ENVIRONMENTAL SOIL MANAGEMENT, INC.
Generator Waste Profile
ESMI Customer:____________________________________________________________________________________
Customer Address:______________________________________City:____________________State:____ Zip:________
Contact:___________________________________ Tel:(____)__________________Fax: (____)__________________
Site Contact:______________________________
Tel/Cell:(____)________________Pager:(____)__________________
Site Name:_____________________________________________ Property Owner’s Phone:(____)________________
Site Address:_________________________________________City:____________________State:_____ Zip:________
History of Site Use: Residential
Commercial
Industrial
If commercial or industrial, please describe history of site:__________________________________________________
_________________________________________________________________________________________________
Event/process generating waste: Leaking UST Leaking AST Surface Spill other(describe):________________
_________________________________________________________________________________________________
Waste Material Description: Soil/media is contaminated with: (check one)
____NON-HAZARDOUS, VIRGIN PETROLEUM CONTAMINATED SOIL
#2, #4, or #6 Fuel Oil Diesel Fuel Gasoline  Motor oil Hydraulic Oil Mixed Fuels (gas/fuel)
____NON-HAZARDOUS, NON-VIRGIN PETROLEUM CONTAMINATED SOIL
 Used Motor Oil Waste Oil Metal Cutting/Cooling Oils Hydraulic Oil Urban FillVirgin
Solvent
Electric Oil/MODF Used Solvent Grease Wax Animal/Vegetable Oil
____NON-HAZARDOUS, COAL TAR or PCB CONTAMINATED SOIL
 Coal TarPCB’s (<50 ppm that are not a TSCA PCB remediation waste and is a non-hazardous waste.)
Are there any known or suspected releases of contaminants other than those listed above? NO_______ YES_______
If YES, Specify ____________________________________________________________________________________
Approximate Tonnage: __________
Physical Characteristics: %Clay _______ % H20________ %Debris________ Describe Debris___________________
I hereby certify, to the best of my knowledge, (a) I am a responsible official of the generator, (b) that the sampling
protocol, as outlined, has been adhered to, (c) that the information provided in the profile is correct and complete, (d) that
the transport, treatment and recycling of the contaminated materials do not violate any laws or regulations of the state of
origin.
Signature:___________________________________________________ Date:_______________________________
Typed/Printed Name:_______________________________________Company:_______________________________
Check One: Owner____ Generator____ Contractor____ Consultant____ Other (explain)______________
Acceptance of this material is based on review and approval of this profile and required analytical results.
67 International Drive, Loudon, NH 03307  (603)783-0228  Fax(603)783-0104