Attachment 4_Waste Information Sheet.pdf

Ref: PSNS&IMFINST P5090.5

WASTE INFORMATION SHEET (WIS) SERIAL NO. 1 7 1 5 0 8

J. 0.SECTION I (Waste Originator) Complete a separate WIS for each type of waste.

Full instructions are provided on reverse Side- Shaded sections MUST be completed by originator.

t. ORIGINATOR (Shop. Ship, Code, Contractor): 2. PROJECTOR SHIP (Hull No. or Name): 3. LOCATION (Bldg., Pier, etc.):

4. POINT OF CONTACT (Name): 4a. PHONE: 5. GOVT. POC (Contractor’s Only):

6. WASTE DESCRIPTION (Not Waste stream Name): 7. WASTE PRODUCED IS:

□ One-Time Waste □ Process Waste

□ Unused Material □ Spill Waste

7a. Approximate Waste Quantity (No. of containers and container size):

□ Secondary Container

8. WASTE STREAM NO. (if known): 9. PRE-DESIGNATED WIS SER. NO. 10. PHYSICAL STATE AND COLOR:

(solid, liquid, sludge, aerosol, red, etc.)

11. HOW WASTE WAS MADE (Specify process that created this waste; include any applicable work document No., IPI, contract No., MILSPEC, etc.):

12. SDS NO. 13. MATERIAL OR TRADE NAME 14. NSN OR PART NO. 15. MANUFACTURER 16.% OF WASTE

1.

2.

3.

17. OTHER POTENTIAL CONTAMINANTS (Either check or include approx, concentration); Lab Analysis No._

□ ASBESTOS □ PCBs □ METALS □ SOLVENTS□ OIL □ OTHER, _(if applicable)

18. DISPOSITION TO BE PERFORMED BY (Contractors only): □ PSNS & IMF □ Contractor-Arranged (Enter proposed transporter and disposition facility.)

TRANSPORTER COMPANY (Name and phone number) _______________________________________________ ___________________ DISPOSITION FACILITY (Name and phone number)

19. ORIGINATOR’S SIGNATURE, BADGE NO. OR RANK, PRINTED NAME, AND DATE CERTIFYING THE MATERIALS NAMED IN SECTION I ARE THE COMPOUNDS IN THE WASTE CONTAINERS LISTED IN SECTION II AND HAVE NOT BEEN MIXED WITH OTHER MATERIALS.

(Sign). (Print).

(Badge No. or Rank) (Date)

SECTION II - CONTAINER INFORMATION (Originator complete Barcode, Cont. Type, and Start Date columns only.)

ITEM

NO.

ID LABEL

BARCODE NO.

CONT. TYPE

AND

CAPACITY

WEIGHT

(LBS)

OPEN AND

INSPECT

(Initials)

START DATE

(NA for Non- Haz Wastes)

STORAGE

SECTION

LAB ANALYSIS

NO.

SECTION III - SHOP 99HM RECEIPT AND INVENTORY

20. INSPECTION SAT? (Circle One):

YES NO (Explain in REMARKS) 20a. INSPECTOR’S INITIALS: 21. DELIVER TO:

22. TRANSPORTED BY (Signature and Date); 23. RECEIVED BY (Signature and Date):

SECTION IV - WASTE DISPOSITION BY CODE 106.33 24. D Check If WSN in Block 8 is correct and tech, resolution is not required.

25. WSN ASSIGNED: 26. DATE: 27. DESIGNATOR’S SIGNATURE: 28. PROFILE:

29. LABELS:

31. REMARKS:

30. DISPOSITION: □ Reutilize

□ HW □ PCB □ Asbestos

□ Landfill Controlled - WDA No.:

□ Recycle

□ Other__

□ Trash

Page 1 of.

PSNS&IMF 4855/612 (Rev. 11-2017) (Front) Routing: White: Shop 99HM Pink: Data Entry Blue: Handlers Yellow: Originator

WASTE INFORMATION SHEET (WIS) INSTRUCTIONS

GENERAL; TOIS PAGE PROVIDES BLOCIC-BY-BLGCK INSTRUCTIONS FOR THE ORIGINATOR.

NOTE: Shq) 99HM has discretiotj in completeness of shaded portions of WlS during waste turn-in pnx:ess.

• ■ Originators aie to complete all sections that are shaded in gray. Enter‘‘NA” if a block is not applicable.

• A job order number should be provided on ail WISs turned into Shop 99HM. A section is provided in the upper-right comer of the fomi for the job order number.

• Please write legibly and press hard enough to clearly imprint on all copies.

SECTION I

1.

2.

3.

4.

4a.

5.

6.

7.

7a.

8.

9.

10.

11, 12.

13.

14.

15.

16.

17.

18.

19.

ORIGINATOR. Tliis is the organization directly creating the waste material. Examples: “Code 350,” “Shop 67,” “ACME Painting.”

PROJECT OR SHIP. Enter the general project or job creating the waste. Examples: “CVN 72,” “BEQ Construction,” “Farragut Ave Repair,” “Shop 71 ” (for multiple projects “various'’ is acceptable).

PROJECT LOCATION. Record the location where the process occurred that created the waste. Be as specific as possible. Examples include:

“sump room - Bldg. 427.” “south end DD3,” “comer of Huey and Duey St.” (for multiple locatioas “various” is acceptable).

ORIGIN.ATOR POINT OF CONTACT. Write the name of the person who is sufficiently knowledgeable to answer questions concerning tlie waste-generation process. This person may be military, civilian, or contractor.

PHONE. List the phone number for the primary point of contact listed in Block 4. Include the area code.

GOVT, POC. THIS BLOCK IS FOR CONTRACTORS ONLY! List a government point of contact. Tliis is the government person who is the contracting officer’s representative.

W.ASTE DESCRIPTION. This block should match the “MATERIAL CONTENTS” section of the ID label located on tlie waste container. (Not to be used for the'Waste Stream Name.)

WASTE PRODUCED IS. Select the appropriate box for the w'aste being originated. “One-time-waste” means waste will not be generated again.

“Untised materials” means material that is excess, expired, or unwanted. “Process waste” means waste that was generated by an ongoing industrial process. “Spill Waste” means material that waste was generated during a spill.

TOTAL WASTE QUANTITY. List the actual number of waste containers inside the DOT container. Estimates are acceptable. Check “Secondary Container” when waste containers aie in DOT container. If tlie only container is the outer DOT container, use that container size and type. For e.xample: three 1-gallon cans in a 55 gallon drum would say "3 1 gallon cans" and the “Secondary Container” box would be checked wheieas a 55-ga!!on dnmi full of liquid would simply .say "I 55-gallon drum".

WASTE STRE.AM NUMBER. If the waste has an established waste stream number, write the number here. If uncertain, leave the block blank.

PRE-DESIGNATED WIS SER. NO. Enter the pre-designation WIS serial number in this block, if known. Otherwise leave die block blank.

PHYSICAL STATE AND COLOR. Describe the waste from a standpoint of what is seen, smelled, or feel (or a combination of diese) if die waste and opened and looked at it. Examples: “thick brown sludge” or “clear oily liquid with banana scent” or “white paste in tubes.”

HOW THE WASTE WAS MADE. Describe the process that created the waste. Be as specific as space allows. Examples: “mild steel water jet cutting'’ Of “removal of dirt. Physical Fitness Center,” or ‘"wiping grease from arresting gear cables,” or “excess from patteni gluing.” The words “excess” and “expired” are not processes. Use these w'ords with the process for which they were intended. Indicate die document diat governs the work process generating the waste. Tin's might be a contract, an IPI, a MILSPEC, an ASTM, an instruction, or any other type of document.

SDS NO. List the Safety Data Sheet number or numbers for hazardous materials that make up the waste.

MATERIAL OR TR.ADE NAME. Write the material or trade name of the product in this block.

NSN OR PART NO. List die stock number(s) of the material(s) that make up the waste. If the raaterial(s) was obtained through'the Federal Supply System, include the FSN and the NUN, if known. - MANUFACTURER. Indicate the manufacturer of the material that makes up the waste.

% OF WASTE. Write an approximate percentage of the material used in proportion to die waste originated. If e.xcess, expired, or unused material, specify “100%”. Ifempty container specify “<1%”.

OTHER POTENTIAL CONTAMINANTS and LAB ANA1.YS1S NO. Indicate potential contaminants that MAY be in the waste (include approximate concentration, if known). List lab analysis number, if applicable DISPOSITION PERFORMED BY. THIS SECTION IS FOR CONTRACTORS ONLY. Check “PSNS & IMF” if your contract states to turn the waste over to PSNS & IMF for disposal. Check “Contractor-Arranged” if the waste will be disposed using hon-govemment resources. If “Contractor-Arranged” is checked, indicate the name and phone number of the planned transporter and disposition facility.

ORIGINATOR’S SIGNATURE. This is the person authorized by the originator’s command or company to request and sign for HW commitments, aswell as having knowledge of the waste.sufficient tocertify an accuratewaste description, ‘

SECTION II

“ID LABEL BARCODE NO” column. Enter the ID Label Barcode Number of each container of waste. PLEASE WRITE CLEARLY. If there are more than four containers use a continuation sheet(s) or additional WlS(.s).

“CONT. TYPE AND CAPACITi'” column. Enter the type and capacity of each container being shipped. The codes defined in the table may be used to abbreviate some container types. . . , ' “START DATE” column. Enter the Start Date from Hazardous Waste or Washington State Dangerous Waste label on the container. Leave blank if the

CODE TV’PE CODE TYPE ■ CODE TYPE

CY Cylinder DF Fiber:dnim or plastic drum DT Dump Truck CF Fiber box or carton DM Metal drum ; : ^ TP Portable Tank

EX.AMPLE - “55g DM” is a 55-gallon metal drum, “5g DM’’ is a 5-gallon can.

PSNS&IMF 4855/612 (Rev. 11-2017) (Back)