NSSI Houston | NSSI Environmental | NSSI | NSSI/Sources & Services Inc

GENERATOR NAME:

FACILITY ADDRESS:

TECHNICAL CONTACT:

PHONE: FAX:

EPA ID NO: STATE ID:

BILLING NAME:

BILLING ADDRESS:

BILLING CONTACT:

PHONE: FAX:

PROFILE#:

WASTE STREAM NAME:

PROCESS GENERATING WASTE:

PHYSICAL CHARACTERISTICS OF WASTE

COLOR

ODOR:

DESCRIBE:

STRONG:

MILD:

PHYSICAL STATE @ 70 DEG F:

% SOLID % SLUDGE:

% LIQUID % POWDER:

SPECIFIC GRAVITY

FREE LIQUIDS

Yes: BI:
MULTILAYERED:

PH:

n/a

<=2 >7 - 10

2.1 - 4 10 - 12.4

>4 - 7 >4 - 7x

LAYERS

HOMOGENOUS:

No:
VOLUME:

SPECIFIC GRAVITY

CHEMICAL COMPOSITION (TOTAL MUST ADD TO 100%) ATTACH ANALYTICAL AND SPECIAL INFORMATION

CONSTITUENT	MIN%	MAX%	CONSTITUENT	MIN%	MAX%

METALS TOTAL(PPM)________TCLP (MG/L)_______ANALYTICAL (ATTACHED)________GENERATOR KNOWLEDGE

ARSENIC	BARIUM	CADMIUM	CHROMIUM
CHROMIUM-HEX	LEAD	MERCURY	SELENIUM
SILVER	COPPER	NICKEL	ZINC
THALLIUM	OTHER(SPECIFY)

OTHER TOTAL(PPM)________TCLP (MG/L)_______ANALYTICAL (ATTACHED)________GENERATOR KNOWLEDGE

CYANDIES	SULFIDES	PCBS		PHENOLICS
CHLORIDES	FLUORIDES	PHOSPHATES		NA+/K+

HAZARDOUS CHARACTERISTICS USEPA HAZARDOUS WASTE:___________STATE HAZARDOUS WASTE:___________

REACTIVITY	NONE	PYROPHORIC	SHOCK SENSITIVE	EXPLOSIVE	WATER	OTHER
OTHER HAZARDS	NONE	RADIOACTIVE	ETILOGICAL	OTHER

EPA WASTE CODES:_____________________________________ STATE WASTE CODES:_____________________________________________

SHIPPING INFORMATION DOT HAZARDOUS MATERIAL?			HAZARD CLASS:	UN/NA NO:
SHIPPING DESC.:
SHIPPING METHOD		DRUM (TYPE/SIZE)	Pricing Code:		Routing Code
ANTICIPATED VOLUME (QUANTITY):			Alt Routing Codes:		Storage Code
FREQUENCY	ONE TIME	WEEKLY	MONTHLY	QUARTERLY	ANNUALLY

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COMPANY INFORMATION

PHYSICAL CHARACTERISTICS OF WASTE

ODOR:

PHYSICAL STATE @ 70 DEG F:

SPECIFIC GRAVITY

FREE LIQUIDS

PH:

LAYERS

SPECIFIC GRAVITY

AUTHORIZED SIGNATURE

DATE

NSSI SIGNATURE

DATE