Quote Request Form |
2. Billing Information | |||
Name: | Name: | ||
Facility Address: | Mailing Address: | ||
Mailing Address: | City/ST/ZIP: | ||
City/ST/ZIP: | Contact Name: | ||
Technical Contact: | Phone Number: | ||
Phone Number: | Fax Number: | ||
Fax Number: | |||
US EPA ID Number:   |
3. Waste Stream Common Name:   | ||
4. Process Generating Waste:   | ||
5. Anticipated Volume:   | Type: | Frequency:   |
6. Packaging Size: | Type: | |
7. Physical State: | ||
8. Color:   | Odor:   |
9. 100% CHEMICAL COMPOSITION  (Do not abbreviate chemical names) | ||
Chemical | Exact% | Range% |
10. Paint Filter Test Pass Fail | ||
% Free Liquids | % Water | |
11. pH | Specific Gravity | Density |
12. Flash Point | BTU/LB | |
Flammable Solid Yes No | ||
13. Viscosity |
14. MATERIAL IS: | YES | NO |
Air or Water Reactive | ||
Unstable | ||
Radioactive | ||
Shock Sensitive | ||
Pyrophoric | ||
Explosive | ||
Ethiological |
DOES THIS MATERIAL CONTAIN OSHA:
Carcinogens Pesticides Herbicides
15. Metal Content TCL | |||
  | mg/L | mg/L EPA Limit | |
Arsenic | (As) | 5.0 | |
Barium | (Ba) | 100.0 | |
Cadmium | (Cd) | 1.0 | |
Chromium | (Cr) | 5.0 | |
Lead | (Pb) | 5.0 | |
Mercury | (Hg) | 0.2 | |
Selenium | (Se) | 1.0 | |
Silver | (Ag) | 5.0 |
16. ADDITIONAL CONTENTS (Specify Units)
Cyanides Phenols Sulfides
Toluene Ethyl benzene Xylene
PCB's
17. ORGANIC CONTENT - TCLP EXTRACT ONLY - | ||||||||
Does the waste contain any of the following at or above the concentrations specified? | ||||||||
EPA LIMIT | EPA LIMIT | |||||||
(mg/L) | YES | NO | (mg/L) | YES | NO | |||
Benzene | 0.50 | Hexachlorobenzene | 0.13 | |||||
Carbon Tetrachloride | 0.50 | Hexachlorobutadiene | 0.50 | |||||
Chlordane | 0.03 | Hexachloroethane | 3.00 | |||||
Chlorobenzene | 100.0 | Lindane | 0.40 | |||||
Chloroform | 6.00 | Methoxychlor | 10.00 | |||||
o-Cresol | 200.00 | Methyl Ethyl Ketone | 200.00 | |||||
m-Cresol | 200.00 | Nitrobenzene | 2.00 | |||||
p-Cresol | 200.00 | Pentachlorophenol | 0.70 | |||||
Cresol | 200.00 | Pyridine | 5.00 | |||||
2,4-D | 10.0 | Tetrachloroethylene | 0.70 | |||||
1,4-Dichlorobenzene | 7.50 | Toxaphene | 0.50 | |||||
1,2-Dichloroethane | 0.50 | Trichloroethylene | 0.50 | |||||
1,1-Dichloroethylene | 0.70 | 2,4,5-Trichlorophenol | 400.00 | |||||
2,4-Dinitrotoluene | 0.13 | 2,4,6-Trichlorophenol | 2.00 | |||||
Endrin | 0.02 | 2,4,5-TP Silvex | 1.00 | |||||
Vinyl Chloride | 0.20 | |||||||
The proceeding constituent composition is based upon:
An attached Waste Analysis
KNOWLEDGE of the hazard characteristic of the waste in light of the materials or process used.
18. Is the waste hazardous per 40 CFR 261.3? Yes No
19. Other Hazardous constituents per 40 CFR 261 Appendix VIII (Specify ppm or wt.%)
20. Special Handling Instructions ( Include extra page)
I certify and warrant that all information as appears in this form and any attachments and supplements is true, accurate, and that all known or suspected hazards have been disclosed. I further certify and warrant that this identification is the result of an analysis of a representative sample obtained and analyzed in accordance with the procedures specified by the U.S. Environmental Protection Agency (SW-846).
I agree to abide to the payment terms of the facility.
Authorized Signature: _____________________________
Title:______________________________ Date:________________
Printed Name:
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![]() Last Updated: September 25, 2003 Copyright � 2003-2007 Liberty Environmental Solutions, Inc. All rights reserved. |