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Waste Material Profile Sheet

1. Generator Information

Generator Name*

WL #

Site Address*

Site City*

Site State*

Site Zip*

Mailing Address*

Mailing City*

Mailing State*

Mailing Zip*

EPA ID # / VSQG*

State ID #*

Emergency Phone*

2. Customer Bill To

Customer Bill To*

Billing Address*

City*

State*

Zip*

3. Profile Information

Profile Name*

4. Generating Process & Material Composition

Profile Description (including chemical/physical description)*

Process generating the waste*

Chemical/Physical/Elemental Constituents

TRI

Chemical/Physical Composition

Typical

CAS#

Min

Max

Unit Type

TRI

Chemical/Physical Composition

CAS#

Typical

Min

Max

Unit Type

TRI

Chemical/Physical Composition

CAS#

Typical

Min

Max

Unit Type

TRI

Chemical/Physical Composition

CAS#

Typical

Min

Max

Unit Type

TRI

Chemical/Physical Composition

CAS#

Typical

Min

Max

Unit Type

TRI

Chemical/Physical Composition

CAS#

Typical

Min

Max

Unit Type

5. Physical & Chemical Properties

Color*

Flash Point*

BTU Value*

Odor*

Flash Point Method*

Specific Gravity (lbs/gal)

pH*

Viscosity*

Phases/Layers*

Total Organic Carbon (TOC)*

Boiling Point*

Physical State*

Solid

Liquid

Sludge

Gas

Ash

Powder

Other Properties

Other Properties*

6. Regulatory Information

Restricted Under LDR*

< 500 PPM VOC*

UHC's*

Alternative Standards of Soil

LDR Subcategory-Non Wastewater*

USEPA Hazardous Waste*

State Waste Code Required?*

RCRA Exempt: Is the solid waste excluded or exempt from regulations as a hazardous waste?

Is the waste a listed hazardous waste? (List waste code(s))

F-Listed per §261.31

Ignitable (D001) per §261.21

K-Listed per §261.32

Corrosive (D002) per §261.22

P-Listed per §261.33

Reactive (D003) per §261.23

U-Listed per §261.33 (f)

Toxic (D004-D043) per §261.24

Federal Universal Waste:*

State Universal Waste*

Used Oil*

Recycle/Reuse?*

Product/Co-Product?*

TSCA Regulated PCB Waste*

CERCLA Regulated Waste*

Benzene NESHAP Waste*

Halogenated Organic Compound*

Medical Waste*

EPA Source Code*

Origin Code*

EPA Form Code*

Determination*

Analysis Date*

Representative Sample Certification

NO SAMPLE TAKEN

Sample collected in accordance with U.S. EPA 40 CFR 261.20(c) guidelines?*

Type of Sample*

Sample Date*

Sample ID No's*

Sampler's Name*

7. Shipping & DOT Information

Volume of waste to be shipped*

Waste Unit*

Frequency*

Is waste a combination package?*

(e.g. Drum w/ inner containers or skid w/ consumer product cases)

Transportation*

DOT Information:

Is this a U.S Department of Transportation (USDOT) Hazardous Material?*

If YES, indicate proper shipping name per 49 CFR 172.101 Hazardous Material Table

9. Certification

I hereby certify that to the best of my knowledge and belief, the information contained herein is a true, complete and accurate description of the material being offered for recycling or disposal and that all known or suspected hazards have been disclosed. All Analytical Results/Material Safety Data Sheets submitted are truthful and complete and are representative of the waste. Notification will be provided immediately if there is a change in the composition of, or process generating this material, prior to offering the material for shipment or management. If I am an agent acting on behalf of the generator, I also certify that I have permission to sign any and all material profile paperwork on the generator’s behalf and that I can produce such certification in writing upon request. I additionally authorize WasteXpress to proceed with submitting waste profiles, analyses and/or waste approval forms on my behalf to secure all necessary approvals to dispose of this waste at a permitted treatment facility.

Generator Representative Name*

Title*

Date*

10. VSQG Certification (if applicable)

State and Federal hazardous waste regulations define a Very Small Quantity Generator (VSQG) (Washington State SQG) as a hazardous waste generator that generates, in one month, no more than 100 kilograms (220 pounds or approximately 25 gals) of hazardous waste, 2.2 pounds of acutely hazardous waste, or 220 pounds of spill cleanup debris containing hazardous waste. Additionally, to qualify as VSQG / SQG a generator must not at any time accumulate more than 2200 pounds (approximately 250 gals) of hazardous waste on site. Generators that do not meet these requirements are no longer defined as VSQG / SQG and must comply with regulations for small quantity or large quantity generators.

Under penalty of law and for the purposes of receiving the benefits of WasteXpress’s VSQG / SQG hazardous waste collection service, I certify my organization complies with all requirements for VSQG / SQG status. I agree to notify WasteXpress immediately if my generator status changes or if I no longer meet VSQG / SQG requirements. I understand that only the types and quantities of waste(s) listed on the Work Order/Quote and approved by WasteXpress may be disposed through this service. Additionally, I acknowledge VSQG / SQG waste being shipped to WasteXpress Environmental will be repackaged, consolidated and shipped on a manifest along with other VSQG / SQG generators to a permitted recycler, subtitle C/D landfill or TSDF per the 40 CFR for proper reclamation or waste disposal.

Generator Representative Name

Title

Date