Attachment_5_-_HWPS.pdf

HAZARDOUS WASTE PROFILE SHEET

PART I (Generator Information)

1. Waste Profile Number (Assigned by DRMO):

2. Generator Name:

3. Technical Point of Contact: 3. Title: Phone:

Fax:

4. Facility Address: (Include complete address and DoDAAC)

PART II (Chemical Information)

5. Name of Waste:

6. European Union Waste Code(s):

7. Process Generating Waste:

8. Projected Annual Quantity (in Kilograms):

9. Is this waste restricted from land disposal according to European Union Regulations? � Yes � No

10. Physical/Chemical Properties:

Layering: ' Multi-layered ' Bi-layered ' Single Phased Flash Point: Water Solubility: % pH: Boiling Point:

11. Material Characterization: Color: 12. Density:

13. Physical State: � Solid � Liquid � Gas � Semi-Solid � Dust

14. Material Composition: (Totals/ranges must equal 100%)

Component Concentration Range

15. Hazardous Material regulated for ADR shipment? � Yes � No

16. Proper Shipping Name:

17. Hazard Class / ADR Classification:: 18. UN Number:

19. Packing Method:

� Drum (Specifiy Size)_________________ � Original Container � Bulk � Other:

20. Special Health & Handling Information:

21. Basis of Information / Generator Certification:

� Chemical Analysis (Attach test results) � User Knowledge (Attach supporting documents -- User knowledge is appropriate when it can be documented (e.g. in & out logs, published info., MSDS, process production info., etc.).

I, __________________________________(print name), HEREBY CERTIFY THAT ALL INFORMATION

SUBMITTED IN THIS AND ALL ATTACHED DOCUMENTS ARE, TO THE BEST OF MY KNOWLEDGE,

AN ACCURATE REPRESENTATION OF THE WASTE TURNED INTO THE DRMO. ALL KNOWN OR

SUSPECTED HAZARDS HAVE BEEN DISCLOSED.

Signature of Generator's Representative Date

Solicitation 6 02 Attachment 5

PART III (WASTE CHARACTERISTICS)

22. TOXIC AND DANGEROUS WASTES

� Explosive � Extremely Flammable (FlashPoint <0 C AND Boiling Point 35 C)

� Easily Flammable (FlashPoint < 21 C)

� Flammable (FlashPoint 21 C and 55

� Carcinogen � Corrosive � Ecotoxic � Infectious � Irritant � Mutagenic � Noxious � Teratogenic � Toxic � Oxidizer � Water/Air Reactive � Other:

23. HAZARDOUS CONSTITUENTS

Indicate the concentration of the constituents, as applicable, in mg/l or mg/kg.

� Acedic Solutions/Solids � Antimony � Aromatic Compounds � Arsenic Concentration:

� Asbestos � Basic Solutions/Solids � Beryllium Concentration:

� Cadmium Concentration:

� Chlorates � Chromium Compounds (Hexavalent):

Concentration:

� Copper Compounds (Soluble):

Concentration:

� Cyanides (Inorganic) Concentration:

� Cyanides (Organics) Concentration:

� Halogenated Solvents Specify Halogen and Concentration:

� Isocyanates � Lead Concentration:

� Mercury Concentration:

� Metallic Carbonyles � Nitrites Concentration:

� PCBs/PCTs Concentration:

� Perchlorates � Peroxides � Pharmaceutical or Veterinary Compounds

� Phenols

� Plague Killers and other Biocides

� Polychlorated Dibenzofuran Compounds

� Polychlorated Dibenzo-para-dioxins

� Selenium:

Concentration:

� Tellurium:

Concentration:

� Thallium Concentration:

� Tar base products from refining/distillation ops

� Organo-halogenated Compounds Concentration:

� Used Synthetic or Mineral Oils, Including Water- Oil Mixtures and Emulsions

� Non-identifiable or new lab chemicals whose effects on the environment are unknown:

Explain:

24. SUGGESTED CONTRACT LINE ITEM NUMBER (CLIN) FOR DISPOSAL:

NOTE: Explosive and infectious wastes cannot be received by the DRMO.

Attachment 5