Quote Request Form
1.  Generator Information 
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
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