1.  General Information:       *required fields

Company Name:	*
Contact Name:	*
Company Reference Number:
Street Address:	*
City:	*
State:	DC DE MD NJ NY PE VA WV*
Zip Code:	*
Phone #:	*
Email	*
Fax #:
USEPA ID #:
2.  Waste Information:
Name of Waste:
Process Generating:
Anticipated Volume:
Units:	Drums Gallons Tons Yards
Frequency:	One-time Monthly Quarterly Yearly
Size and Type of Container:
DOT Shipping Name:
Hazard Class:
UN/NA #:
Packing Group:
Sample Included:	Yes No
Special Handling Precautions:
3.  RCRA Characteristics:
RCRA Waste Codes:
Form Code: B
Virgin Product or Chemical:	Yes No
MSDS Attached:	Yes No
F001-F006 Solvent Waste:	Yes No
Waste is used in electroplating:	Yes No
Spill Cleanup:	Yes No
Debris:	Yes No
4.  Chemical Composition:
Chemical	Min-Max Range %
	%
	%
	%
	%
	%
	%
	%
	%
	%
Waste Is:
Radioactive:	Yes No
Water Reactive:	Yes No
Oxidizer:	Yes No
OSHA Carcinogen:	Yes No
Explosive:	Yes No
Pesticide:	Yes No
Polymerizable:	Yes No
Organic Peroxide:	Yes No
Infectious:	Yes No
Pyrophoric:	Yes No
Other:
Flash Point	less than 100°F 100-140°F 140-200°F greater than 200°F
Odor:	None Mild Strong
Color:
% Water	less than 5% 5-10% 10-20% greater than 20%
% Halogens	less than 5% 5-10% 10-20% greater than 20%
pH	less than 2 2-4 4-6 6-8 8-10 10-12.5 greater than 12.5
Layers:	Single Bi Multi
BTU/Pound (x1000)	less than 2 2-5 5-10 10-16 greater than 16
Total Suspended Solids (% wt)	less than 1 1-5 5-10 10-20 greater than 20
Viscosity	Low Medium High