Attachment_5_-_Sample_HWPS.pdf

SP4520-17-R-0001, Attachment 5

HAZARDOUS WASTE PROFILE SHEET

PART I (Generator Information)

1. Waste Profile Number (Assigned by DLA Disposition Services Site):

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

SP4520-17-R-0001, Attachment 5

PART III (WASTE CHARACTERISTICS)

22. TOXIC AND DANGEROUS WASTES

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

Easily Flammable (FlashPoint < 21C)

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 DLA Disposition Services.