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WASTE PROFILE FORM

Generator

Site Address

Mailing Address (if different)

U.S. EPA ID Number

SIC Code:

Technical Contact

Title

Phone Number

( )

Fax Number

( )

Name of Waste

Process of Generating Waste

Broker Information

Name

Address

City

State

Zip

Contact

Phone

( )

Fax

( )

Characteristics

Color

BTU/LB

Odor

Mild Strong None

Physical State@70

Liquid Semi-Solid Solid

Layers

Multilayered Bi-layered Single Layered

Free Liquids

No Yes if yes then %

Flash Point

<70 70-100 101-139 140-200 >200 No Flash Exact

Density

Lbs/Gal Lbs/Ft API Gravity

PH Range

<2 2.1-4 4.1-10 10.1-12.4 >12.5

Metals

None TCLP (MG/L) Totals(ppm)

Arsenic

Barium

Cadmium

Chromium

Lead

Mercury

Selenium

Silver

Copper

Nickel

Zinc

Cyanides

Physical/Chemical Composition

Totals =

Shipping Information

Proper shipping Name

Hazard Class

UN/NA #

State Code

(required if shipping as Non RCRA)

EPA Code

We do not accept any EPA codes.

Non RCRA Hazardous

Yes No

Volume

Drums Boxes/Sacks Gallons Yards

One Time Monthly Annually

Bulk Liquids Bulk Solids Drums

Method of Shipment

Special Handling Information

Generator of this waste certifies, that the information above is true and accurate. The determination of this waste stream was derived by state certified analysis and/or generator knowledge. If the physical or chemical composition(s) of the waste stream changes, the generator will notify Filter Recycling Services Inc. prior to shipment. The generator is solely responsible for the disposal of any material that may be delivered to Filter Recycling Services, Inc. that is not disclosed in the above profile.

Your Name

Title

Email Address

Date

Contact Phone Number

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