Larson & Associates, Inc.
Filtration Specialists

 

Generator Information

Name
Street
City
State
Zip
Phone Number

  Click here if Site Address is same as above.

Street
City
State
Zip
Phone Number

Non-Hazardous Conditionally Exempt Small Quantity Generator less than 1/2 (55gal drum/month)
Small Quantity Generators less than 5 (55 gal drums/month) Large Quantity Generators - (more than 5 drums/month)

Waste Description

Detailed description of process(es) by which this waste is generated and detail of the type of business: 

 

List ALL chemical products by specific NAME (i.e. cleansers, degreasers, solvents, fuels or other constituents) that may be present in the waste. If no products are present please state such. Attach Material Safety Data Sheets (MSDS) for EACH item listed.

A. D.
B. E.
C. F.

Volume in Gallons:

Common Name of Waste: (e.g. Water, Oil, and Sludge, Oily Waste)

Check if your waste stream is on any of the following EPA hazardous waste lists:

Non-source Specific (i.e. Spent solvents used in cleaning, degreasing or dioxins) 40 CFR 261.31 F-List
ALL SPENT SOLVENT (including but not limited to mixtures/blends) used in degreasing, containing 10% BEFORE USE those solvents listed on the 'F LISTING' (attached).
Disposal of Commercial Products (i.e. Acetone, Benzene, Formaldehyde, etc) 40 CFR 261.33 P-List
Acutely Hazardous Disposal of Commercial Chemical Products (i.e. Endrin, Arsenic, Poisons) 40 CFR 261.33 U-List
Source Specific - Hazardous Waste and/or Materials (i.e. Chemical or Pesticide Manufacturing) 40 CFR 261.32 K-List

Check if your waste stream is not any of the following:

Potential Hazardous Waste by EPA Characteristics: (See Toxicity Characteristic Leaching Procedure Testing Parameters)

The waste is not ignitable (D001) based on: 40 CFR 261.21
Attached MSDS(s) Attached analytical Generator Knowledge
 
The waste is not corrosive (D002) based on: 40 CFR 261.22
Attached MSDS(s) Attached analytical Generator Knowledge
 
The waste is not reactive (D003) based on: 40 CFR 261.23
Attached MSDS(s) Attached analytical Generator Knowledge
 
The waste is not characteristic for metals (D004-D011) based on: 40 CFR 261.24
Attached MSDS(s) Attached analytical Generator Knowledge
 
The waste is not characteristic for volatiles (D018-19, D021-22, D028-29, D035, D039-40, D043) based on: 40 CFR 261.24
Attached MSDS(s) Attached analytical Generator Knowledge
 
The waste is not characteristic for semi-volatiles (D023-27, D030, D032-34, D036-38, D041-42) based on: 40 CFR 261.24
Attached MSDS(s) Attached analytical Generator Knowledge
 
The waste is not herbicides and pesticides (D012-17, D020, D031) based on: 40 CFR 261.24
Attached MSDS(s) Attached analytical Generator Knowledge
 
Pesticide/Herbicide Warranty
I hereby certify the following: The waste identified in Section B of this waste profile form does not contain Endrin, Methozychlor, 2,4-D Lindane, Toxaphene, 2,4,5, -TP (Silvex), Chlordane, or Heptachlor (and its Epoxide). These constituents are not use at the location where this waste was generated, nor are they known to be present in the materials of which the above waste is comprised. Hence, there is no reason to suspect their presence in the waste.
Generator's Initials:
Polychlorinated Biphenyl (PCB) Warranty
I hereby certify the following: The waste identified in Section B of this waste profile form does not contain PCBs at a concentration of 40 PPM when measured in each container or vessel; that the material is not contaminated with PCBs from a source containing 50 PPM or greater PCBs; and hereby agree to indemnify and hold harmless from any cost, damages, or liability resulting from the breach of this warranty.
Generator's Initials:
Solvent Warranty
I hereby certify the following: The waste identified in Section B of this waste profile form does not contain solvents, if solvents are used on site, there (circle) is/ is not secondary containment and no spills have occurred; and hereby agree to indemnify and hold harmless from any cost, damages, or liability resulting from the breach of this warranty.
Generator's Initials:
Federal Categorical Pretreatment Standard Warranty
I hereby certify the following: The waste identified in Section B of this waste profile form (circle) is / is not generated from a manufacturing process that is subject to Federal Categorical Pretreatment Standards; and hereby agree to indemnify and hold harmless from any cost, damages, or liability resulting from the breach of this warranty. 40 CFR 401
Generator's Initials:
Service Provider's Declaimer In accordance with Federal and State Regulation, it is necessary for the Generator of potential hazardous waste to properly identify the waste for their records as well as to supply Larson & Associates, Inc with the information necessary to handle the waste. L & A will not be held liable in any way should the generator fail to adequately provide required information which may delay disposal approval and/or may require additional testing at the generators expense.
 
Generator's Statement "I certify under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage that system or those persons directly responsible for gathering information, submitted is, to the best of my knowledge and belief, true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations."
Generator’s Initials (Please write your Full Name)
Generator’s Title
Date