ENV IROSAF E
PROFILE
ENVIROSAFE SERVICES OF OHIO, INC.
876 Otter Creek Road, Oregon, Ohio 43616
U.S. EPA Identification No. OHD045243706
Telephone: (800) 537-0426 or (419) 698-3500
Telefax: (419) 698-8663
WASTE PRODUCT QUESTIONNAIRE
Section A – Generator and Customer Information
1.
Generator:
ESOI USE ONLY
Address:
Generator #
City/State:
Zip:
Customer #
Technical Contact(s):
ESOI
Telephone:
Subtitle D
Fax:
Acceptance Code
2.
EPA ID.:
3.
SIC:
4.
Broker/Invoice Address:
Update Analysis Code
Address:
Source Code
City/State
Laboratory Testing Code
Zip:
Form Code
Billing/Broker Contact(s):
Generator State Code
Telephone:
Fax:
Section B – Waste Description
1.
Common Name for This Waste:
2.
Process Generating This Waste:
3.
Annual Quantity:
4.
Shipment Duration:
6.
Container Type:
Tons
Permanent (1 Year or Longer)
Bulk
Boxes
Yards
Temporary (Less Than 1 Year)
Cloth Bags
Drums
Drums – 30-Gal.
One Time Disposal
Gondola
Hopper
Intermodal
Flatcar
5.
Drums – 55-Gal.
Transportation Mode:
Drums – 85-Gal.
Highway
Rail
Other – Explain in Section H
Section C – Physical Properties
1.
Describe Physical State at 70 ºF:
Dry Solid
2.
Semi-Solid / Gel
Flowable Liquid
Describe Load Bearing Strength at 70 ºF:
Solid / Rigid
3.
Damp Solid
Sludge
2.1
Labpack
Penetrometer PSI:
2.2
% Solids @ 105 °C:
Weak / None
Describe Physical Appearance of Waste (Include Color, Variations):
4.
Apparent Density of Waste:
Lb./Cu. Yard
5.
Flash Point (TAG or Setaflash Closed Cup):
25-70°F
6.
100-140°F
5.1
Actual Flash Point:
>140ºF
2.0-5.0
5.0-10.0
Describe Odor of Waste:
None
ESOI Form WPQ-3-03
Slight
Combustible:
Yes
6.1
10.0-12.5
8.
Strong
5.2
°F
pH (10% Slurry in Distilled Water for Solids):
<2.0
7.
70-100°F
No
Actual pH (S.U.):
>12.5
Describe Temperature of Waste at Time of Disposal:
Ambient - 100°F
100-140°F
>140°F
Envirosafe Services of Ohio, Inc. (“ESOI”)
Waste Product Questionnaire
Page 2 of 4
PROFILE
Section D – Waste Composition
1.
List all components within the waste stream by percentage. Account for 100 percent of waste in Typical %
column.
RANGE %
TYPICAL %
1.
-
2.
-
3.
-
4.
-
5.
-
6.
-
7.
-
8.
-
9.
-
10.
Section E – Analytical Report, Sampling Certification
1.
Values Reported are:
2.
Sample collection method:
3.
Indicate sample collection type:
Actual
Highest
Lowest
Grab
Composite
Average
Other
Other
4. USEPA SW-846 test methods are required for all RCRA-mandated testing. List the methods your laboratory used below.
Result
PARAMETER
Antimony
Arsenic
Barium
Beryllium
Cadmium
Chromium (hex)
Chromium (total)
Copper
Lead
Mercury
Nickel
Selenium
Silver
Thallium
Zinc
Endrin
Lindane
Methoxychlor
Toxaphene
2,4-D
2,4,5-TP (Silvex)
Chlordane
Heptachlor &-OH
Hex-Cl-Benzene
Hex-Cl-Ethane
Hex-Cl-1,3 Butdi
2,4,5-TCl-Phenol
2,4,6-TCl-Phenol
Penta-Cl-Phenol
2,4-Dinitrtoluene
Sample Prep Method
EP-Toxicity Extraction
TCLP Extraction
ESOI Form WPQ-3-03
Method
Reference
PARAMETER
Cyanide Total
Cyanide Free
HCN @ pH 2.0
Sulfide Total
Sulfide Free
H2S @ pH 2.0
Phenolics
Chloride
Fluoride
Phosphate
Sulfate
Nitrate-N
Nitrite-N
Ammonia-N
Kjeldahl-N
Oil & Grease
TOC (Carbon)
TOX (Halogen)
PCB’s
HOC’s – (268)
Result
Method
Reference
pH10% Slurry
SW 846:
Flash Point
Sample Prep Method
SW 846:
PARAMETER
•Acetone
•Butanol
•Carbon Disulfide
•Carbon Tetrachloride
•Chlorobenzene
•Cresols- [o],[m],[p]
•Cresylic Acid
•Cyclohexanone
•1,2-Dichlorobenzene
•Ethyl Acetate
•Ethyl Benzene
•Ethyl Ether
•Isobutanol
•Methanol
•Methylene Chloride
•Methyl Ethyl Ketone
•Methyl Isobutyl Ketone
•Nitrobenzene
•Pyridine
•Tetrachloroethylene
•Toluene
•1,1,1-Trichloroethane
•Trichlorotrifluoromethane
•Trichloroethylene
•Trichlorofluoromethane
•Xylene(s)
Benzene
1,1,2-Trichloroethane
2-Ethoxyethanol
2-Nitropropane
Chloroform
1,4-Dichlorobenzene
1,2-Dichloroethane
1,1-Dichloroethylene
Vinyl Chloride (monom.)
Result
Method
Reference.
Envirosafe Services of Ohio, Inc. (“ESOI”)
Waste Product Questionnaire
Page 3 of 4
PROFILE
Section F – Waste Classification, HSWA Data
1.
Is the waste HAZARDOUS under RCRA 40 CFR 261?:
YES (it is a RCRA waste)
2.
NO (it is non-hazardous)
RCRA EPA HW Number(s) from 40 CFR 261:
3.
(or ESOI Non-Hazardous identification Code)
Does the waste contain any of the
following?: If YES, Explain in Section H
Explosive
Yes
No
Shock Sensitive
Yes
No
Pyrophoric
Yes
No
Pathogenic
Yes
No
Infectious
Yes
No
Radioactive
Yes
No
Water Reactive
Yes
No
4.
Is the waste subject to Land Disposal Restrictions in 40 CFR 268?:
5.
At the time of shipment will the waste described herein contain FREE LIQUIDS as determined by the Paint
No (there are no free liquids)
Yes
Filter Test (EPA SW-846 Method 9095)?
6.
Indicate if the waste or treatment residue contains any of the following HALOGENATED compounds:
No
Yes (Notification and/or Certification
Required with Manifest)
Yes
No
PCB’s (Polychlorinated Biphenyls) 50 parts per million (ppm) or greater
7.
Indicate by circling if waste or treatment residue contains any of the following DIOXIN codes in 40 CFR 261:
8.
Indicate by circling if waste or treatment residue contains any of the following SOLVENT codes in 40 CFR 261:
F020 F021 F022 F023 F026 F027 F028
The waste described herein contains NONE of these HW#’s
F001 F002 F003 F004 F005
9.
The waste described herein contains NONE of these HW#’s
Indicate if waste or treatment residue contains any of the “•”-marked chemical CONSTITUENTS in Section E.
Column 3, by reporting the concentration in the space provided.
The waste described herein contains NONE of
these chemicals
10. Does the waste described herein contain EPA HW #’s not reported on or with this form (40 CFR 262.11)?:
Yes
No
11. Is this waste LESS than 500 ppmw VO per 40 CFR 265.1084 or meets all applicable organic treatment
standards in 40 CFR 268.40 and IS NOT subject to 40 CFR 264 / 265 Subpart CC air emission requirements?
Yes
No
12. The above information was determined by:
Generator knowledge of the waste
Laboratory analysis
Section G – U.S. DOT Shipping Description
1.
U.S. DOT Proper Shipping Name (PSN):
2.
DOT Reportable Quantity:
3.
Class Code
7.
Technical Names or Additional DOT Descriptions:
8.
ERC 24-Hour Emergency 49 CFR 172.604 Telephone:
.
Lb
5.
Packing Group:
Kg
I
II
III
6.
UN/NA No.:
Section H – Additional Comments or Waste Information
ESOI Form WPQ-3-03
Envirosafe Services of Ohio, Inc. (“ESOI”)
Waste Product Questionnaire
Page 4 of 4
PROFILE
Section J – Generator Certification
1.
GENERATOR CERTIFICATION STATEMENT:
I hereby certify that as an authorized representative of the generator named herein, to the best of my knowledge all
information submitted in this and all attached documents is true and accurate. I certify that a sample (if any)
representative of the waste described herein was collected and analyzed according to the methods on the forms
submitted and all known and/or suspected hazardous compounds have been included in the documentation.
Are the transportation or disposal services to be performed by ESOI subject to any prevailing wage
requirements?
2.
Yes
No
GENERATOR SIGNATURE:
Name (Printed or Typed)
Title
Company
Date
Section K – Envirosafe Site Use Only
01.
02.
03.
04.
05.
06.
07.
08.
09.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
X
X
Schedule initial bulk shipment, 5 or more shipments/day, all containerized & all treatment, first stab. Approx. 15 yards
Profile number must appear on each manifest required by EPA or DOT; ERC Document, phone, route information
Generator must provide annual updated analysis; Generator retest if waste changes due to modifications to process, etc
Generator must provide 40 CFR 262.11 updated analysis
and annually thereafter
pH of a 10% slurry of waste in distilled waste must be at least
but less than
by ESOI methods
Flash Point of incoming material must be
°F of greater by ESOI methods
Annual volume $200 ton subject to OEPA WMA program; Acceptance ends
Initial due OEPA
Waste temperature acceptance requirements ($100°F always OK). Odoriferous waste may not be acceptable (sample)
LDR Notification-Certification Required; one-time must accompany initial shipment:
No unauthorized materials or free liquids in bulk loads
20.
Heat or gas in contact with water requirements
Waste must contain sufficient moisture to suppress dust
21.
Caustic may not heat & exceed 60% (w/w)
Total/Claussen cyanide (#250) & sulfide (#500) limit
Prohibition on mixing loads in same shipping container
22.
Waste billed by cubic yard if <2000 pounds per yard
23.
PCB concentration limit requirements
Material solid, non-flowable & penetrometer standard
24.
Non-leaking PCB ballasts & capacitors acceptance
Miscellaneous debris 3 feet dimension limit
25.
ESOI may request test or impound to verify LDRs
Metal drums <800 pounds unless authorized herein
26.
ESOI may treat debris by alternate 268.45 tech std.
Palletized boxes acceptance requirements
27.
Off-Spec waste stabilization mix design price adjust.
Woven cloth bags acceptance requirements
28.
Narrative description for incinerator wastes
Stencil profile number on top & side each container
29.
Conditions for acceptance of labpacks
Non-haz waste Consent-To-Service form required
30.
Conditions for asbestos 40 CFR 261 Subpart M
Name
Title
Date
If transportation for this waste is provided by ESOI, then ESOI’s standard technical requirements for transportation are applicable.
Section L – Regulatory Agency Use Only
1.
ACCEPTANCE STATUS:
Accepted (ACP)
2.
Conditional (CON)
Withheld (WHO)
Acceptance Denied (DNY)
CONDITIONS FOR ACCEPTANCE OR REASONS FOR DENIAL:
Name
ESOI Form WPQ-3-03
Title
Date
Agency