Generator Waste Profile
Generator Name: Generator EPA #
Facility Address:
Contact Name: Phone: Fax:
Customer/Billing Address
Customer Name:
Billing Address:
Contact Name: Phone: Fax:
Waste Information
Waste Name:
Process Generating Waste:
Petroleum for Recycle: Gasoline: Diesel: Fuel Oil:
Date of Last Analysis: MSDS Available:
Volume: Frequency:
Does the waste contain: Listed Waste: Yes No
  Reactive Cyanide: Yes No
  PCB's: Yes No
  Reactive Sulfide: Yes No
  Herbicide or Pesticide: Yes No
Physical Characteristics
% Solid: % Sludge: % Liquid:
Odor: Color:
Composition: % %
Certification certifies that all information submitted in this and all attached documents is complete and accurate, that all known or suspected hazards have been disclosed, and that this waste is classified as non-hazardous according to US EPA and any applicable State regulations.
Date: October 27, 2011