Non-Hazardous Waste Water Facility
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Non-Hazardous Waste-Water Facility

Waste Characterization

Non-Hazardous Waste Water Characterization

Click the icon below to download a PDF version of the Waste Characterization form.

Address of Billable Party

Name

Authorized Rep

Phone Number

E-Mail

Address

City

State

Zip Code

Generator Address

Name

Contact

Phone Number

Address

City

State

Zip Code

Activity or Process Producing Wastewater (Check all that apply)

Monitoring well sampling

Excavation and Dewatering

Monitoring well development/auger

Pump Test

Suspected Source of Contaminants

Does (or did) the site contain one or more underground storage thanks (UST's) for fuel?

YES NO

Is a UST the suspected source of contamination?

YES NO

Are you aware of any other possible sources of causes of waste water contamination at the site? If Yes, please describe

YES NO

Wastewater Characterization

Please provide copies of the results of any analytical work carried out on the wastewater.

Is the pH less than 2 or greater than 12.5?

YES NO

Is the flashpoint less than 140 ^F ( 60 ^C )?

YES NO

Is there any reason to suspect the presence of reactive cyanides or sulfides?

YES NO

Is there any reason to suspect that the waste water would prove toxic in a fish bio-assay test?

YES NO

Is there separate-phase liquid present in the waste water?

YES NO

Can you detect any hydrocarbon odor from the wastewater?

YES NO

Is there any reason to suspect the presence of chlorinated hydrocarbons such as trichloroethylene?

YES NO

Was the wastewater tested for chlorinated hydrocarbons?

YES NO

Is there any reason to suspet the presence of heavy metals, such as lead?

YES NO

Was the wastewater tested for heavy metals? If "Yes", please describe tests and attach copies of the test results.

YES NO

Was the wastewater tested for anything other than the above contaminants? If "Yes", Please describe tests and attach copies of the test results.

YES NO

Is there any other analytical test data ( eg soil samples ) for this site?

YES NO

Is there any soil vapor monitoring data for this site?

YES NO

Please describe the appearance of the waste water.

Color

Estimated amount of sediment ( % wt )

Is there evidence of an emulsion?

YES NO

Estimated volume of waste water (USG)

Generator's Certification that Wastewater is Non-Hazardous

Description of water: Certify that the above named material is a liquid exempt from rcra per 40 cfr 261.4(b)(10) and does not meet the criteria of hazardous waste as describe in 22 ccr article 11 or any other applicable state law, has been properly described, classified and packaged and is in proper condition for transportation according to applicable regulations.

The information and representations presented above are true and correct to the best of my knowledge.

Generator/Authorised Agent

Signature

Date

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