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: