CHEMICAL WASTE PROFILE

GENERAL INFORMATION:

 Contact Name
Generator   Phone
Address Fax
E-mail
City State
Zip USEPA ID No.

WASTE DESCRIPTION :

   Bulk drum solid   Bulk drum liquid
Labpack Other

WASTE CHARACTERISTICS:

   (at 70 o F unless otherwise specified )
color Liquid %   PHASES: Single layer
Odor None Solid % Double layer
Mild Sludge % Multilayer
Strong Other

CHEMICAL COMPOSITION:          (MUST TOTAL 100%)

     %
     %
     %
     %
     %
      %
     %
     %
     %
     %

METALS:

  TOTAL(PPM) TCLP(MG/L)   TOTAL(PPM) TCLP(MG/L)   TOTAL(PPM) TCLP(MG/L)
Arsenic Lead Zinc
Barium Selenium Antimony
Cadmium Silver Beryllium
Chromium Copper Thallium
Mercury Nickel  

PHYSICAL/CHEMICAL PROPERTIES: (Check the appropriate boxes.)

Specific Gravity Viscosity
(centipoise)		 pH BTU
000/lb		 Flash Point
(closed cup)		 Halogens
%
<0.6 1-100 <2 <1 <100 F Chlorine
0.6-0.8 100-1000 2-6 1-4 100-140 F Bromine
0.8-1.0 1000-10,000 6-8 4-8 141-200 F Fluorine
1.0-1.2 >10,000 8-10 8-12 >200 F Iodine
1.2-1.4     10-12.5 12-16     Total
1.4-1.7     >12.5 >16        

HAZARDOUS CHARACTERISTICS: FUEL DATA:   (weight percent)
Shock sensitive Water Reactive Explosive
Pyrophoric Radioactive PCBppm
Etiological Pesticide Other
Water Sodium
Potassium Phosphorus
Ash Content  

RCRA INFORMATION:

USEPA Waste Yes No
List all applicable EPA waste codes.
SHIPPING INFORMATION:
DOT Hazardous Material Yes No
Proper Shipping Name

Hazard Class  UN
Anticipated Volume Gals lbs
One Time Other

BENZENE EXEMPTION:
Is this waste subject to Benzene Waste Operations NESHAP? Yes No
(If yes, contact NSSI for Benzene NESHAP form..)


Check here if the waste contains VOC's greater then 500 ppm.

 

Check here if you are aware that the waste stream contains any Toxic Release Inventory ("TRI") chemical(s) (EPCRA Section 313 Chemicals)

If you checked the box above, then provide the following for each toxic chemical:
1) Chemical Name: 
2) CAS Number:
3) Amount of Toxic Chemical(s) present is Total lbs, gallons, ppm or % of waste stream.
The list of TRI Toxic Chemicals can be found at http://www.epa.gov/tri/chemical.htm

Chemical Name CAS Number Total Amount
Attach sheet for additional chemicals.

 

GENERATORS CERTIFICATION: (Wastes cannot be accepted for treatment unless completed and signed.)

I certify that:

1. All information submitted in this and all attached documents contain true and accurate descriptions of this waste and all relevant information regarding known or suspected hazards in the possession of the generator, have been disclosed.
2. NSSI is authorized to obtain a sample from any waste shipment for the purposes of testing and certification.
3. If this certification is made by a broker, the undersigned signs as an authorized agent for the generator. (Please attach a letter of authorization signed by the generator.)

Name Date

   

***Please Sign and Fax the completed form to 713-641-6153. If you are using a version of Internet Explorer 3.0 or Netscape 3.0 or older, you will need to click the right side of the page and use your browser's print button to print this form.***