SOUTH YUMA COUNTY LANDFILL
EPA#AZR000506980 A CERCLA APPROVED FACILITY
19536 S. AVE 1E, YUMA, AZ 85366
(928) 341-9300
WASTE PROFILE #
GENERATOR WASTE PROFILE SHEET
I. GENERATOR INFORMATION
DATE:
GENERATOR NAME:
GENERATOR SITE ADDRESS:
CITY:
COUNTY:
STATE:
ZIP:
COUNTY:
STATE:
ZIP:
STATE:
ZIP:
GENERATOR MAILING ADDRESS:
CITY:
GENERATOR CONTACT NAME:
PHONE NUMBER:
FAX NUMBER:
II. TRANSPORTER INFORMATION
TRANSPORTER NAME:
TRANSPORTER ADDRESS:
CITY:
COUNTY:
TRANSPORTER CONTACT NAME:
PHONE NUMBER:
FAX NUMBER:
III. WASTE STREAM INFORMATION
NAME OF WASTE:
PROCESS GENERATING WASTE:
TYPE OF WASTE:
CONTROL WASTE
PHYSICAL STATE:
OTHER:
INDUSTRIAL WASTE
METHOD OF SHIPMENT:
ESTIMATED ANNUAL VOLUME:
FREQUENCY:
MONTHLY
OR
SOLID
BULK
POLLUTION
SEMI-SOLID
DRUM
LIQUID
BAGGED
OTHER:
CUBIC YARDS:
WEEKLY
ONE TIME ONLY
SPECIAL HANDLING INSTRUCTIONS:
IV. REPRESENTATIVE SAMPLE CERTIFICATION
IS THE REPRESENTATIVE SAMPLE COLLECTED TO PREPARE THIS PROFILE AND LABORATORY ANALYSIS
COLLECTED IN ACCORDANCE WITH U.S. EPA AND 40 CFR 261.2 (C) GUIDELINES OR EQUILAVENT RULES?
SAMPLE DATE:
CHECK ONE:
SAMPLE
COMPOSITE SAMPLE
SAMPLERS EMPLOYER:
SAMPLERS NAME (PRINTED):
SIGNATURE:
YES
NO
GRAB
WASTE PROFILE #
% BY WEIGHT (RANGE)
V. PHYSICAL CHARACTERISTICS OF WASTE
CHARACTERISTIC COMPONENTS
1.
2.
3.
4.
Color
Odor
(describe)
Liquids
% Solid
Ph:
Flash Point:
Phenol
YES
NO
ppm
Attach Laboratory Analytical Report (and/or Material Safety Data Sheet)
including Required Parameters provided for this profile
Does this waste or generating process contain regulated concentrations of the
following pesticides and/or herbicides: Chlordane, Endrin, Hepachlor (and its
epoxides), Lindane, Methoxychlor, Texaphene, 2.4-D.2,4.5,-TP Silvex as defined in 40
CFR 261.33?
Does this waste or generating process cause it to exceed OSHA exposure limits from
high levels of Hydrogen Sulfide or Hydrogen Cyanide as defined in 40 CFR 261.23?
Does this waste contain regulated concentrations of Polychlorinated Biphenyls (PCB’s)
as defined in 40 CFR Part 761?
Does this waste contain regulated concentrations of 2,3,7,8- tetrachlorodienzodioxin
(2,3,7,8-TCCD) or any other dioxin as defined in 40 CFR 261.31?
YES
NO
YES
NO
YES
NO
YES
NO
YES
Is this a hazardous waste as defined by 40 CFR Part 261 or ARS 49-921?
NO
YES
Is this radioactive waste as defined by federal or state regulations?
NO
Is this a regulated medical or infectious waste as defined by federal or state
regulations?
YES
NO
YES
Is this waste generated at a Federal Superfund clean-up site?
NO
VI. GENERATOR CERTIFICATION
I hereby certify that to the best of my knowledge and belief, the information contained herein is a true and
accurate description of the waste material being offered for disposal. I further certify that by utilizing this
profile, neither myself or any other employees of the company will deliver for disposal or attempt to deliver
for disposal any waste which is classified as toxic, hazardous waste, medical or infectious waste, or any other
waste material this facility is prohibited from accepting by law. Our company hereby agrees to fully indemnify
this disposal facility against any damages resulting from this certification being inaccurate or untrue.
AUTHORIZED REPRESENTATIVE NAME & TITLE (PRINTED)
AUTHORIZED REPRESENTATIVE SIGNATURE
COMPANY NAME
DATE
VII. SOUTH YUMA COUNTY LANDFILL DECISION
APPROVED
CONDITIONS:
REJECTED
EXPIRATION