NON-HAZARDOUS MATERIAL PROFILE FORM Water Depot, Inc. 1301 Avondale Rd New Windsor, MD, 21776 Phone: (410) 857-9670 Fax: (410) 857-2814 www.oilwaterdisposal.com Page 1 of 2 A. Generator Information Invoice Information Generator Name:________________________________ Company Name:_________________________________ Address:______________________________________ Address:_______________________________________ Address 2:_____________________________________ Address 2:______________________________________ City:___________________State:______ Zip:_________ City:___________________State:______ Zip:__________ Contact Name:__________________________________ Contact Name:___________________________________ Phone: ___________ ______________, Ext:__________ Phone: ________________________, Ext:____________ Fax: ________________ Phone 2: _________________ Fax:_________________ Phone 2:___________________ Email:_________________________________________ Email:__________________________________________ EPA ID#:______________________________________ EPA ID#:_______________________________________ B. Waste Information Name of Waste:___________________________________________________________________________________ Process of Generating Waste (be specific):______________________________________________________________ Generator has provided the following: Sample MSDS Waste Analysis Generator Knowledge Product Grade: No. 2 No. 4 No. 6 Used Oil Wastewater Non-Wastewater List all RCRA Waste Codes: ___________ ___________ ___________ ___________ ___________ ___________ Proper DOT Shipping Name: RQ___________lbs/ ____________________________________________________ Technical Description:___________________________ Hazard Class:__________ ID#:__________ PG:___________ Sub Hazard Class:________ RQ Substance / Waste Code:_______ Poison Inhalation Hazard / Zone:________ 24 HOUR EMERGENCY RESPONSE PHONE NUMBER:_____________________________ C. Physical Characteristics: Color:________________________________ Odor:__________________________ None Mild Strong Physical State @ 70 0 F: Liquid____% Solid____% Sludge____% Powder____% Compressed Gas Layers: Single Phase Bi-layered Multi-layered Other:__________________________ Specific Gravity: <0.8 0.8–1.0 1.1-1.2 1.3-1.4 1.4-1.7 >1.7 Actual:______ pH: NA <2 2-4 4-6 6-8 8-10 10-12 12.5 or greater Exact or Range:__________ Flash Point ( 0 F): NA <110 110-140 141-200 >201 Closed Cup Open Cup BOD:______ COD:_______ TKN:_______ Phosphorus:______ Halogens:_______ Salinity:______ Silicone:_______ D. Metals Less than regulatory levels Total TCLP Generator Knowledge ppm mg/l mg/kg Antimony Sb ____________ Beryllium Be ____________ Chrome VI Cr 6 ____________ Arsenic As ____________ Cadmium Cd ____________ Cobalt Co ____________ Barium Ba ____________ Chromium Cr ____________ Copper Cu ____________ Lead Pb ____________ Pesticides ____________ Vanadium V ____________ Mercury Hg ____________ Selenium Se ____________ Zinc Zn ____________ Molybdenum Mo ____________ Silver Ag ____________ Nickel Ni ____________ Thallium Th ____________ Otherwise, please fill in Invoice information below. Generator Information. Please check here if Invoice Information is same as
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NON-HAZARDOUS MATERIAL PROFILE FORM
Water Depot, Inc. 1301 Avondale Rd
New Windsor, MD, 21776 Phone: (410) 857-9670 Fax: (410) 857-2814
www.oilwaterdisposal.com
Page 1 of 2
A. Generator Information Invoice Information
Generator Name:________________________________ Company Name:_________________________________
H: Special Instructions / Notes (Please include any special instructions or notes below):
I. Hazardous Characteristics:
Is this material an EPA listed Hazardous Waste per 40 CFR Part 261? Yes No
Is this material an EPA Characteristic Hazardous Waste per 40 CFR Part 261? Yes No
Does this material contain concentrations of PCB’s as defined in 40 CFR Part 261? Yes No
Does this material contain concentrations of listed Hazardous Wastes in 40 CFR Part 261? Yes No
Is this material a TSCA Regulated Waste? Yes No
Does this material contain TCLP Volatile or Semi-Volatile Organics? Yes No
Does this material contain TCLP Herbicides or Pesticides? Yes No
J. Generator’s Certification: I hereby certify that all information submitted in this and all attached documents are true and accurate descriptions of this waste. This waste has not been combined or blended in any amount with PCB’s, Herbicides, Pesticides, or any other material defined as Hazardous Waste. Generator/Shipper agrees to indemnify and hold Water Depot Inc. harmless for any damages arising from or in any way relating to a breach of this Certification Statement. I will be responsible for any cost associated with the cleanup, decontamination or fines associated with providing Water Depot Inc. with Hazardous or unacceptable material.
If electronically signing, I agree that my electronic signature below, is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding. To sign electronically, please check the box below, then type your first and last name. To use an ink signature, leave the box unchecked, print this document, and then hand write your signature in ink.
I understand that checking this box constitutes that I am opting to provide my electronic signature. My first and last name, typed below, is the legally binding equivalent to my handwritten signature. Conversely, I understand that to opt out of using my electronic signature, I have left this box unchecked, printed this document, and hand signed below in ink.