CHESAPEAKE WASTE SOLUTIONS, INC.

2005 Old Greenbrier Rd. Suite 106, Chesapeake, VA 23320     Phone (757) 461-6850     Fax (757) 461-4772

Proprietary Waste Application for SPSA Facilities

Download a Copy of the Form

I
CUSTOMER INFORMATION Date:
Applicant's Name:
Address:
City/State/Zip: ,
Contact Person:
Phone Number:
Invoicing Contact:
Invoicing Address:
Is applicant the generator of the waste?
If no, Generator Name:
Address:
Contact Name:
Phone Number:
Generator EPA ID No.:
II
WASTE INFORMATION
Generator's Description of Waste:
Describe Process Generating Waste:
Reason for Destruction:
Current Disposal Method:
Physical State:
Liquid Semi-Solid Solid Granular
Powder Other
Color: Odor: pH Range:
CAS #: % Moisture:
III
WASTE CONSTITUENTS
List all active and/or inactive ingredients, chemical names and/or forumulas contained in the material.
Chemical Name/Ingredients Percent
Supporting analytical documentation to be emailed to edougherty@cwsva.com as PDF files.
Note: Additional analytical documentation may be required for consideration of acceptance to SPSA facilities.
MSDS Sheet Sample of Material Sulfides
Total Metals Sampling Plan Cyanides
TCLP Metals PCB's pH
TCLP Other TOX
Is the Material RCRA, TSCA or DOT Regulated?
Explain:
Does the material contain any Conditionally-Exempt Small Quantity Generator hazardous waste?
Does the material contain any medical waste?
Is the material flammable?
Does the material contain any PCB's?
Does this material contain or is it contaminated with used oil as defined by 40CFR Part 279?
If the material contains or is contaminated with used oil, please email analysis for total arsenic, cadmium, chromium, lead, total organic halogens,
PCBs and flash point to edougherty@cwsva.com. SPSA is permitted to burn used oil according to the
requirements of 40 CFR Part 279.65. SPSA�s EPA ID No. is VAR000500041.
Describe recommended fire fighting equipment and techniques:
Describe any safety equiment required during handling:
IV
SHIPPING AND TRANSPORTATION INFORMATION
Transporter Name:
Address:
Contact Name:
Phone Number:
Transporter EPA ID No. (for used oily waste only):
Delivery Vehicle:
Box Trailer Dump Trailer/Truck Roll-off
Flat Bed Walking Floor Tanker
Other
Shipping Container:
Steel Drums Gaylord Boxes Shrink-wrap on Pallets
Fiber/Poly Drums Super Sacs Pails
Roll-offs Other
Quantity per Delivery: Frequency of Delivery:
Special handling instructions/requests:
V
CERTIFICATION
I certify that all information submitted in this and all attached documents contain true and accurate descriptions of this material and all
relevant information regarding known or suspected hazards in the possession of the owner has been disclosed. I further certify that the
waste described above is not a hazardous waste under RCRA or any other current regulations and the waste contains no asbestos or
polychlorinated biphenyls (PCBs). The waste has not been exposed to or contaminated with any listed hazardous waste. I also certify
that this waste was generated with the proper local, state and/or federal permits and that the material poses no serious public safety or
health threats to SPSA facilities, operating personnel or the general public.
Authorized Signature: Date:
Company/Title: