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Special Waste Characterization Form
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View Instructions / Mail in copy of form:
Special Waste Characterization Form
GENERATOR/HAULER INFORMATION:
Are you a Waste Generator or Hauler?
*
Generator
Hauler
Company / Agency:
*
Contact Name:
*
Name of individual submitting request
Phone:
*
Fax:
Email:
*
Generator Address / Address:
*
Material generated outside Santa Rosa County?
*
Yes
No
Method of Payment:
*
Comm. Charge Account
Prepaid Account
Cash
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
Account #:
MATERIAL INFORMATION
Waste Name:
*
Disposal Request:
*
One Time
Recurring
If recurring, estimated number of loads or completion date:
Description of waste's origin:
*
Example: Sand blast media, domestic sludge, petroleum contaminated soil, etc..
ASBESTOS DISPOSAL ONLY
Asbestos Disposal?
*
Yes
No
Asbestos Disposal Only:
Friable:
Non-Friable:
Estimated Cubic Volume:
Material Packaging:
PHYSICAL / CHEMICAL CHARACTERISTICS
(Not required for Asbestos Disposal)
Laboratory Testing Documents
Yes
No
Please fill in Constituent levels in waste below. LRL = less than regulatory limit
Explain why you do not have laboratory testing documents:
Physical State:
Phases / Layers:
(Explain if more than one)
ph:
Flash Point:
Ar:
Ba:
Cd:
Cr:
Pb:
Hg:
Se:
Ag:
Oil:
Hydraulics:
Diesel:
Gasoline:
Other / Notes:
Attach Testing Documents (Required)
Attach laboratory analysis and MSDS (if applicable), constituent must equal 100%
STATUS
(Not required for Asbestos Disposal)
Resource Conservation and Recovery Act (RCRA) Haz-Waste
Yes
No
Has the waste been Treated?
Yes
No
Has the waste been Diluted?
Yes
No
Bio-hazardous
Yes
No
Does waste contain Herbicides?
Yes
No
Does waste contain Pesticides?
Yes
No
Does waste contain PCB's?
Yes
No
Does waste contain Solvents?
Yes
No
Any yes, explain:
Certification:
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.
*
I agree
Print Name:
*
Title:
*
Date:
*
Date:
Leave This Blank:
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