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2. View Instructions / Mail in copy of form:
   Special Waste Characterization Form
6. GENERATOR/HAULER INFORMATION:
8. Are you a Waste Generator or Hauler?*

   1. Generator

   1. Hauler
10. Company / Agency:*
11. Contact Name:*
    Name of individual submitting request
13. Phone:*
14. Fax:
16. Email:*
17. Generator Address / Address:*
19. Material generated outside Santa Rosa County?*

    1. Yes

    1. No
23. Method of Payment:*

    1. Comm. Charge Account

    1. Prepaid Account

    1. Cash

    1. Credit/Debit Cards

    Credit/Debit Cards must be in name of person presenting for payment or if company card must match logo on disposal vehicle
25. Account #:
29. MATERIAL INFORMATION
31. Waste Name:*
32. Disposal Request:*

    1. One Time

    1. Recurring
34. If recurring, estimated number of loads or completion date:
36. Description of waste's origin:*
    Example: Sand blast media, domestic sludge, petroleum contaminated soil, etc..
40. ASBESTOS DISPOSAL ONLY
42. Asbestos Disposal?*

    1. Yes
    2. No
44. Asbestos Disposal Only:

    1. Friable:

    1. Non-Friable:
45. Estimated Cubic Volume:
47. Material Packaging:
51. PHYSICAL / CHEMICAL CHARACTERISTICS
    (Not required for Asbestos Disposal)
53. Laboratory Testing Documents

    1. Yes
    2. No

    Please fill in Constituent levels in waste below. LRL = less than regulatory limit
55. Explain why you do not have laboratory testing documents:
57. Physical State:
58. Phases / Layers:
    (Explain if more than one)
59. ph:
60. Flash Point:
62. Ar:
63. Ba:
64. Cd:
65. Cr:
67. Pb:
68. Hg:
69. Se:
70. Ag:
72. Oil:
73. Hydraulics:
74. Diesel:
75. Gasoline:
77. Other / Notes:
79. Attach Testing Documents (Required)
    Attach laboratory analysis and MSDS (if applicable), constituent must equal 100%
83. STATUS
    (Not required for Asbestos Disposal)
85. Resource Conservation and Recovery Act (RCRA) Haz-Waste

    1. Yes
    2. No
86. Has the waste been Treated?

    1. Yes
    2. No
87. Has the waste been Diluted?

    1. Yes
    2. No
88. Bio-hazardous

    1. Yes
    2. No
90. Does waste contain Herbicides?

    1. Yes
    2. No
91. Does waste contain Pesticides?

    1. Yes
    2. No
92. Does waste contain PCB's?

    1. Yes
    2. No
93. Does waste contain Solvents?

    1. Yes
    2. No
95. Any yes, explain:
99. Certification:
101. I certify that the information furnished on this application is true and accurately describes the material that is being disposed of at the Santa Rosa County’s Central Landfill and that the materials is not a hazardous waste, nor does it exhibit characteristics of hazardous waste as defined by federal, state or local regulations.*

     1. I agree
103. Print Name:*
104. Title:*
105. Date:*
     Date:
Leave This Blank:


107. 1. Receive an email copy of this form.
108. Email address

     This field is not part of the form submission.

109. Submit

* indicates a required field