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Generator Information

Name
Address
Address Line 2
City
State
Zip
Contact
Title
Phone
Fax
Mobile
Email
EPA ID #
State ID #
SIC Code
Benzene NESHAP?	Yes No
NAIC Code

Billing Information

Name
Address
Address Line 2
Mail Stop
City
State
Zip
Contact
Title
Phone
Fax
Mobile
Email

Manifest Return Information

Name
Attention
Address
Address Line 2
City
State
Zip

Waste Information

Form Code

Source Code

Mgt. Method

Waste Name/Comman Name

Generating Process

Analysis Attached Yes No

MSDS Attached Yes No

Sample Yes No

Annual Generation Quantity

lbs gals drums tons other

Shipping Frequency

Daily Weekly Monthly Quarterly Yearly One time

Shipping Container Type

Bulk Liquid Bulk Solid Container (size/type)

Is the waste restricted under
EPA Land Restrictions
(40CFR 268, if yes please complete LDR form)

Yes No

Waste Type

Wastewater Non-wastewater Debris

Alternative Soil Standard

Yes No

Physical Characteristics

Physical state at 70 degrees F	Gas Liquid Sludge
Layer	Gas Liquid Sludge Solid Range % to %
Free Liquid	None Yes Liquid Range % to %
Odor	None Mild Strong Actual
Specific Gravity	<0.8 0.8-1.0 1.0-1.2 >1.2 140-200F >200F Actual
Flash Point	<73F 73-100F 101-140F
Flash Test Method	MSDS Generator Knowledge Open Cup Closed Cup None
pH	<=2 2.1-5.9 6.0-8.0 8.1-12.4 >=12.5 Actual
Color
Shock Sensitive	Yes No
Fuel Characteristics	BTU Halogens % Water %

Chemical Composition

Metal	Code	Non-Reg (TCLP)	TCLP	Total
Arsenic	(D004)	<5 ppm	ppm	ppm
Barium	(D005)	<100 ppm	ppm	ppm
Cadmium	(D006)	<1 ppm	ppm	ppm
Chromium	(D007)	<5 ppm	ppm	ppm
Mercury	(D008)	<0.2 ppm	ppm	ppm
Lead	(D009)	<5 ppm	ppm	ppm
Selenium	(D010)	<1 ppm	ppm	ppm
Silver	(D011)	<5 ppm	ppm	ppm
Thallium				ppm
Sulfur				ppm
Copper				ppm
Nickel				ppm
Zinc				ppm

Toxics	None	Actual	Analysis	Generator Knowledge
PCBs		ppm
Dioxins		ppm
Herbicides		ppm
HOCs		ppm
Aromatic Amines		ppm
Pesticides		ppm
Fungicides		ppm
Urea/Thiourea		ppm
Phenols		ppm
TOCs		ppm
VOCs		ppm
Quinones		ppm
Ammonia		ppm

Cyanides
Reactive		ppm
Amenable		ppm
Total		ppm

Sulfides
Reactive		ppm
Total		ppm

Cas #	Characteristic Organics	Chemical Name	Minimum	Maximum
			%	%
			%	%
			%	%
			%	%
			%	%

Transportation Information

DOT Hazardous Material	Yes No
DOT Shipping Name
Hazard Class
ERG #
UN/NA #
Packaging Group
Reportable Quantity (RQ) in lbs

Regulatory Information

USEPA regulated hazardous waste?	Yes No
State regulated hazardous waste?	Yes No
Subject to categorical discharge standards?	Yes No
TSCA regulated PCBs?	Yes No
CERCLA cleanup action waste?	Yes No
Dioxin bearing waste per 40 CFR 261.31	Yes No

Radioactive Waste?	Yes No
Explosive Waste?	Yes No
Does this material contain friable asbestos?	Yes No
Does this material contain non-friable asbestos?	Yes No
Waste subject to Subpart CC regulations?	Yes No
Infectious or medical waste?	Yes No

State Waste Code
EPA Waste Code(s)
Additional Information

Certification

I certify this material may be disposed of without further treatment

Yes No

Certification Statement: I hereby certify that as an authorized representative of the generator named about, all information submitted in this and all the attached documents are true and accurate. Pre-shipment and all other samples provided are a true representative sample of the waste and were sampled in accordance with 40 CFR Part 261.20. Any analysis of the waste was conducted in accordance with the approved test methods in 40 CFR Part 261 on a representative sample as defined in documentation. All material, description and packaging will comply with all current regulations.