DRY CREEK LANDFILL, INC. WASTE PROFILE FORM

Transcription

1 Page 1 Office Use Only GENERATOR INFORMATION P. O. Box 3187 Central Point, OR Phone: Lee Fortier Beverly Sorensen Fax Generator Name: Address of Waste: 2. Mailing Address of Generator: 3. Billing Name and Address of Responsible Party: Fax: 4. Alternate Contact Name and Phone: WASTE INFORMATION The information in this section will be compared to DEQ and EPA regulatory standards for hazardous waste. 5. Process generating the waste: 6. Waste name: 7. Is this an EPA or Oregon state hazardous waste? YES NO 8. Chemical composition: List all hazardous and nonhazardous constituents from laboratory test data. Concentration Concentration Constituents Range Units Constituents Range Units

2 Page 2 9. Does the waste contain PCBs, explosives, or infectious, carcinogenic, pyrophoric, oxidizing, or shock-sensitive compounds? YES NO Note: If the waste contains asbestos, asbestos disposal policies must be followed and a chain-of-custody form must be attached. 10. Physical state at 70 F: Solid Liquid Sludge 11. List known waste characteristics. a) Flash Point: b) ph (if liquid): c) Color: d) Odor: e) Other Description: 12. Have you attached laboratory test results and chain-of-custody documentation to this waste profile form? YES NO 13. Have you attached a DEQ letter of approval to this waste profile form? YES NO SHIPPING INFORMATION 14. Packaging: Bulk Solid Bulk Liquid Drum Type/Size: 15. Anticipated Volume: Units:

3 Page 3 DRY CREEK LANDFILL, INC. All contaminated soil must be tested for the following parameters to be accepted by Dry Creek Landfill, Inc. for disposal. Gasoline: ALL ITEMS WITH TCLP VALUES SHOULD TEST FOR TCLP LIMITS!! Total Petroleum Hydrocarbons (TPH) naphthalene, lead, ethylene diobromide (EDB) ethylene dichloride (EDC) methyl t-butyl ether (MTBE) Diesel: Total Petroleum Hydrocarbons (TPH) polynuclear aromatic hydrodcarbons (PAHs) Waste Oil: polynuclear aromatic hydrodcarbons (PAHs) TCLP-metals, cadmium, chromium and lead Volatile chlorinated solvents Volatile aromatic hydrocarbons PCB s

4 Page 4 GENERATOR S CERTIFICATION AND APPROVAL I hereby certify that all information submitted in this form and all attached documents contain true and accurate descriptions of the waste stream. Name of Generator Signature of Generator Printed Name/Title Dry Creek Landfill, Inc. Signature Waste Acceptance Fee: $50.30 per ton Permit Expires: Waste Accepted not to exceed No waste authorized under this profile will be accepted after the expiration date stated above without prior authorization.

5 Page 5 WASTE CHARACTERIZATION DECLARATION Name of Generator: (Please Print Clearly) Address of Generator: Name of Waste: Source of Waste: Approximate Amount of Waste (cubic yard): The Generator listed above, by generator knowledge, confirmed by chemical and physical analysis, determined that the subject waste material (as named above) is not a hazardous waste by Oregon Department of Environmental Quality (DEQ) or US Environmental Protection Agency (EPA) criteria (ref.: OAR and 40 CFR Subparts B-D, Part 261). The Generator also determined that the above-listed waste material is not Flammable, Corrosive, reactive, Toxic, EPA-Listed, or DEQ-Listed, as defined in the abovereferenced regulations. The Generator assumes all environmental liabilities if this waste is later determined to be an EPA or DEQ hazardous waste. Authorized Signature: Title: Note: Laboratory test data must be attached to this form.