Crosby & Overton- Environmental Services - Waste Treatment and Disposal Crosby & Overton- Environmental Services - Waste Treatment and Disposal
Phone: 562-432-5445
Fax: 562-491-2181
Waste Treatment Questionnaire
I. General Information
Generator Name:
Address:
City: State: Zip:
Contact:

Email:

Phone: Fax:
EPA Number:
Billing Name:
Address:
City: State: Zip:
Contact:
Phone: Fax:
II. Waste Product Description & Characteristics
A. Waste Product Common Name:
1. Process Generating Waste:
B. Hazardous Properties:  

1. U.S. EPA Hazardous Waste?
Yes No

 2. State Code (s):
 

EPA Code (s):
C. Physical Properties at 70°F

1. Pysical State:

2. Layers:

3. Flash Point
(closed Cup Only):

4. Viscosity, similar to:
Solid Multilayered < 70°F Water
Liquid Bi-Layered 70 - 100°F Motor Oil
Sludge Homogenous 101 - 139°F Honey
Empty Container   140 - 200°F Other:
Any free liquids at 70°F   No Flash  
Yes No   Exact:  

D. 1. Density:

2. % Solids:

3. Odor:

4. Ph:
Liquid lbs a gallon By Wieght None < 2
Solid lbs a gallon By Volume Strong 2 - 5
Any Debris in waste: Total: Mild 5.1 - 9
Yes No   Describe: 9.1 - 12.5
Explain:   > 12.5
        Exact:
E. Chemical Composition
(Account for 100% of total):
Range
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Metals:
Total (PPM)
EP Toxicity (mg a liter)
Pestciides, Herbicides: PPM

Edrin

Lindane

Methoxychlor

Toxaphene

2,4-D.

2,4,5-TP

Other:
Reactives & Other Wastes (PPM)
Cyanides
Sulfides
HOC
Dioxin
PCBs
Phenols
Arsenic (As)
Barium (Ba)
Cadmium (Cd)
Chromium (Cr)
Copper (Cu)
Lead (Pb)
Mercury (Hg)
Nickel (Ni)
Selenium (Se)
Silver (Ag)
Zinc (Zn)
F. Shipping and Handling Information 
1. D.O.T. Hazardous Material? Yes No
2. Proper D.O.T. Shipping Name:
3. D.O.T. Hazard Class:
4. D.O.T. ID Number: PG:
5. Method of Shipment: Drum and/or Bulk Other
6. D.O.T. Shipping Container
7. Projected Volume: Tons Gallons Cubic Yards Other
8. RQ Amount per One Time Week Month Quarter Year
Comments: 

III. Generator Certification Statement
I hereby certify that as an authorized representative of the generator named above, all information submitted in this and all the attached documents is true and/accurate. Analysis of the waste was conducted in accordance with the approved test methods in 40 CFR 261 on a representative sample as defined in 40 CFR 261.20. To the best of my knowledge, all known (40 CFR 261) and suspected hazardous components have been included in this documentation. All material and packaging will comply with all current regulations.