Section_J_-_Atch_66_-_Material-Waste_Transfer.pdf

Material / Waste Transfer Document Date:

NMR00000_______

Generator Information

Name: Bldg. No: Phone:

Organization Name: Organization Type:

Material / Waste Identification Item Description:

Associated Documents Reason for Turn-in

Container Description SAA Container No(s). Qty Type Size Volume Comments

Generator Certification: I certify to the best of my knowledge that the above material/waste identification and associated documents provided are accurate and complete.

(Printed Name) (Signature) (Date)

Physical and Visual Inspection Upon receipt, I have reviewed the provided information and have performed s physical and visual inspection of the containers and their content. As a result of my assessment I have determined this item to be:

Check all that apply: ____ Solid ____Semi-Solid ____Liquid

____Flammable (D001 – FP:____) ____Corrosive (D002 – Ph:____) ____Reactive (D003: ______________________)

____Toxic (EPA D, P or U Codes: _________, _________, _________) ____F-Listed (EPA Codes:_______, ________)

(Printed Name) (Signature) (Date)

Storage / Disposition Information

____RCRA Waste ____ Non-Regulated ____Universal ____Recycle/Scrap ____Other (______________________)

Storage Container ID No:__________________________ ASD:_____________ Storage Location:______________

DOT Shipping Name:__________________________________________________ Shipment No:_____________________

Shipping Date:_________________ Manifest No:_______________________ Manifest Line No:_____ CLIN:_______

Attachment 66 (Page 1 of 1)