TE 5 DLA FORM 2511.pdf

Page of

HAZARDOUS WASTE PROFILE SHEET Prescribed by: DOD 4160.21-M &

DRMS-I 4160.14

Sponsor: Disposition Services

DLA FORM 2511, NOV 2016 (Formerly DRMS Form 1930) PDF (DLA)

PART I

NOTE: Explosives, Shock Sensitive, Pyrophic, Radioactive, and Etiological Waste are not normally accepted by the DLA Disposition Services Site.

Contact your DLA Disposition Services Site for further guidance if your waste meets any of these categories.

A. GENERAL INFORMATION

1. GENERATOR'S NAME: WASTE PROFILE NO.:

2. FACILITY ADDRESS: 3. ZIP CODE 4. GENERATOR USEPA ID: 5. GENERATOR STATE ID:

6. TECHNICAL CONTACT: 7. TITLE: 8. PHONE:

B. WASTE INFORMATION

1. NAME OF WASTE:

2A. US EPA WASTE CODE: A

F

B

G

C

P

D

Q

E2B. DEMIL CODE:

2C. STATE/LOCAL/HOST-NATION WASTE CODES:

3. PROCESS GENERATING WASTE:

4. PROJECTED ANNUAL VOL.: 5. MODE OF COLLECTION:

6. IS THIS WASTE A DIOXIN LISTED WASTE AS DEFINED IN 40 CFR 261.31? YES NO

7. IS THIS WASTE RESTRICTED FROM LAND DISPOSAL? (40 CFR 268)

HAS AN EXEMPTION BEEN GRANTED?

DOES THE WASTE MEET APPLICABLE TREATMENT STANDARDS ALREADY?

(If Yes, Enter Reference Standards in Part II, Block 6)

YES NO

YES NO

YES NO

PART II

1. MATERIAL CHARACTERIZATION (Optional - Unless otherwise indicated)

COLOR: DENSITY: BTU/LB:

TOTAL SOLIDS: ASH CONTENT LAYERING Multilayered Bilayered Single Phase

PHYSICAL STATE

(Mandatory) Solid Liquid Semi-Solid Gas Other

2. RCRA CHARACTERISTICS (Check all that apply) IGNITABLE (D001) CORROSIVE (D002) REACTIVE (D003)

WATER REACTIVE CYANIDE REACTIVE SULFIDE REACTIVE FLASH POINT: PH:

HIGH TOC (> 10%) LOW TOC (< 10%) TREATMENT GROUP: WASTEWATER NON-WASTEWATER

TOXICITY CHARACTERISTIC (D004-D043) CORRODES STEEL

3. CHEMICAL/MATERIAL COMPOSITION (List all components and contaminants, including PCB's and any applicable F-Listed and Underlying Hazardous Constituents)

CAS#

COMPONENT

Be as descriptive as possible. Chemical names or generic descriptions, e.g. 'sludge', paint solids, 'water', etc. are acceptable.

CONCENTRATION RANGE

DRMS-I 4160.14

Sponsor: Disposition Services

DLA FORM 2511, NOV 2016 (Formerly DRMS Form 1930) PDF (DLA)

(Continued)

3. MATERIAL COMPOSITION/UNDERLYING HAZARDOUS CONSTITUENTS

CAS#

COMPONENT

Be as descriptive as possible. Chemical names or generic descriptions, e.g. 'sludge', paint solids, 'water', etc. are acceptable.

CONCENTRATION RANGE

RANGE TOTAL MUST EQUAL AT LEAST 100%

4. SHIPPING INFORMATION:

DOT HAZARDOUS MATERIAL? (If "NO" skip to block 5)YES NO

PROPER SHIPPING NAME:

HAZARD CLASS: U.N. OR N.A. NO.: PACKING GROUP:

ADDITIONAL DESCRIPTION:

METHOD OF SHIPMENT BULK NON-BULK OTHER:

DOT REPORTABLE QTY (RQ) LBS (REF: 49 CFR 72.101, Appendix A)

EMERGENCY RESPONSE GUIDE EDITION: EMERGENCY RESPONSE NO.:

5. SPECIAL HANDLING INFORMATION

6.GENERATOR CERTIFICATION: CHEMICAL ANALYSIS (Attach Test Results)

USER KNOWLEDGE (Attach Supporting Documents) (Explain how and why these documents comply with RCRA requirements.

CERTIFICATION:

I, HEREBY CERTIFY THAT ALL INFORMATION SUBMITTED IN THIS AND ALL ATTACHED DOCUMENTS IS TO THE BEST OF MY KNOWLEDGE AN ACCURATE REPRESENTATION OF THE WASTE TURNED IN TO THE DLA DISPOSITION SERVICES SITE. ALL KNOWN

OR SUSPECTED HAZARDS HAVE BEEN DISCLOSED.

Signature of Generator's Representative

DATE:

DRMS-I 4160.14

Sponsor: Disposition Services

DLA FORM 2511, NOV 2016 (Formerly DRMS Form 1930) PDF (DLA)

INSTRUCTIONS:

PART I

A. GENERAL INFORMATION (Required) WASTE PROFILE NUMBER - A unique number assigned to this waste stream for future reference. The preferred format is a Generator DoDAAC + five digit serial number assigned by either the Generator or the DLA Disposition Service Site. any variation from this format must be approved by your DLA Disposition Service Site.

1. GENERATOR NAME - Enter the name of the generating facility. (Should match official name associated with the EPA ID number).

2. FACILITY ADDRESS - Enter the address of generating facility listed in block A1.

3. ZIP CODE - Enter the generating facility's five or nine-digit Zip Code.

4. GENERATOR USEPA ID - Enter the12-character, alpha-numeric descriptor issued by the USEPA to the facility identified in block A.1. (If not applicable, enter "NONE")

5. GENERATOR STATE ID - Enter the descriptor issued by the Resident State to the facility identified in block A.1.

6. TECHNICAL CONTACT - Enter the name of the person to contact for more information about this waste.

7. TITLE - Enter the Technical Contact's official title. (e.g. "HW-Manager", Shop Chief, etc.).

8. PHONE - Enter the Technical Contact's telephone number.

B. WASTE INFORMATION (Required)

1. Enter a name that is generally descriptive of this waste (e.g., paint wastes, oil water separator, sludge, PCB-contaminated dirt, etc.)

2A. USEPA WASTECODE(S) - List all that apply. If non-RCRA, enter "NONE".

2B. DEMIL CODES - Check applicable Demil Code.

2C. STATE/LOCAL/HOST NATION WASTE CODE(S) - List all that apply. If not applicable, enter "NONE".

3. PROCESS GENERATING WASTE - List the specific process/operation or source that generates this waste (e.g., paint-booth spray, PCB spill, metal plating operation, etc.).

4. PROJECTED ANNUAL GENERATIONS - The quantity of waste projected for turn-in annually, (preferably in pounds, but other units of measure may be used, e.g., gallons, kilograms, etc.)

5. MODE OF COLLECTION - Describe the method used to collect and store this waste stream (e.g. drums, tanks, etc.)

6. DIOXIN WASTE - Storage of Dioxin wastes requires special attention. If this waste is a USEPA-listed Dioxin waste, indicate "YES" and contact your DLA Disposition Service representative for further instructions.

7. A. IS THIS WASTE RESTRICTED FROM LAND DISPOSAL? - Check "YES" or "NO" B. HAS AN EXEMPTION BEEN GRANTED? - If "YES", explain in PART II, block 6, at "Explain how and why these documents comply with RCRA requirements".

C. DOES THIS WASTE MEET APPLICABLE TREATMENT STANDARDS ALREADY? - If "YES", explain in Part II, block 6, at "Explain how and why these documents comply with RCRA requirements".

PART II

1. MATERIAL CHARACTERIZATION (Optional unless otherwise indicated)

1. COLOR - Describe the color of the waste (e.g., blue, clear, varies, etc.)

2. DENSITY - The specific gravity of water is 1.0. Most organics are less than 1.0. Chlorinated solvents, most inorganics, and paint sludge are greater than 1.0.

3. BTU/LB - This entry may be required if you request that this waste be used as a fuel substitute.

4. ASH CONTENT - This entry may be required if you request recovery of used oil.

5. TOTAL SOLIDS - Content can be expressed as either a weight percentage, or dry-weight concentration (mg/kg).

6. LAYERING - Select applicable entry. Multi-layered means more than two layers (e.g., oil/water/solvent/sludge).

Bilayered means the waste is comprised of two layers which may or may not be the same phase (e.g., oil/water, solvent/sludge).

Single phase means the waste is homogeneous.

7. PHYSICAL STATE - If the choices do not apply, a description should be entered after "Other".

2. RCRA CHARACTERISTICS (Required as applicable) IGNITABLE - Check this box if the waste meets the criteria list at 40 CFR 261.21.

FLASH POINT - For liquids, list the flash point, regardless of whether the waste is ignitable (D001) or NOT.

TOTAL ORGANIC CARBON (TOC) - Required for Ignitable Liquids CORROSIVE - Check this box if the waste is corrosive as defined in 40 CFR 261.22.

- If applicable, include the PH reading in the space provided (40 CFR 261.22(a)(1).

- If applicable, check the "Corrodes Steel" box. (40 CFR261.22(a)(2) REACTIVE - Indicate if the waste is reactive as defined in 40 CFR 261.23. If so, indicate the reason by checking the appropriate box. If other than one of the reasons provided, explain n detail as Part II, "Special Handling Requirements."

TOXICITY CHARACTERISTICS - If the waste exhibits the characteristic of toxicity, as defined in 40 CFR 261.24, check this box, and include the contaminant level in Part II, block 3.

DRMS-I 4160.14

Sponsor: Disposition Services

DLA FORM 2511, NOV 2016 (Formerly DRMS Form 1930) PDF (DLA)

3. CHEMICAL/MATERIAL COMPOSITION (Required as applicable) CAS # - Chemical Abstract Number (Optional) May be used instead of the chemical name in the "Component" block.

COMPONENT - List all chemical and material contaminants.

- Examples of chemical components and contaminants.

"PCB's" "methanol", "oil", "endrin"," sodium chloride", "napthalene, gasoline, etc.

applicable F-listed constituents, e.g., for waste numbers F001-F005. For certain characteristic waste numbers, D001-D043, you have to examine the waste components for UHCs. Look in 40 CFR, Table 268.40. If the treatment standard given includes the words "and meet 268.48 standards"., then you must indicate any UHCs present in the waste (if they are present above the levels specified in part 268.48.

- Examples of material components and contaminants: water, dirt, sand, paint sludge, rags, etc.

CONCENTRATION - Use this column for constituents of concern which do not exceed 10,000 ppm (1%). Include the concentration level in ppm or mg/L.

RANGE - For components comprising greater than or equal to 1% of the total waste stream, estimate the range (in percent) in which the component is present. The total maximum values of the components must be greater than, or equal to 100%, including chemical and material components.

4. SHIPPING INFORMATION - Refer to 49 CFR to complete this part.

NOTE: Information provided in this portion of the waste profile is not meant to constitute a standard USDOT certificate given by a shipper offering a package to a transporter, but is needed to identify any other health and safety hazards, which are not readily apparent from the basic waste description.

5. SPECIAL HANDLING INFORMATION - Describe those hazards which you know or reasonably believe are or may be associated with short term or prolonged human exposure to this waste (29 CFR 1920.1200). If known, please identify any carcinogens present in this waste of 0.1% 29 CFR 1910.1200(d)(4). Failure to make an entry in this part is considered to be a representation that you neither know nor believe that there are any adverse human health effects associated with exposure to this waste.

6. GENERATOR CERTIFICATION (Required) CHEMICAL ANALYSIS - Attach a copy, if applicable (see Note below).

USER KNOWLEDGE - User knowledge is approriate when it can be documented (e.g., in-out logs, published information, MSDS, process production information, etc.). There is room provided to explain "what" and "why" user knowledge is used in lieu of analysis.

CERTIFICATION - Include the PRINTED NAME of the person providing the Certification Signature.

SIGNATURE - An authorized representative of the generator must sign and date this certification on the completed Hazardous Waste Profile Sheet.

DATE - Date Signed by Certifier*.

* This Hazardous Waste Profile Sheet (HWPS) may be used for subsequent turn-ins of the same waste stream, for a period of one year. If a turn-in date is more than one year past the Certification Date listed, the generator must either re-certify the HWPS, or provide a new HWPS, with the current date. See instructions at DOD 4160.14-M, Chapter 10, par. D.2.a(3)(b).

If you require assistance completing this form, please contact your local DLA Disposition Service Site.

HAZARDOUS WASTE PROFILE SHEET

Prescribed by: DOD 4160.21-M & DRMS-I 4160.14 Sponsor: Disposition Services DLA FORM 2511, NOV 2016 (Formerly DRMS Form 1930)

PDF (DLA)

DRMS1930 Sep 9 08.pdf

LSC1872

10.0.2.20120224.1.869952

PART I

NOTE: Explosives, Shock Sensitive, Pyrophic, Radioactive, and Etiological Waste are not normally accepted by the DLA Disposition Services Site.

Contact your DLA Disposition Services Site for further guidance if your waste meets any of these categories.

A. GENERAL INFORMATION

B. WASTE INFORMATION

2B. DEMIL CODE:

6. IS THIS WASTE A DIOXIN LISTED WASTE AS DEFINED IN 40 CFR 261.31?

7. IS THIS WASTE RESTRICTED FROM LAND DISPOSAL? (40 CFR 268)

HAS AN EXEMPTION BEEN GRANTED?

DOES THE WASTE MEET APPLICABLE TREATMENT STANDARDS ALREADY?

(If Yes, Enter Reference Standards in Part II, Block 6)

PART II

1. MATERIAL CHARACTERIZATION (Optional - Unless otherwise indicated)

LAYERING

PHYSICAL STATE (Mandatory)

2. RCRA CHARACTERISTICS (Check all that apply)

TREATMENT GROUP:

3. CHEMICAL/MATERIAL COMPOSITION (List all components and contaminants, including PCB's and any applicable F-Listed and Underlying Hazardous Constituents)

CAS#

COMPONENT

Be as descriptive as possible. Chemical names or generic descriptions, e.g. 'sludge', paint solids, 'water', etc. are acceptable.

CONCENTRATION

RANGE

(Continued)

3. MATERIAL COMPOSITION/UNDERLYING HAZARDOUS CONSTITUENTS

CAS#

COMPONENT

Be as descriptive as possible. Chemical names or generic descriptions, e.g. 'sludge', paint solids, 'water', etc. are acceptable.

CONCENTRATION

RANGE

RANGE TOTAL MUST EQUAL AT LEAST 100%

4. SHIPPING INFORMATION:

DOT HAZARDOUS MATERIAL? (If "NO" skip to block 5)

METHOD OF SHIPMENT

LBS (REF: 49 CFR 72.101, Appendix A)

6.GENERATOR CERTIFICATION:

CERTIFICATION:

I, HEREBY CERTIFY THAT ALL INFORMATION SUBMITTED IN THIS AND ALL ATTACHED DOCUMENTS IS TO THE BEST OF MY KNOWLEDGE AN ACCURATE REPRESENTATION OF THE WASTE TURNED IN TO THE DLA DISPOSITION SERVICES SITE. ALL KNOWN OR SUSPECTED HAZARDS HAVE BEEN DISCLOSED.

INSTRUCTIONS:

PART I

A. GENERAL INFORMATION (Required) WASTE PROFILE NUMBER - A unique number assigned to this waste stream for future reference. The preferred format is a Generator DoDAAC + five digit serial number assigned by either the Generator or the DLA Disposition Service Site. any variation from this format must be approved by your DLA Disposition Service Site.

1. GENERATOR NAME - Enter the name of the generating facility. (Should match official name associated with the EPA ID number).

2. FACILITY ADDRESS - Enter the address of generating facility listed in block A1.

3. ZIP CODE - Enter the generating facility's five or nine-digit Zip Code.

4. GENERATOR USEPA ID - Enter the12-character, alpha-numeric descriptor issued by the USEPA to the facility identified in block A.1. (If not applicable, enter "NONE")

5. GENERATOR STATE ID - Enter the descriptor issued by the Resident State to the facility identified in block A.1.

6. TECHNICAL CONTACT - Enter the name of the person to contact for more information about this waste.

7. TITLE - Enter the Technical Contact's official title. (e.g. "HW-Manager", Shop Chief, etc.).

8. PHONE - Enter the Technical Contact's telephone number.

B. WASTE INFORMATION (Required)

1. Enter a name that is generally descriptive of this waste (e.g., paint wastes, oil water separator, sludge, PCB-contaminated dirt, etc.)

2A. USEPA WASTECODE(S) - List all that apply. If non-RCRA, enter "NONE".

2B. DEMIL CODES - Check applicable Demil Code.

2C. STATE/LOCAL/HOST NATION WASTE CODE(S) - List all that apply. If not applicable, enter "NONE".

3. PROCESS GENERATING WASTE - List the specific process/operation or source that generates this waste (e.g., paint-booth spray, PCB spill, metal plating operation, etc.).

4. PROJECTED ANNUAL GENERATIONS - The quantity of waste projected for turn-in annually, (preferably in pounds, but other units of measure may be used, e.g., gallons, kilograms, etc.)

5. MODE OF COLLECTION - Describe the method used to collect and store this waste stream (e.g. drums, tanks, etc.)

6. DIOXIN WASTE - Storage of Dioxin wastes requires special attention. If this waste is a USEPA-listed Dioxin waste, indicate "YES" and contact your DLA Disposition Service representative for further instructions.

7. A. IS THIS WASTE RESTRICTED FROM LAND DISPOSAL? - Check "YES" or "NO" B. HAS AN EXEMPTION BEEN GRANTED? - If "YES", explain in PART II, block 6, at "Explain how and why these documents comply with RCRA requirements".

C. DOES THIS WASTE MEET APPLICABLE TREATMENT STANDARDS ALREADY? - If "YES", explain in Part II, block 6, at "Explain how and why these documents comply with RCRA requirements".

PART II

1. MATERIAL CHARACTERIZATION (Optional unless otherwise indicated)

1. COLOR - Describe the color of the waste (e.g., blue, clear, varies, etc.)

2. DENSITY - The specific gravity of water is 1.0. Most organics are less than 1.0. Chlorinated solvents, most inorganics, and paint sludge are greater than 1.0.

3. BTU/LB - This entry may be required if you request that this waste be used as a fuel substitute.

4. ASH CONTENT - This entry may be required if you request recovery of used oil.

5. TOTAL SOLIDS - Content can be expressed as either a weight percentage, or dry-weight concentration (mg/kg).

6. LAYERING - Select applicable entry. Multi-layered means more than two layers (e.g., oil/water/solvent/sludge).

Bilayered means the waste is comprised of two layers which may or may not be the same phase (e.g., oil/water, solvent/sludge).

Single phase means the waste is homogeneous.

7. PHYSICAL STATE - If the choices do not apply, a description should be entered after "Other".

2. RCRA CHARACTERISTICS (Required as applicable) IGNITABLE - Check this box if the waste meets the criteria list at 40 CFR 261.21.

FLASH POINT - For liquids, list the flash point, regardless of whether the waste is ignitable (D001) or NOT.

TOTAL ORGANIC CARBON (TOC) - Required for Ignitable Liquids CORROSIVE - Check this box if the waste is corrosive as defined in 40 CFR 261.22.

- If applicable, include the PH reading in the space provided (40 CFR 261.22(a)(1).

- If applicable, check the "Corrodes Steel" box. (40 CFR261.22(a)(2) REACTIVE - Indicate if the waste is reactive as defined in 40 CFR 261.23. If so, indicate the reason by checking the appropriate box. If other than one of the reasons provided, explain n detail as Part II, "Special Handling Requirements."

TOXICITY CHARACTERISTICS - If the waste exhibits the characteristic of toxicity, as defined in 40 CFR 261.24, check this box, and include the contaminant level in Part II, block 3.

3. CHEMICAL/MATERIAL COMPOSITION (Required as applicable) CAS # - Chemical Abstract Number (Optional) May be used instead of the chemical name in the "Component" block.

COMPONENT - List all chemical and material contaminants.

- Examples of chemical components and contaminants.

"PCB's" "methanol", "oil", "endrin"," sodium chloride", "napthalene, gasoline, etc.

applicable F-listed constituents, e.g., for waste numbers F001-F005. For certain characteristic waste numbers, D001-D043, you have to examine the waste components for UHCs. Look in 40 CFR, Table 268.40. If the treatment standard given includes the words "and meet 268.48 standards"., then you must indicate any UHCs present in the waste (if they are present above the levels specified in part 268.48.

- Examples of material components and contaminants: water, dirt, sand, paint sludge, rags, etc.

CONCENTRATION - Use this column for constituents of concern which do not exceed 10,000 ppm (1%). Include the concentration level in ppm or mg/L.

RANGE - For components comprising greater than or equal to 1% of the total waste stream, estimate the range (in percent) in which the component is present. The total maximum values of the components must be greater than, or equal to 100%, including chemical and material components.

4. SHIPPING INFORMATION - Refer to 49 CFR to complete this part.

NOTE: Information provided in this portion of the waste profile is not meant to constitute a standard USDOT certificate given by a shipper offering a package to a transporter, but is needed to identify any other health and safety hazards, which are not readily apparent from the basic waste description.

5. SPECIAL HANDLING INFORMATION - Describe those hazards which you know or reasonably believe are or may be associated with short term or prolonged human exposure to this waste (29 CFR 1920.1200). If known, please identify any carcinogens present in this waste of 0.1% 29 CFR 1910.1200(d)(4). Failure to make an entry in this part is considered to be a representation that you neither know nor believe that there are any adverse human health effects associated with exposure to this waste.

6. GENERATOR CERTIFICATION (Required) CHEMICAL ANALYSIS - Attach a copy, if applicable (see Note below).

USER KNOWLEDGE - User knowledge is approriate when it can be documented (e.g., in-out logs, published information, MSDS, process production information, etc.). There is room provided to explain "what" and "why" user knowledge is used in lieu of analysis.

CERTIFICATION - Include the PRINTED NAME of the person providing the Certification Signature.

SIGNATURE - An authorized representative of the generator must sign and date this certification on the completed Hazardous Waste Profile Sheet.

DATE - Date Signed by Certifier*.

* This Hazardous Waste Profile Sheet (HWPS) may be used for subsequent turn-ins of the same waste stream, for a period of one year. If a turn-in date is more than one year past the Certification Date listed, the generator must either re-certify the HWPS, or provide a new HWPS, with the current date. See instructions at DOD 4160.14-M, Chapter 10, par. D.2.a(3)(b).

If you require assistance completing this form, please contact your local DLA Disposition Service Site.