Form WAG-501-F1
Rev. 6
Shipment Summary Form
Required for EnergySolutions Bear Creek & Gallaher Rd.
Processing Facilities
Generator:
Page 1 of 2
Shipment Date:
Shipment Number:
TN License for Delivery No:
Contract/Release Number:
Total # of Containers:
Special Quote #:
Total Activity (mCi):
Shipment Weight:
SNM Grams:
Highest Contact Dose Rate Package:
Highest Contact Dose Rate Material:
MATERIALS SHIPPED
Please Estimate Percentage of Total Material by Weight (Must Add to 100%)
DAW
(Incineration, Compaction)
DAW
%
Asbestos
%
Metals
%
Asbestos
%
Lead Blankets
%
Lead Sheets
%
Lead Brick
%
Other (specify):
%
Resins
Powdex
%
Bead
%
(Dewatering, Incineration)
Charcoal
%
Type of Liner
Aqueous Liquids
%
Sludge
%
Oil
%
Oily Waste
%
Grease
%
EHC
%
Plant Trash
%
Construction & Demolition Debris
%
Wastewater Sludge (NOTE 1)
%
Sewage Sludge (NOTE 1)
%
Cation/Anion Resin
%
Asbestos
%
Carbon Filter Media
%
Paint Chips/Blast Media (NOTE 1)
%
METALS
(Melting, Volume Reduction &
Disposal)
LIQUIDS
(Incineration, Drying,
Solidification)
POTENTIALLY
CLEAN MATERIAL
(Green Is Clean)
Other (specify):
%
Describe nature of project in Special Instructions, below
(e.g., Transship, Source Encapsulation, RCRA, etc.)
SPECIAL PROJECT
NOTE 1: Requires TCLP Analysis prior to shipment of each campaign of similar waste.
WASTE INFORMATION
(ITEMS IDENTIFIED WITH ** REQUIRE ENERGYSOLUTIONS APPROVAL PRIOR TO SHIPMENT; SEE SECTION 8 OF THE WAG)
3 day prior notification required for OOW
**Metals > 200 mrem/hr @ contact with waste
**SNM/Source Material
**DAW > 200 mrem/hr @ contact with waste
Liquid Filters (Separate Isotopics Required)
**Trans-shipment
**High Smearable
**Sealed Sources
Activated Material
Refrigeration Equipment
**Lead-Acid Batteries
CLASSIFIED/NOFORN
Biological
Asbestos
Sharps
Beryllium
**PCBs
**Mixed Waste
RCRA Empties
Hot Particles
**Paint Chips (NOTE 1)
Class 7 Labeled Waste
White I
Yellow II
Yellow III
SHIPMENT CONFIGURATION/SPECIAL INSTRUCTIONS
(Include Package Tare Weight for RTC)
If necessary, provide additional information on a separate page.
DISPOSAL SITE
Clive
Other/Return (specify):
CONTAINERS
EnergySolutions-Owned Containers
Containers to Be Returned to Generator
Shipment Summary Form
Required for EnergySolutions Bear Creek & Gallaher Rd.
Processing Facilities
Form WAG-501-F1
Rev. 6
Page 2 of 2
COMPLETE AND SIGN EITHER SECTION 1 OR SECTION 2 AS APPLICABLE
SECTION 1 - SHIPMENT WASTE/MATERIAL CHARACTERIZATION CERTIFICATION
Waste/Material
Description:
This certification must be completed and signed by an individual knowledgeable in environmental compliance regulations
referenced herein. This waste/material has been characterized per 40 CFR 262.11, 40 CFR 279.11 and 40 CFR 761 as applicable,
using the following: (Check all that apply).
Laboratory Analysis**
Process Knowledge**
**EnergySolutions personnel may request characterization documentation for purposes of surveillances, audits or regulatory
inspections as applicable to 40 CFR 262.40(c) and 40 CFR 279.72.
Check all that applies to the contents of this shipment.
Hazardous Waste
I certify, to the best of my knowledge: The waste identified above meets definition of hazardous waste as defined in 40 CFR 261.3
when measured in each container delivered to EnergySolutions BCF. (WAG-501 Appendix A requirements must be met.)
Used Oil (as defined in 40 CFR 279.1 Definitions)
I certify, to the best of my knowledge: The waste identified above complies with the On-Specification criteria listed in 40 CFR
279.11 and contains less than 1,000 parts per million of halogens and less than 2 parts per million unregulated PCBs.
Non-Poly Chlorinated Biphenyl (PCB) (note: bulk product PCBs are the only PCBs authorized for acceptance at the BCF).
I certify, to the best of my knowledge: The waste identified above does not meet the definition of PCB Articles, Containers,
Remediation Waste, Bulk Product Waste, R&D waste, regulated PCB liquid waste or PCB contaminated waste per 40 CFR 761.3.
Poly Chlorinated Biphenyl (PCB) (note: bulk product PCBs are the only PCBs authorized for acceptance at the BCF)
I certify, to the best of my knowledge: The waste identified above meets definition of PCB Bulk Product Waste per 40 CFR 761.3
I certify, to the best of my knowledge, that the above information is complete and accurate. No deliberate or willful omissions of
composition or properties exist and that all known or suspected hazards have been disclosed. I certify that the waste stream has
been characterized and identified to EnergySolutions per 40 CFR 262.11, 40 CFR 279.11 and 40 CFR 761 as applicable. I
certify that this waste meets the EnergySolutions Bear Creek Facility Waste Acceptance Guidelines (WAG-501) or has been
granted Special Approval by EnergySolutions for waste acceptance.
Title
Name
Signature
Date
Technical Contact(s) must be identified below.
Title
Phone Number/Email Address
SECTION 2 - WASTE/MATERIAL CHARACTERIZATION CERTIFICATION – REQUIRES PRIOR DOCUMENTATION ON FILE
EnergySolutions has received waste characterization information from the Generator and has documents on file for the
waste/material identified on page one of this Form. This shipment meets EnergySolutions’ waste certification requirements.
Printed Name
Signature
Title
Date
SECTION 2
Printed Name
SECTION 1
Non-Hazardous Waste or Exempted Material (i.e. lead for recycle, universal waste, etc.)
I certify, to the best of my knowledge: the waste identified above does not meet the definition of hazardous waste as defined in 40
CFR 261.3 when measured in each container delivered to EnergySolutions Bear Creek and Gallaher Rd. Facilities.