All fields in red are required for submission. I. Generator Information Name:   Billing Name: Address:   Billing Address: City:   City: State: AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN IT KS KY LA MA MD ME MI MN MO MS MT NC ND NH NJ NM NY NE NV OH OK OR PA RI SC SD TN TX UT VA VT WV WA WI WY Zip:   State: AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN IT KS KY LA MA MD ME MI MN MO MS MT NC ND NH NJ NM NY NE NV OH OK OR PA RI SC SD TN TX UT VA VT WV WA WI WY Zip: Technical Contact:   Phone no.: Title:   Fax: EPA ID No.:   State Waste Code No: State ID No.:   Vopak Sales Contact: Charles Bradley Richard Newman II. Waste Information Name of Waste Stream: Original Process Generating Waste (must be specific): Volume: UOM: Lbs Gal Tons Cu Yards Frequency: Weekly Daily Monthly Quarterly Yearly One-time Waste Container: Truck Drum 5 Drum 15 Drum 30 Drum 55 Tote Railcar Overpack Roll-off Barge Ship Sample Source: Has sample been submitted? Yes No III. Physical Characteristics of Waste Stream pH: <2.0 2.0-4.0 4.0-12.5 >12.5 Exact: Flash Point: <140F 140F-200F >200     Exact: BTU value: <5.000 5.000-10.000 >10.000     Exact: Physical State: Solid Semi-solid Liquid         Odor: None Mild Strong         Phases/Layers: Single Multiple             Density (#/gal or S.G): Color/Appearance Solid % IV. Chemical Composition - Constituents (Do not use generic terms) Constituent % ppm Indication Tri Listed Chemical Yes No Yes No Yes No Yes No Yes No                                       Total Concentration   % (Must be =/> 100%)       Additional Row Has MSDS been sent? Yes No V. Waste Content - Check all that apply and fill in additional information if required Sulfide ppm   Pesticide/Herbicide PCB TSCA Waste Cyanide ppm   PCB's >50 ppm Dioxins Reactive Sulfides ppm   Explosive Radioactive Reactive Cyanides ppm   Water reactive Shock sensitive Benzene No Yes If yes, then indicate if Benzene is NESHAP regulated No Yes Sara Title III Section 313 Chemicals Yes No If yes, indicate tri chemicals in section IV. If necessary, send a complete tri chemical list to Vopak. VI. RCRA Characterization 1. Is this material   wastewater (< 1% TOC and < 1% TSS)   non-wastewater (> 1% TOC and > 1% TSS)? 2. Is this material a US EPA hazardous waste (40 CFR Part 261)?   Yes   No 3. If the answer on question 2 is Yes, click on the buttons below to select all EPA waste code numbers (D, F, K, P, U) below. (if specific EPA waste code is not available on Vopak-list, please contact Vopak)   D-Codes F-Codes K-Codes P-Codes U-Codes   VII. Additional Information (Health & Safety Precautions) 1. Generator wishes to PROHIBIT management of this waste stream by: None Underground Injection Subtitle C/D Landfill 2. Generator waste disposal preference: (Indicate order of preference:1, 2, 3, or No) a.  Waste Water Treatment: 1 2 3 No   b.  Underground Injection 1 2 3 No   c.  Incineration 1 2 3 No   d.  Landfill 1 2 3 No   e.  Fuels Blending 1 2 3 No 3. Comments: VIII. Generator's certification Hereby certify that the above and attached description is complete and accurate to the best of my knowledge and ability to determine that no deliberate or willful omissions of composition or properties exist and that all known or suspected hazards have been disclosed. I authorize Vopak to obtain a sample from any waste shipment for purposes of recertification.   Printed Name &Title   Date