Office Use Only

Authorized by ___________ Profile# _________________

Date Received: ___________ Approved: Yes ___ No ___

Subcategory: Oil _________ Organics ________

GENERATOR CERTIFICATION/WASTE PROFILE Permit requires waste to be analyzed every 3 years.

GENERATOR INFORMATION

Generator Name: ________________________________________ Street: _________________________________________________ City: ___________________________ State: ____ Zip: _________ Contact Name: ___________________ Title: ___________________ Phone: _________________________ Fax: ____________________

Correspondence will be sent to:

Customer Name: _____________________________________________ Street: _____________________________________________________ City: __________________________ State: _______ Zip: ____________ Contact Name: __________________ Title: ________________________ Phone: _________________________Fax: ________________________ WASTE QUESTIONNAIRE (CHECK ALL THAT APPLY)

Is this material a hazardous waste (F, K, U, or P listed) as defined by 40 CFR 261 Subpart D? Yes ____ No ____

If yes to the above, identify the listing:

Has this material been mixed with a hazardous waste as defined by 40 CFR 261? Yes ____ No ____

Does this material exhibit: Ignitability? (40CFR Part 261.21) Yes ____ No ____

Any of the following hazardous: Corrosively?( 40CFR Part 261.21) Yes ____ No ____

Waste characteristics: Reactivity? (40 CFR Part 261.21) Yes ____ No ____

Toxicity? (40CFR Part 261.21) Yes ____ No____

Does this material contain: Herbicides, pesticides, insecticides? Yes ____ No ____

Dioxins? Yes ____ No ____

Radioactive substances? Yes ____ No ____

Domestic waste? Yes ____ No ____

Biohazardous materials Yes ____ No ____

Is this waste from an underground storage tank (UST)? Yes ____ No ____

If waste is derived from fuel, is the fuel leaded? Yes ____ No ____

Used Oil (as defined by CFR 279.1)

Is this material Used Oil as defined by 40CFR 279? Yes ____ No ____ Has this Used Oil been mixed with hazardous waste? Yes ____ No ____ Is the source of the waste a Conditionally Exempt Small Quantity Generator?

Yes ____ No ____

Does this Used Oil contain chlorinated paraffins? If yes, attach MSDS.

Yes ____ No ____

Does this Used Oil contain TSCA (40 CFR 761) regulate levels of PCB?

If yes list PCB level: Yes ____ No ____

Does this Used Oil contain less(<) then or equal to 1,000 mg/L total organic Halogens (TOX)?

(If 0, Mark “No”) Yes ____ No ____

* If no, rebuttal per 40CFR 279.10 (b)(1) (II) must be included.

Is this Used Oil soluble in water ? Yes ____ No ____

*if you checked yes to any of the above waste, it will not be accepted by WITS.

As the Generator of the Waste described above, I certify that I have provided all relevant information as required by this Profile, and that the information provided is, to the best of my knowledge, and

believe, true, accurate and complete. Generator agrees not to deliver or arrange for delivery of any material that does not conform to the waste characterized above in this profile. I further certify that

this material is not a RCRA hazardous waste pursuant to Federal, State, or Local Laws. The waste has not been mixed with any chlorinated solvents or any contaminants including, without limitation,

PCBs, Pesticides or other hazardous wastes. If Water Integrated Treatment Systems LLC. (WITS) accepts the material for processing, and the material is later determined by WITS, or any other person to

be, or contain hazardous waste within the meaning of any federal, state or local law or contain PCBs in sufficient quantity, to render it a TSCA regulated material the generator agrees to pay all costs

incurred by WITS to properly treat, store, dispose or otherwise handle the material and any fines or penalties resulting from WITS handling of the generator’s material. Generator agrees to promptly

notify WITS of any change in the composition of the material or process generating the material, and agrees to provide WITS with a new Generator/Certification Waste Profile prior to delivering new

material to WITS. The undersigned is an authorized representative of the generator.

Profile Information

State ID# US EPA ID: NAICS# Analytical Attached ____ MSDS Attached _____

Non-Hazardous Waste

Please Read and Sign Below * Generator Certification and Guarantee *

Generator Authorization Signature ___________________________ Print Name and Title_______________________________ Date___________

Is this a virgin or off-spec product? Yes ____ No ____

(If yes, must include MSDS)

Unused Product or Chemical? Yes ____ No ____

Waste Byproduct from Process? Yes ____ No ____

Spill Clean up? Yes ____ No ____

Planned Site Remediation? Yes ____ No ____

Representative Sample Provided ? Yes ____ No ____

Petroleum Contact Water (PCW)/Leaking? Yes ____ No ____

Underground Storage Tank (UST) Water? Yes ____ No ____

Is the generator a Conditionally Exempt Small Quantity Generator (CESQG)? Yes ____ No ____

Does this waste contain oils, lubricants, coolants or petroleum products? Yes ____ No ____

WASTE DESCRIPTION

Common name of Water:_______________________________________

Detail:_______________________________________________________

Process Generating Waste: ______________________________________

(Add additional sheet if necessary)

Analytical Provided? Yes__ No __ MSDS Provided? Yes __ No __

If no, waste may be rejected based on WIT System’s Laboratory Analysis.

PHYSICAL STATE

100% Solid without free liquid: ________ ________ % Free Liquid

100% Liquid with no solid: __________ ________ % Settled Solids

Liquid solid mixture: ________ ________ % Total Suspended Solids

LAYERS Single Phase: _______ Bi-layered: _________ Multi Layered: ______

pH < 2 ______ 2-6______

6-8______ 8-12.5___ > 12.5___ N/A_____

ODOR None: _____ Mild: ______ Strong: _____

FLASH POINT < 73F: ___ 73-100F: ___ 101-140F: ___

141-200F: ___ > 200F: ___

COLOR _________________

SPECIFIC GRAVITY Range _________ To __________

Waste Stream Composition % must equal 100 %

___________ _____% ___________ _____% Water Content _______%

___________ _____% ___________ _____% Total =100 %

Anticipated Volume: Day _____ Week ______ Month ______ Year _____ Once ____

*Wastes containing any concentrations of Mercury or Cyanide will not be accepted by WITS.