Office Use Only
Number:
8260 Port Road • Louisville, KY 40258
WASTE PROFILE
I.
GENERATOR INFORMATION
Generator Name:
Facility Address:
Contact Name:
Phone:
EPA I.D. Number:
Email:
Billing Address (if different):
SIC Code:
II. GENERAL WASTE INFORMATION
Description of Waste:
Process Generating Waste:
Quantity Generated:
Per:
Is This a RCRA Hazardous Waste Per 40 CFR Part 261?
Is This Waste a Used Oil as Defined by 40 CFR Part 279?
If Halogens Present, Explain:
Are MSDSs Available For Waste Stream Components?
Is This a DOT Hazardous Material?
If Yes, Provide Proper Shipping Name:
Special Shipping & Handling Requirements:
III. CHEMICAL & PHYSICAL PROPERTIES
Physical State (%):
Viscosity:
Liquid
Low
Sludge
Medium
Solid
High
Powder
Color
Characteristic Odor
Specific Gravity
Number of Layers
IV.
No
No
Current Accumulation:
If Yes, List All Applicable Waste Codes:
Are Halogens (Chlorine, Bromine, Fluorine) Present?
Yes
Yes
No
No
Is Analytical Data Available?
If Yes, Attach.
Flash Point (°F):
<73
73-99
100-139
140-199
>200
<2.0
>2.0 <7.0
>7.0 <12.5
>12.5
CHEMICAL COMPOSITION
METALS (ppm)
Arsenic
Chromium
Mercury
Silver
Fax:
Yes
Yes
pH:
Barium
Copper
Nickel
Zinc
HAZARDOUS CHARACTERISTICS
Reactivity:
None
Pyrophoric
Shock Sensitive
Explosive
Water Reactive
Other
Yes
No
Yes
No
Temp. as Shipped:
°F
Heat Content
BTU/Gal.
BTU/Lbs.
V.
TOTAL
VI.
Contact Name:
Phone:
State I.D. Number:
Fax:
100%
Cadmium
Lead
Selenium
Other Hazardous Characteristics:
None
Radioactive
Etiological
Pesticide
Other
VII. OTHER COMPONENTS (ppm)
Ammonia
Cyanide
PCBs
Sulfide
VIII.
CERTIFICATION
I hereby certify that the above and attached description is complete and accurate and that the waste stream contains no PCBs. All known or suspected hazards
associated with the material described have been disclosed. I also certify that the obtained sample is representative of the waste material described above and
give Rivergreen Water Recycling, LLC permission and consent to make amendments and corrections.
Name
(For Company Use)
Title
Salesperson
Approval Number
Date
Treatment Cat:
Facility
Date
Comments:
9/13