NEWARK CARTING PRICING REQUEST

Print out the following page, fill-in all the appropriate information and fax to (973) 491-0046

or download the file, GENERATOR.DOC, and do the same.

A.            Waste Generator Information

1.     Generator Name:   ________________________________________________                       

2.     Phone:   _____/_______/_________

3.     Facility Street Address:  ____________________________________________                     

4.     State:   __________________________________

5.     Zip Code:  ________________                              

6.     County:   ________________________________

7.     Customer Name:  _______________________________                

8.     Customer Phone:  _____/______/_________    Fax:  _____/______/_________

9.     Customer Contact:  ______________________________                              

10.   Billing Address:  ___________________________________________________________________ Same as above ____

11.   Site Name:  ________________________________________________________________________ Same as above____

12.   Site Address:  ______________________________________________________________________ Same as above ____

B.             Waste Stream Information

1.             Description

                a.   Name of Waste:  ______________________________________________________

                b.   Process Generating Waste:  _____________________________________________________

                _______________________________________________________________________________

                _______________________________________________________________________________

2.             Shipping Information

                a. Anticipated Volume / Frequency:  __________  Drums____   Bulk ____  CY ____ Tons _____

                b. DOT Shipping Name:  __________________________________________________________

                c. Method of Shipment:  __________________________________________________________

3.             Physical Characteristics of Waste

                Color:  __________     Odor:  __________     % Free Liquids:  __________    

pH:  ___ <2         ___ 9 – 12.5     ___ 2 – 5     ___ >12.5     ___ 5 – 9    Actual ____

 (Total Waste Composition Must Equal 100%)

(Answer yes or no)

___ Oxidizer                ___ Pyrophoric              ___ Explosive                 ___ Radioactive    

___ Carcinogen           ___ Infectious                 ___ Shock Sensitive       ___ Water Reactive

Is the waste represented by this waste profile sheet a “Hazardous Waste” as defined by USEPA, Canadian, Mexican and/or state/province regulation in the location where generated or ultimately managed?  _____

Is this a USDOT Hazardous Material?  ______

Does the waste represented by this profile contain any of the carcinogens which require OSHA notification?  _____

Does the waste represented by this profile contain any dioxins? _____

Does the waste represented by this profile contain any asbestos? _____  

If yes….. Friable ____  Non-Friable ____

Does the waste represented by this profile contain any benzene? _____   If yes, concentration _______ ppm

Does the waste represented by this profile a RCRA waste? _____

If yes, list waste codes: __________________________________________________________________________

Does the waste represented by this profile a listed waste?  _____

If yes, list waste codes: ___________________________________________________________________

Does the waste represented by this profile contain any PCB’s?  _____   If yes, concentration _______ ppm

Has all relevant information within the possession of the Generator regarding known or suspected

hazards pertaining to the waste been disclosed to the Contractor?  ______

Laboratory Analysis Attached:    _____ Yes     _____ No

 GENERATOR CERTIFICATION

I hereby certify that all information submitted in this and all attached documents are true and accurate based on my inquiry of those individuals immediately responsible for obtaining this information.  I believe that the submitted information is true and complete to the best of my knowledge and that all suspected hazards have been disclosed.

Signature: ___________________________________     Title:  _________________________    

Print Name: __________________________________     Date:  _________________________