WASTESTREAM INFORMATION PROFILE Recertification WIP No. WORKWASTE LOCATION 779 South Main Street Manchester, New Hampshire 03102 1. Generator Information Generator Name EPA ID No.: Site Address Internal Wastestream No. City State Country ZIP Site Contact Telephone:
Generator Mailing Address City State Country ZIP NAICS (SIC) Code:
2. Waste Information Waste Name Process Generating Waste Type of Waste Manufacturing Process Waste (Liquid) Manufacturing Process Waste (Solid) Soil Groundwater Debris Decontamination Fluid Used Oil (Total Halogens > 1000 ppm < 1000 ppm) Other (Describe ) Waste Codes (Hazardous Wastes Only) Under the LDR program, is the waste a: Wastewater Non-wastewater Sub Category
3. Shipping and Packaging Information DOT Proper Shipping Name: Hazard Class UN/NA No. Packing Group RQ amt lbs
RQ Desc: 1. 2. DOT Desc: 1. 2. Packaging: Bulk Solid Type/Size: Bulk Liquid Type/Size: Drum Type/Size: Other Shipping Frequency: Units Per Month Quarter Year One Time Other
1 of 2 WIP 2009 4. Physical Characteristics
Physical State Odor Halogens Layers: Solid none Br % Bromine multilayered: Liquid mild Cl % Chlorine bi-layered Other (Describe Below) strong F % Fluorine single phase: describe I % Iodine pH Specific Gravity Flash Point (F) Solids Other a < 2 a < 0.8 a < 80 % suspended % ash b 2 - 5 b 0.8 - 1.0 b 80 - 100 % settleable water solubility c 5 - 9 c 1.0 c 101 - 140 % dissolved BTU/lb d 9 - 12.5 d 1.0 - 1.2 d 141 - 200 e > 12.5 e > 1.2 e > 200 Free Liquid Range to % exact exact f no flash exact
5 Chemical Composition
Constituents Range Units Constituents Range Units
Total Composition Must Equal or Exceed 100% Is analytical data or an MSDS available that describes the waste? Yes No If yes, please attach. 6 Other Information: a. Is the waste stream being imported into the USA? Yes No b. Is the waste stream subject to Benzene NESHAP Notification and Control Requirements? Yes No If yes, please see instructions for additional information required. c. Does the waste stream contain PCBs regulated by 40 CFR 761? Yes No PCB concentration ppm d. Is the waste stream subject to RCRA subpart CC controls? Yes No Volatile organic concentration, if known ppmw Subpart CC approved analytical method Generator Knowledge
7 Additional Information:
8 Generator Certification I hereby certify that all information submitted in this and all attached documents contains true and accurate descriptions of this waste. Any sample submitted is representative as defined in 40 CFR 261 - Appendix I or by using an equivalent method. All relevant information regarding known or suspected hazards in the possession of the generator has been disclosed. I authorize sampling of any waste shipment for purposes of recertification.
NAME (PRINT OR TYPE) PHONE DATE
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2 of 2 WIP 2009 WASTESTREAM INFORMATION PROFILE INSTRUCTIONS
Section 1: Generator Information EPA ID No. - Please enter the 12 digit alpha numeric identification for your facility. The number must be completed for all hazardous waste, PCB waste, and nonhazardous waste streams. If you are a conditionally exempt small quantity generator that does not have a permanent or temporary EPA ID number, please enter “CESQG in this space. Generator Name, Address, City, State, Zip – Please enter the appropriate SITE information, including the name of the parent corporation, if applicable. Generator Mailing Address – If the mailing address is different from the site address, please provide the mailing information. This is the address that will be used to send notifications, certificates of disposal, and manifest copies. This address will help us to insure timely delivery. Also, please include all mail codes, etc. Site Contact – Please provide the name, phone, and fax of the generator’s employee responsible for the proper management of this waste. NAICS Number – Enter the NAICS code for the facility.
Section 2: Waste Information Waste Name – Please provide the common name of the waste stream. Process Generating Waste– Please provide as much information as possible describing the complete process that generated the waste. This information is used to determine if the waste is from a regulated process. For remediation sites: Please explain the source of the contamination. Type of Waste – Please check box that applies. Waste Codes –Please provide up to six waste codes that best describe your waste stream. If there is a state waste code that is not duplicative of a EPA waste code, please indicate in this area well. LDR Information – For hazardous waste, please indicate whether the waste is a wastewater (< 1 % Total Organic Carbon by weight AND < 1% Total Suspended Solids) or a Non-wastewater under the Land Disposal Restriction regulations. Also, please indicate the subcategory of your hazardous waste, if applicable (See 40 CFR 268.40)
Section 3: Shipping Information Shipping Frequency– Please enter the estimated volume of the waste and indicate the frequency of shipment. DOT Shipping Name – Please provide the proper DOT Shipping Name to be used on the shipping papers. Packaging – Please mark the type of packaging anticipated for your waste stream. Please check all that may apply.
Section 4: Physical Information Physical State – Please check box that applies. Odor – Please describe relative strength and type of odor associated with your waste. Halogens – Indicate the halogen content for your waste stream (if known). Layers – Please check box that applies. pH – Please indicate the most appropriate pH range for your waste stream. If the exact pH is known, please enter it in the space provided. Specific Gravity – Please indicate the most appropriate specific gravity range for your waste stream. . If the exact specific gravity is known, please enter it in the space provided. Flash Point – Please indicate the most appropriate flash point range for your waste stream. . If the exact flash point is known, please enter it in the space provided. Solids – Please indicate the type and amount of solids associated with your waste stream. Other Please indicate the percentage of ash in the waste stream, if any. Please indicate whether the waste is water soluble. Please indicate the heat of combustion of the waste (if known). Free Liquids Range – Please indicate the percentages of free liquids associated with your waste stream
WIP 2009 Section 5: Waste Composition Please indicate the constituents comprising the waste (hazardous and non-hazardous). Please include constituents and concentrations that render the waste hazardous and/or otherwise regulated (e.g., PCBs, asbestos, underlying hazardous constituents). Also indicate whether there are any constituents which would pose a significant exposure hazard (e.g., hydrofluoric acid).
If analytical data or a Material Safety Data Sheet (MSDS) is available for the waste stream, please check box and submit with the competed Waste Information Profile.
Section 6: Other Information a. Please check the box that applies. b. Please check the box that applies. The waste stream is subject to Benzene NESHAP notification and control requirements if it: 1. Contains > 10 ppm benzene, and 2. Is generated by a chemical manufacturing plant, petroleum refinery or coke by-product recovery plant, and 3. The generator’s Total Annual Benzene (TAB) is > 10 Mg/yr This information is required by most disposal facilities prior to waste acceptance. c. Please indicate whether your waste stream contains PCBs regulated under the Toxic Substances Control Act (TSCA). If the waste is regulated by TSCA, please indicate the concentration of PCBs in your waste. d. Waste streams with > 500 ppm may be subject to 40 CFR 264-265 Subpart CC Air Emission Standards. This information is required by most disposal facilities prior to waste acceptance.
Section 7: Additional Information Please include information that may be specific to your facility or your waste stream. For example: Do you have an approved waste disposal facilities list that you must use? Do you have site-specific security requirements? Do you have site personal protective equipment requirements? Do you have issues that may make waste pickups at you facility difficult (e.g., limited turning room, overhead obstructions, vehicle with lift gate required, dock-height truck required, any special equipment required).
Section 8: Generator Certification Please sign and provide the requested information indicating the information regarding your waste is accurate.
WIP 2009