5. Does the waste represented by this waste profile contain true and accurate descriptions of the waste material, and has all relevant information within the possession of the Generator regarding known or suspected hazards pertaining to the waste been disclosed to the contractor?

6. Will all changes occur in the composition of the waste be identified by the Generator and disclosed to the contractor prior to making the waste available for pumping, transportation and disposal?

Any sample submitted is representative as defined in 40 CFR 261 - Appendix 1 or by using equivalent method. I authorize Russell Reid to obtain a sample from any waste shipment for purposes of recertification. If approved by management, Contractor has all neccessary permits and licenses for the waste that has been categorized and identified by this approval profile. By entering the below fields, I understand I am electronically signing this form.

Additional information attached (file limit: 1.5MB): YesNo

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