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Cleveland, Ohio   44109
216-741-9310     800-362-0693
Fax: 216-741-4080
 

Waste Profile Form
* Fields Are Required
CSI Customer #*: Sales #*:
GENERATOR INFORMATION BILLING FACILITY (IF DIFFERENT)
GENERATOR NAME*:
 NAME:
PLANT ADDRESS*:
 MAILING ADDRESS:
CITY*:
 CITY:
STATE*:  STATE: 
ZIP CODE*:  ZIP CODE: 
PHONE*:  PHONE: 
USEPA ID #*:
 BILLING CONTACT:
TECHNICAL CONTACT*:
 BILLING CONTACT TITLE:
TECHNICAL CONTACT TITLE:
 BROKER: 
GENERAL WASTE INFORMATION
WASTE NAME*:
 KNOWN WASTE CODES:
PROCESS GENERATING WASTE*:
RCRA NON-HAZARDOUS/EXEMPT?*:  Yes No If yes, please provide appropriate citation:
USED OIL?*:  Yes No If yes, does oil contain chlorinated paraffins?:
Yes No
SPENT LAMPS?*:  Yes No               If yes,  Lamps should be managed as Universal Waste
 Lamps must be managed as Hazardous Waste
ANTICIPATED VOLUME*:   GALLONS      POUNDS      CUBIC YARDS
PER*:  ONE TIME     WEEK     MONTH     QUARTER      YEAR
METHOD OF SHIPMENT*:  BULK LIQUID     BULK SOLID     BOX/TUBE     DRUM
     - TYPE & SIZE OF CONTAINER: 
DISPOSITION OF WASTE*    DISPOSAL    REUSE*     TURNAROUND**     INCINERATION ONLY
      * SIGNED REUSE AGREEMENT REQUIRED      ** I F MATERIAL IS FOR TURNAROUND, PLEASE SUMBIT  T / A  SPECS
PHYSICAL PROPERTIES
ODOR*:  NONE     MILD     STRONG     DESCRIPTION: 
COLOR*: 
pH*:  NA     <2     2-4     4-10     10-12.5     >12.5
FLASHPOINT*:  <73F     73-100F     100-140F     140-200F     >200F     NONE
OXIDIZER*:  YES     NO
PHYSICAL STATE @ 70F*:  LIQUID     SLUDGE     SEMI-SOLID     SOLID     POWDER
LAYERS*:  SINGLE PHASE     BI-LAYERED     MULTI-LAYERED
DOES THE WASTE CONTAIN ANY OF THE FOLLOWING*:          IF YES, ATTACH DOCUMENTATION
PCB's*:   Yes No       INSECTICIDES, PESTICIDES, HERBICIDES, OR RODENTICIDES:   Yes No
INFECTIOUS OR BIOLOGICAL WASTE*:   Yes No       NRC REGULATED ACTIVITY:   Yes No
IS MATERIAL SUBJECT TO NATIONAL EMISSIONS STANDARDS FOR BENZENE WASTE OPERATIONS (40 CFR 61 SUBPART FF?)*   Yes No
REACTIVITY:   None  Water Reactive  Pyrophoric  Shock Sensitive  Cyanides  DOT Explosive
                          Sulfides    Other 
SAMPLE AND MSDS INFORMATION
TYPE OF SAMPLE*:    NONE      GRAB      COMPOSITE                    MSDS INCLUDED*:   Yes   No
CERTIFICATION:
By initialing the box below, I hereby certify that the above and attached description os complete and accurate to the best of my knowledge and ability. The characterization of this waste stream has no willful omissions of composition or properties, and all known or suspected hazards have been disclosed. I also ceritfy that any sample provided for testing used to substantiate the information on this form is representative of all materials described.
INITIALS*:           PRINTED NAME*:          DATE*: 
TITLE*:           COMPANY*:            Broker Generator
   

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