Non-Hazardous Waste Water Characterization Form
| Address
of Responsible Party |
Site Address (if different) |
| Name:
________________________________ |
Name: ________________________________ |
| Authorized
Rep: ________________________ |
Contact: ______________________________ |
| Street:
________________________________ |
Street: ________________________________ |
| City:
______________________State: ______ |
City: ______________________State: ______ |
| Phone:
________________________________ |
Phone: ________________________________ |
Activity or Process Producing Wastewater (check all that apply):
| ______Monitoring
well sampling ______Monitoring well development/auger rinsate |
Excavation
and Dewatering ______
Pump test ______ |
Other
(describe): _____________________________________________________________________
___________________________________________________________________________________
Suspected
Source of Contaminants:
| Does (or did) the site contain one or more underground storage tanks (UST's) for fuel? | Yes__ | No__ |
| Is a UST the suspected source of contamination? | Yes__ | No__ |
| Are
you aware of any other possible sources or 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__ |
| Was the wastewater tested for hydrocarbons? | 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 suspect 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 DESCRIBED 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.
|
___________________________________
|
___________________________________ |
Approval#
