Waste Generator Questionnaire Generator Information Site Information Waste Information Analytical data attached (file limit: 1.5MB): YesNo MSDS attached (file limit: 1.5MB): YesNo Waste Type (NO Flammable, Corrosive, Reactive or Toxic Materials) Industrial ProcessFood ProcessResidualSludgeOily Waste WaterGround WaterBentoniteSpent Filter MediaSlurryGray WaterGrease Trap WasteSeptageRain WaterOther Physical State Oil SheenLiquidSludgeSolid Quantity of Waste: Shipping Information Vacuum Straight TruckDewatering BoxVacuum TankerRoll Off ContainerJetVacVacuum Container Size of Bulk Load (pick one): 5,0006,0007,000Other Per: MonthQuarterYearDayOne TimeOther Shipping History 1. Was this waste stream previously transported for disposal at an approved facility? YesNo If yes, can you provide us with the facility’s name and the proper shipping name under which the waste was classified? Project Duration/Start Date 1. Intended start date: 2. Project end date: Generator's Certification 1. Is this waste considered hazardous? YesNoUnknown 2. Is this waste generated at a CERCLA/Superfund Site? YesNoUnknown 3. Does the waste contain Polychlorinated Biphenyls (PCBs)? YesNoUnknown 4. Are there any specific approval, manifesting or reporting requirements for this project? YesNoUnknown Name: Signature: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application. Date:
