B.01.01 Section J, Attachment 2 - RWD Request Form.pdf

CENWK Blanket Purchase Agreement Request Form

Section A: GENERAL INFORMATION A1. Date Submitted:______________ A2. Requesting Agency/District: ____________________________________ A3. Project:_________________________________________________________________________ A4. Program: _______________________________________________________________________ A5: POC Name: ____________________ Email:_____________________ Phone:________________ A6. Labor Funding - (USACE cross labor code below) or MIPR/Funding # if not USACE: __________________ A6a. CECT-NWK-H (G5P000) Labor Code: ______________________ A6b. CENWK-ED-EG (G5L0350) Labor Code: ____________________ A6c. CENWK-ED-EH (G5L0320) Labor Code: ____________________ A7. Contract Funding - MIPR/Funding Number: ____________________________________________ A8. Pricing for transportation is requested Y/N: ____

Section B: GENERATOR INFORMATION B1. Generator and Site/Facility Name: ________________________________________________________ B2. Facility Address: ______________________________________________________________________ B3. Mailing Address: ______________________________________________________________________ B4. Technical Contact Name: ___________________ Phone: _________________ Fax: ________________ B5. Generator Status: CESQG____ SQG____ LQG____ NONE____ B6. EPA ID #:___________________ State ID #:____________________________ B7. Any Clarifying or Additional Information: _____________________________________________________ B8.Location of pickup (if transport required): _____________________________________________________ B9. Desired shipping date and turnaround time for disposal: _________________ ______________________

Section C: DESCRIPTION OF WASTE C1. Licensing history of waste:________________________________________________________________ C2. Regulatory/Contractual Description (Source; LARW; TENORM; SNM; AEA 11e-1,2,3,4; etc.):________________ C3. Other descriptors (e.g. Waste Class): _______________________________________________________ C4. Other information: ______________________________________________________________________

Section D: SHIPPING INFORMATION D1. US DOT Shipping name: _________________________________________________________________ D2. Hazard Class: _________________________________________________________________________

D3. UN/NA #: ____________________________

D4. Packaging Group: _____________________ D5. RQ: _________________________________________________________________________________ D6. Conveyance and Container Type (List all you want pricing for): e.g. Rail/Truck/IMC/Gon/Cask/Bulk/Totes/ Roll-Off/Drums/B-25/Sacks or Other: ___________________________________________________________ D7. Frequency: Year/Quarterly/Monthly/1 time/Other: _____________________________________________ D8. Shipment: Size: ____________________________ Quantity: ___________________________________ D9. Waste Import: Y/N: ____ D10. Highest package unshielded dose rate in mR/hr: _____________________________________________ D11: Decontamination level requested: ________________________________________________________

Section E: WASTE INFORMATION E1. Common name for this waste: _____________________________________________________________ E2. Process generating the material: ___________________________________________________________ E3. Describe physical appearance and odor of the waste: __________________________________________ E4. Odor of the waste: None/Slight/Strong: ______________________________________________________ E5. Physical State: % Liquid/ % Sludge/ % Solid: _________________________________________________ If Solid, % PPE, % Debris, % Soil, % Moisture, etc: ________________________________________________ E6. Describe Color: ________________________________________________________________________ E7. Liquid phases: Single/Double-layer/Multi-layer: ________________________________________________ E8. Knowledge is from: Lab analysis/MSDS/Process/generator knowledge: _____________________________ E9. Waste Type: Industrial/Non-Industrial/Hazardous/Non-Hazardous:_________________________________ E10. Is the waste restricted under EPA Land Disposal Restrictions (§268)? Y/N: ____ E11. If LDR “Yes”, is waste: Wastewater/ Non-wastewater /Debris (§268.2): ____________________________

E12. Alt. Standards for soil? Y/N: ____ E13. Is the waste RCRA hazardous waste containing benzene? Y/N: ____ E14. VOConc.(§264.1083): <500 ppmw ≥500ppmw: _______________________________________________ E15. Has waste been treated after point of generation? Y/N: ____ E16. CERCLA Regulated (Superfund) Waste: Y/N: ____ E17. Butadiene waste regulated by §63 Subpart XX: Y/N: ____ E18. Waste contains UHC constituent(s) (§268.48), other than those which exhibit a characteristic. Y/N: ____ E19. Waste exempt from definition of “solid waste” or “hazardous waste” Y/N: ___ (If Y, by 40CFR _________) E20. Is the waste oil bearing waste from Petroleum Refining, Production or Transportation practices: Y/N: ___ E21. Is the waste a marine pollutant: Y/N: ____ E22. State Waste Codes: ____________________________________________________________________ E23. RCRA Waste Codes: ___________________________________________________________________ E24. SIC Codes: ___________________________________________________________________________ E25. This material may be disposed without further treatment. Y/N: _______ If No, what treatment is required at the disposal facility? ______________________________________________________________________

Section F: WASTE SPECIFICS F1. Oxidizer Y/N: ____ F2. Explosive Y/N: ____ F3. Organic peroxide Y/N: ____ F4. Shock sensitive Y/N: ____ F5. Tires Y/N: ____ F6. Pyrophoric Y/N: ____ F7. Compressed gas Y/N: ____ F8. Halogenated organics Y/N: ____ F9. Reactive sulfides Y/N: ____ (if Y ____________ppm) F10. Reactive cyanides Y/N: ____ (if Y ____________ppm) F11. Water/air reactive Y/N: _____ F12. Thermally unstable Y/N: ____ F13. TSCA regulated PCB waste (control sheet required with shipment) Y/N: ___ If Y max PCB conc _____ppm F14. Does the waste contain asbestos? Y/N: ____ If yes, is asbestos friable_____ or non-friable_____ F14. Medical/infectious waste Y/N: ____ F15. Radioactive: Y/N: ____ Add information in F20.

F16. Possibility of incidental liquids from transportation? Y/N: ____ F17. Is waste a solid using the paint filter test? Yes (solid) No (not solid): ____ F18. pH: Range ________ to _________ Typical __________ F19. Flash Point: __________º F F20. Content and Concentration (Chemical and Radiological)A

Contaminant Chemical/Radionuclide

Average/Typical Concentration

Range Units Total mCi (Sum of all anticipated shipments)

U-238 U-234 U-235 Th-232 Th-230 Ra-226

A List all known contaminants: if any of first 6 are not present in the waste enter “NA”; if known to be present at typical background levels (as in soils) but not analyzed for, enter typical background level. Add additional Sheet if Required.

Use separate pages to attach any additional information necessary for bid/price quote.