GENERATOR WASTE PROFILE SHEET
Section 1 - General Information
Generator Name:
Site Address:
Town, State, Zip:
Mail Address:
Town, State, Zip:
Facility Contact/Title:
E-Mail address:
Phone:
Fax:
EPA ID#:
Section 2 - Billing Information
Name:
Mail Address:
Town, State, Zip:
Contact/Title:
E-Mail address:
Phone:
Fax:
EPA ID#:
Section 3 - Waste Composition
Name and Description of Material:
Process Generating Waste:
Estimated Annual Volume:
Quantity:
Units/Size:
Shipping Frequency:
Type of Shipment:
Bulk
Drums
Other
Waste Description (Chemical Composition)*
*Attach additional pages if needed. All substances that are regulated by 29CFR
1910.1000 Subpart Z and 29CFR 1910.1200 must be listed.
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Section 4 – Material Properties
Total Metals
Arsenic
< 40 ppm
Barium
< 500 ppm
Beryllium
< 10 ppm
Cadmium
< 20 ppm
Chromium
< 70 ppm
Lead
< 100 ppm
Mercury
<
2 ppm
Molybdenum
< 70 ppm
Nickel
< 150 ppm
Selenium
< 20 ppm
Silver
< 80 ppm
Zinc
< 5000ppm
TX(For Oil Only)<1000ppm
Yes
No
N/A
Btu/pound:
Flashpoint
Sulfur
Bromine
Chlorine
Fluorine
Iodine
Reactive Cyanides
Reactive Sulfides
Aluminum Oxide
Silicates
Silicone
This determination was based upon:
Analytical Data
Physical State:
Liquid
Pumpable
Single Phase
Sludge
Pourable
Bilayered
Solid
Dumpable
Multilayered
Water Reactive
Oxidizer
Acid Reactive
None
Reactivity:
F
%
ppm
%
ppm
ppm
ppm
%
%
%
%
Generator Knowledge
Powder
Other:_________________
Alkaline Reactive:
Color:
Odor:
None
pH:
<2
Mild
>2-6
Strong
>6-9
Describe:_____________________________
>9-12.5
>12.5
NA
Section 4 – Regulatory Waste Classification
Is the waste an EPA Listed Waste per 40 CFR 261?
Yes
No
Is the waste an EPA Characteristic Hazardous Waste per 40 CFR 261?
Yes
No
The regulatory classification determinations above were based upon:
Analytical Data (attach all relevant analysis)
Generator Knowledge: (check all that apply)
Knowledge of the waste regulations
MSDS provided for material(s)
Information describing the process and materials generating the waste
Proper DOT Shipping Description:
Shipping Name:
UN/NA:
PG:
Hazard Class
Waste Codes:
Attach all relevant Material Safety Data Sheets (MSDS), Laboratory Analyses, Waste
Sampling Plans, Flow Chart or Process Schematic if available. Attach separate sheets
to disclose all known and suspected hazards, special handling precautions and
additional comments.
Desired Destruction Method:
Waste to Energy
Landfill
Recycling/Treatment
Engineered Fuel
Section 5 - Certifications
GENERATOR'S CERTIFICATIONS
I hereby certify the above information is correct to the best of my knowledge.
I
further certify that WRS will be notified in writing of any process changes, which
could significantly alter the composition, and/or chemical/physical properties of the
waste described above.
I further certify that the waste has not been intentionally
mixed with hazardous materials and that all known or suspected hazards have been
disclosed. I further certify that this material neither contains nor has been mixed
in any way with Polychlorinated Biphenyls (PCBs), Pesticides, or Herbicides to the
best of my knowledge and is non-hazardous based upon Federal, State and local
Regulations.
RESOURCE RECOVERY FACILITIES NON-HAZ CERTIFICATION
I certify that the waste materials consigned to WRS for recycling/reuse/ treatment or
destruction by incineration at a Resource Recovery facility are classified as nonhazardous according to federal regulations, 40 CFR Part 261. The waste does not
exhibit the RCRA characteristics of ignitability, corrosivity, reactivity, or
toxicity.
It does not contain any hazardous levels of toxic metals, air emissions
metals, volatile or semi-volatile organics, pesticides or herbicide constituents, nor
is it a listed hazardous waste. This determination has been made based upon generator
knowledge and/or analytical data.
Print Name:
Title:
Generator Signature: ____________________________________ Date:
(Your profile sheets must be signed)
Section 6 - WRS Review
Residual Waste Code: ____________________________
Destination: ____________________________________
Approval Code: __________________________________
Reviewed By: ____________________________________