Office Use Only Authorized by ___________ Profile# _________________ Date Received: ___________ Approved: Yes ___ No ___ Subcategory: Oil _________ Organics ________ GENERATOR CERTIFICATION/WASTE PROFILE Permit requires waste to be analyzed every 3 years. GENERATOR INFORMATION Generator Name: ________________________________________ Street: _________________________________________________ City: ___________________________ State: ____ Zip: _________ Contact Name: ___________________ Title: ___________________ Phone: _________________________ Fax: ____________________ Correspondence will be sent to: Customer Name: _____________________________________________ Street: _____________________________________________________ City: __________________________ State: _______ Zip: ____________ Contact Name: __________________ Title: ________________________ Phone: _________________________Fax: ________________________ WASTE QUESTIONNAIRE (CHECK ALL THAT APPLY) Is this material a hazardous waste (F, K, U, or P listed) as defined by 40 CFR 261 Subpart D? Yes ____ No ____ If yes to the above, idenfy the lisng: Has this material been mixed with a hazardous waste as defined by 40 CFR 261? Yes ____ No ____ Does this material exhibit: Ignitability? (40CFR Part 261.21) Yes ____ No ____ Any of the following hazardous: Corrosively?( 40CFR Part 261.21) Yes ____ No ____ Waste characteriscs: Reacvity? (40 CFR Part 261.21) Yes ____ No ____ Toxicity? (40CFR Part 261.21) Yes ____ No____ Does this material contain: Herbicides, pescides, inseccides? Yes ____ No ____ Dioxins? Yes ____ No ____ Radioacve substances? Yes ____ No ____ Domesc waste? Yes ____ No ____ Biohazardous materials Yes ____ No ____ Is this waste from an underground storage tank (UST)? Yes ____ No ____ If waste is derived from fuel, is the fuel leaded? Yes ____ No ____ Used Oil (as defined by CFR 279.1) Is this material Used Oil as defined by 40CFR 279? Yes ____ No ____ Has this Used Oil been mixed with hazardous waste? Yes ____ No ____ Is the source of the waste a Condionally Exempt Small Quanty Generator? Yes ____ No ____ Does this Used Oil contain chlorinated paraffins? If yes, aach MSDS. Yes ____ No ____ Does this Used Oil contain TSCA (40 CFR 761) regulate levels of PCB? If yes list PCB level: Yes ____ No ____ Does this Used Oil contain less(<) then or equal to 1,000 mg/L total organic Halogens (TOX)? (If 0, Mark “No”) Yes ____ No ____ * If no, rebual per 40CFR 279.10 (b)(1) (II) must be included. Is this Used Oil soluble in water ? Yes ____ No ____ *if you checked yes to any of the above waste, it will not be accepted by WITS. As the Generator of the Waste described above, I cerfy that I have provided all relevant informaon as required by this Profile, and that the informaon provided is, to the best of my knowledge, and believe, true, accurate and complete. Generator agrees not to deliver or arrange for delivery of any material that does not conform to the waste characterized above in this profile. I further cerfy that this material is not a RCRA hazardous waste pursuant to Federal, State, or Local Laws. The waste has not been mixed with any chlorinated solvents or any contaminants including, without limitaon, PCBs, Pescides or other hazardous wastes. If Water Integrated Treatment Systems LLC. (WITS) accepts the material for processing, and the material is later determined by WITS, or any other person to be, or contain hazardous waste within the meaning of any federal, state or local law or contain PCBs in sufficient quanty, to render it a TSCA regulated material the generator agrees to pay all costs incurred by WITS to properly treat, store, dispose or otherwise handle the material and any fines or penales resulng from WITS handling of the generator’s material. Generator agrees to promptly nofy WITS of any change in the composion of the material or process generang the material, and agrees to provide WITS with a new Generator/Cerficaon Waste Profile prior to delivering new material to WITS. The undersigned is an authorized representave of the generator. Profile Informaon State ID# US EPA ID: NAICS# Analycal Aached ____ MSDS Aached _____ Non-Hazardous Waste Please Read and Sign Below * Generator Cerficaon and Guarantee * Generator Authorization Signature ___________________________ Print Name and Title_______________________________ Date___________ Is this a virgin or off-spec product? Yes ____ No ____ (If yes, must include MSDS) Unused Product or Chemical? Yes ____ No ____ Waste Byproduct from Process? Yes ____ No ____ Spill Clean up? Yes ____ No ____ Planned Site Remediaon? Yes ____ No ____ Representave Sample Provided ? Yes ____ No ____ Petroleum Contact Water (PCW)/Leaking? Yes ____ No ____ Underground Storage Tank (UST) Water? Yes ____ No ____ Is the generator a Condionally Exempt Small Quanty Generator (CESQG)? Yes ____ No ____ Does this waste contain oils, lubricants, coolants or petroleum products? Yes ____ No ____ WASTE DESCRIPTION Common name of Water:_______________________________________ Detail:_______________________________________________________ Process Generang Waste: ______________________________________ (Add addional sheet if necessary) Analycal Provided? Yes__ No __ MSDS Provided? Yes __ No __ If no, waste may be rejected based on WIT System’s Laboratory Analysis. PHYSICAL STATE 100% Solid without free liquid: ________ ________ % Free Liquid 100% Liquid with no solid: __________ ________ % Seled Solids Liquid solid mixture: ________ ________ % Total Suspended Solids LAYERS Single Phase: _______ Bi-layered: _________ Mul Layered: ______ pH < 2 ______ 2-6______ 6-8______ 8-12.5___ > 12.5___ N/A_____ ODOR None: _____ Mild: ______ Strong: _____ FLASH POINT < 73F: ___ 73-100F: ___ 101-140F: ___ 141-200F: ___ > 200F: ___ COLOR _________________ SPECIFIC GRAVITY Range _________ To __________ Waste Stream Composion % must equal 100 % ___________ _____% ___________ _____% Water Content _______% ___________ _____% ___________ _____% Total =100 % Ancipated Volume: Day _____ Week ______ Month ______ Year _____ Once ____ *Wastes containing any concentraons of Mercury or Cyanide will not be accepted by WITS.