NON-HAZARDOUS MATERIAL PROFILE FORM

Water Depot, Inc. 1301 Avondale Rd

New Windsor, MD, 21776 Phone: (410) 857-9670 Fax: (410) 857-2814

www.oilwaterdisposal.com

Page 1 of 2

A. Generator Information Invoice Information

Generator Name:________________________________ Company Name:_________________________________

Address:______________________________________ Address:_______________________________________

Address 2:_____________________________________ Address 2:______________________________________

City:___________________State:______ Zip:_________ City:___________________State:______ Zip:__________

Contact Name:__________________________________ Contact Name:___________________________________

Phone: ___________ ______________, Ext:__________ Phone: ________________________, Ext:____________

Fax: ________________ Phone 2: _________________ Fax:_________________ Phone 2:___________________

Email:_________________________________________ Email:__________________________________________

EPA ID#:______________________________________ EPA ID#:_______________________________________

B. Waste Information

Name of Waste:___________________________________________________________________________________

Process of Generating Waste (be specific):______________________________________________________________

Generator has provided the following: Sample MSDS Waste Analysis Generator Knowledge

Product Grade: No. 2 No. 4 No. 6 Used Oil Wastewater Non-Wastewater

List all RCRA Waste Codes: ___________ ___________ ___________ ___________ ___________ ___________

Proper DOT Shipping Name: RQ___________lbs/ ____________________________________________________

Technical Description:___________________________ Hazard Class:__________ ID#:__________ PG:___________

Sub Hazard Class:________ RQ Substance / Waste Code:_______ Poison Inhalation Hazard / Zone:________

24 HOUR EMERGENCY RESPONSE PHONE NUMBER:_____________________________

C. Physical Characteristics:

Color:________________________________ Odor:__________________________ None Mild Strong

Physical State @ 700F: Liquid____% Solid____% Sludge____% Powder____% Compressed Gas

Layers: Single Phase Bi-layered Multi-layered Other:__________________________

Specific Gravity: <0.8 0.8–1.0 1.1-1.2 1.3-1.4 1.4-1.7 >1.7 Actual:______

pH: NA <2 2-4 4-6 6-8 8-10 10-12 12.5 or greater Exact or Range:__________

Flash Point (0F): NA <110 110-140 141-200 >201 Closed Cup Open Cup

BOD:______ COD:_______ TKN:_______ Phosphorus:______ Halogens:_______ Salinity:______ Silicone:_______

D. Metals Less than regulatory levels Total TCLP Generator Knowledge ppm mg/l mg/kg

Antimony Sb ____________ Beryllium Be ____________ Chrome VI Cr6 ____________

Arsenic As ____________ Cadmium Cd ____________ Cobalt Co ____________

Barium Ba ____________ Chromium Cr ____________ Copper Cu ____________

Lead Pb ____________ Pesticides ____________ Vanadium V ____________

Mercury Hg ____________ Selenium Se ____________ Zinc Zn ____________

Molybdenum Mo ____________ Silver Ag ____________

Nickel Ni ____________ Thallium Th ____________

Otherwise, please fill in Invoice information below.Generator Information.Please check here if Invoice Information is same as

NON-HAZARDOUS MATERIAL PROFILE FORM

Water Depot, Inc. 1301 Avondale Rd

New Windsor, MD, 21776 Phone: (410) 857-9670 Fax: (410) 857-2814

www.oilwaterdisposal.com

Page 2 of 2

E. Chemical Composition (All constituents must be identified): Actual / Range F. Hazardous Components

_______________________________________ ______-______% (Mark all that apply)

Affected Benzene

Air Reactive

Asbestos

Biological

Bromine:____________%

Chlorine:____________%

Controlled Benzene

Cyanides:__________ppm

Dioxins / Furans

Etiological

Explosive

Fluorine:____________%

Fuming / Smoking

Iodine:______________%

Marine Pollutant

Ozone Depleting

PCB’s:__________ppm

Phenolics:__________ppm

Pyrophoric

Radioactive

Shock Sensitive

Sulfides:__________ppm

Waste Oil with >1,000ppm Chlorine

Water Reactive

>500 VOC’s

_______________________________________ ______-______%

_______________________________________ ______-______%

_______________________________________ ______-______%

_______________________________________ ______-______%

_______________________________________ ______-______%

_______________________________________ ______-______%

_______________________________________ ______-______%

_______________________________________ ______-______%

_______________________________________ ______-______%

_______________________________________ ______-______%

_______________________________________ ______-______%

_______________________________________ ______-______%

G. Shipping Information Volume:____________________________________

Container Description

Tanker Vacuum Truck Drums Other:___________________________________

H: Special Instructions / Notes (Please include any special instructions or notes below):

I. Hazardous Characteristics:

Is this material an EPA listed Hazardous Waste per 40 CFR Part 261? Yes No

Is this material an EPA Characteristic Hazardous Waste per 40 CFR Part 261? Yes No

Does this material contain concentrations of PCB’s as defined in 40 CFR Part 261? Yes No

Does this material contain concentrations of listed Hazardous Wastes in 40 CFR Part 261? Yes No

Is this material a TSCA Regulated Waste? Yes No

Does this material contain TCLP Volatile or Semi-Volatile Organics? Yes No

Does this material contain TCLP Herbicides or Pesticides? Yes No

J. Generator’s Certification: I hereby certify that all information submitted in this and all attached documents are true and accurate descriptions of this waste. This waste has not been combined or blended in any amount with PCB’s, Herbicides, Pesticides, or any other material defined as Hazardous Waste. Generator/Shipper agrees to indemnify and hold Water Depot Inc. harmless for any damages arising from or in any way relating to a breach of this Certification Statement. I will be responsible for any cost associated with the cleanup, decontamination or fines associated with providing Water Depot Inc. with Hazardous or unacceptable material.

If electronically signing, I agree that my electronic signature below, is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding. To sign electronically, please check the box below, then type your first and last name. To use an ink signature, leave the box unchecked, print this document, and then hand write your signature in ink.

I understand that checking this box constitutes that I am opting to provide my electronic signature. My first and last name, typed below, is the legally binding equivalent to my handwritten signature. Conversely, I understand that to opt out of using my electronic signature, I have left this box unchecked, printed this document, and hand signed below in ink.

Generator’s Authorized Signature

Title

Date

Water Depot, Inc. Use Only

Approved By:__________________________________________________________________________ Approval Date:___________________

Check this box

ONLY if signing

electronically!