WWS Environmental Services - Waste Water Systems, LLC
640 63rd Avenue SW Phone: 319-247-2403
Cedar Rapids, IA 52404 Fax: 319-362-0399
www.wwsenvironmental.com Toll Free: 866-823-8642
Material Profile Form
CUSTOMER INFORMATION
1. Customer Name _____________________________________________________________________
2. Customer Address____________________________________________________________________
City ________________________________________State ________Zip_________
3. Billing Address (if other than above) ______________________________________________________
City _________________________________________State ________Zip________
4. Technical Contact _____________________________________________Phone__________________
Fax____________________
GENERATOR INFORMATION
1. Generator Name ______________________________________________________________________
SIC/NAICS Code____________________ Generator EPA ID Number__________________
City ________________________________________State ________Zip__________
2. Name of Material or Waste______________________________________________________________
3. Estimated Volume____________________4. Units____________ __per day __per quarter
__per week __per year
__per month __one time
PROCESS GENERATING WASTE / MATERIAL
(Give a detailed description of the process that generates the waste or material. Include all steps in the process, and any suspected or known contaminants). ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
QUESTIONNAIRE
___ Used Oil:
Is the used oil paraffin based? __Yes __No If yes, attach an MSDS for the product.
Has the used oil been mixed with a hazardous waste?__Yes__No
If yes, this stream will not be accepted by Waste Water Systems.
___ Waste stream:
Is this waste
hazardous by: Ignitability?
(regulated under
40 CFR 261.21)
___Yes ___No
Corrosivity? (regulated under 40 CFR 261.22)
___Yes ___No
Reactivity? (regulated under 40 CFR 261.23) ___Yes
___No
Is this a hazardous waste (F, K, U, or P listed) as defined under 40 CFR 261 Subpart D? __Yes __No
If yes to the above, this stream will not be accepted by Waste Water Systems.
Is the waste derived from outside an underground storage tank (UST)? ___Yes ___No
If yes to the above, list the material(s) stored______________________________________________
If waste is derived from a fuel, is it leaded? ___Yes ___No
PHYSICAL CHARACTERISTICS
Color _____________________ pH ________ Flash Point (100 – 140) _____________Over 200__________
Odor? __Yes __No If yes,describe____________________________________________________________
Physical State: ( ) Solid ( ) Liquid ( ) Semi-solid ( ) Powder Layers: ( ) Single Phase ( ) Multi-layered ( ) Bi-layered Viscosity: ( ) Very thin ( ) Thin ( ) Moderate ( ) Thick ( ) Does not pour
WASTE COMPOSITION
__________% __________% __________% 100 % – TOTAL WASTE MUST EQUAL 100%
REPRESENTATIVE SAMPLE CERTIFICATION
Sample Source______________________________________ Sample Date ____________________________
Sampler Name______________________________________ Sampler Title_____________________________
Sampler Employer (if other than the generator):_____________________________________________________________________
The sampler's signature certifies that any sample submitted is representative of the material described above pursuant to 40 CFR 261.20 (c) or equivalent rules.
Sampler Signature____________________________________________________________________________________________
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GENERATOR CERTIFICATION / RE-CERTIFICATION By
signing this profile, you certify that: 1.
You
are the generator or the duly authorized representative of the
generator. 2.
This
waste is not a hazardous waste as defined by USEPA Federal
regulation, unless noted above. 3.
This
waste does not contain regulated materials or regulated
concentrations of PCB's (polychlorinated biphenyls). 4. This sheet contains true and accurate descriptions of the material and all relevant information in your possession regarding known or suspected hazards have been disclosed. 5. The analytical data presented herein or attached hereto were derived from testing a representative sample taken in accordance with 40 CFR 261.20 (c) or equivalent rules. 6.
This
waste generation process has not changed, and that all waste
stream acceptance parameters have remained unchanged. 7.
If
the material is Petroleum Contaminated Water, there are no
hazardous constituents to be found in the source of the petroleum. 8.
PESTICIDE
/ HERBICIDE CERTIFICATION I,
a duly authorized representative of the generator, do hereby
certify that the initialed item below applies to our waste
material described in item 2 of the GENERATOR section above: _____ This waste does not contain Chlordane, 2,4-D, Endrin, Heptachlor (and its epoxide), Lindane, Methoxychlor, Toxaphene, or 2,4,5-TP (Silvex). These constituents are not used at the location where this waste was generated, nor are they known to be present in the materials of which the above waste is comprised. Hence, there is no reason to suspect their presence in this waste. _____ I hereby certifiy this waste stream to be fully and accurately described, and, contains no regulated materials as described in (initials) 40 CFR 261 parts C & D. Generator Signature______________________ Printed Name____________________________ Title____________________________________ Date_________________
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