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Phone : 718-981-4600
Email : dispatch@cwofny.com
Generators Waste Profile Form
Generator Information
Company
Address
City
State
Zip/Postal Code
Contact
Phone Number
Site Name
Site Address
Site Contact
Cell Phone
Invoice Information
Company
Address
City
State
Zip/Postal Code
Contact
Phone Number
Fax Number
Email
PO
JOB
Waste Information
Name of Waste
Process Generating Waste
Characteristics
Color
Odor
Halogens
Physical State
Solid
Liquid
Sludge
Powder
Layers
Single Phase
Bi-Layered
Multi-Layered
Emulsified
Flash Point
<100 F
100 F-140 F
> 140 F
Corrosivity (pH)
3-5
5-7
7-9
9-12
Actual
Chemical Composition
% Water
% Oil
% Solids
Transporters
1.
2.
3.
Was waste generated from a regulated CERCLA/Super Fund Site?
YES
NO
Did load originate at a utility?
YES
NO
(If this load originates at a utility, you must send in PCB analysis. Max PCB concentration must be less 2 ppm.)
Does this waste contain greater than 2 ppm PCB's or are PCB's derived from a source greater than 2 ppm?
YES
NO
Does this waste contain greater than 1000 ppm total HOC (Halogenated Organic Compounds)?
YES
NO
Manifest Information
Proper Shipping Name
Non-DOT, Non-RCRA Regulated Liquids
Non-DOT, Non-RCRA Regulated Solids
Anticipated Volume/Units
Frequency
Daily
Weekly
Monthly
Yearly
One Time
Method of Shipment
Bulk Liquid
Drum
Other
Generator Certification
I hereby certify that all information submitted in this and all attached documents is true and accurate, based on my inquiry of those individuals immediately responsible for obtaining this information. I believe that the submitted information is true and complete to the best of my knowledge and that all suspected hazards have been disclosed. I am aware that there are significant penalties for submitting false information including the possibility of fine and imprisonment for knowing violations.
Name & Title
Send
