For Rumpke Use
Rumpke Approval Number:	Re-certification Date:

1. Generator Information
Company Name:	E-mail:
Street Address:	City:	County:	State:	Zip:
Company Contact:	Phone:	Fax:
EPA Generator ID # (if applicable):	Facility SIC Code:
2. Waste Generation Location
Generating Facility Location:
Street Address:	City:	County:	State:	Zip:
Facility Contact Name:	Phone:	Fax:
3. Billing Information
Company Name:	E-mail:
Street Address:	City:	State:	Zip:
Billing Contact:	Phone:	Fax:
Purchase Order Number:	Amount:	Expiration Date:
4. Waste Stream Information
a. Waste Description:
b. Process Generating the Waste:
c. Chemical Composition (Please list the complete composition of the waste. Total should be at least 100%. Ranges are acceptable.)
Constituent	%	Constituent	%
d. Virgin Product? Yes No MSDS attached? Yes No
e. Physical Form: Solid Semi-solid/Sludge Powder Liquid
f. Amount: Tons Cubic Yards Gallons Other:

Frequency: One time only Weekly Monthly Other:
g. Method of Shipment: Bulk/Loose Drum Bagged/Boxed Other:
h. Transportation by: Rumpke Other
i. Recommended Special Handling:
j. Does the waste contain free liquids?	Yes	No
k. Pursuant to 40 CFR 261 and applicable state regulations, is this waste a listed or characteristic hazardous waste?	Yes	No
l. Have Material Safety Data Sheets applicable to the waste been reviewed to determine if the material should be managed as a RCRA, TSCA, and/or othe regulated waste?	Yes	No
m. Does the waste contain regulated asbestos material?	Yes	No
n. Does the waste generate heat, fugitive dust, or exhibit a strong odor? (please specify)	Yes	No
o. Is this waste a listed DOT hazardous material? (please specify)	Yes	No
p. Does the waste contain any radioactive material, including NORM?	Yes	No
q. Does the waste contain any concentrations of PCBs?	Yes	No
r. Does the waste contain any infectious agents, DEA regulated substances, or FIFRA regulated substances? (please specify)	Yes	No
s. Is this a CERCLA regulated waste?	Yes	No

t. Has the waste been treated? If yes, please describe (attach additional information if necessary):	Yes	No
5. Sampling & Analysis
a. Has a representative sample (or samples) been analyzed to characterize this waste?	Yes	No
b. Representative Sample Certification:

1. Was the sample obtained in accordance with 40 CFR 261 or equivalent methods? Yes No

2. Type of sample(s): Grab Composite

3. Applicable sample ID names/numbers:

4. If multiple samples, briefly describe sampling protocol (attach additional information if necessary):
c. Please attach a copy of the final, signed laboratory report with case narrative and chain of custody. Preliminary reports will not be accepted.
6. Generator Certification
I certify I personally have examined and am familiar with the waste stream identified above and all information is true, accurate, and complete to the best of my knowledge. All analytical results, Material Safety Data Sheets, and other supporting information submitted are truthful and representative of the waste. No waste classified as hazardous waste, regulated PCB waste, infectious waste, or any other waste prohibited from being accepted by the disposal facility will be delivered for disposal. I am aware of the significant penalties for submitting a false certification, including the possibility of fine and imprisonment. I will immediately notify Rumpke of any changes to this waste that may impact its regulatory classification.

I am an employee of the company identified in Section 1 Generator Information.

I am an agent signing on behalf of the company identified in Section 1 Generator Information. Proof of authorization is available upon request.

Name: Title:

Signature: Date:

Rumpke Decision

Approved Rejected by:

Disposal Facility:

Approval Number:

Re-certification Date:

Waste Characterization Data Sheet Instructions

1. Generator Information: The company who is generating the waste.

2. Waste Generation Location: Where the waste is being generated.

3. Billing Information: The company to be billed.

4. Waste Stream Information

a. Waste Description: Name of the waste stream. Multiple waste streams cannot be combined for waste determination purposes.

b. Process Generating the Waste: Describe the process that generates the waste at the point of generation. Please include enough information to demonstrate no hazardous waste listings are applicable and to allow verification that all possible hazardous waste characteristics are addressed.

c. Chemical Composition: List all constituents of the waste stream in percentages (ranges are acceptable). Total percentage should be at least 100%.

d. Virgin Product?: Indicate if the waste is virgin (unused) material.

e. Physical Form: Indicate the physical structure of waste.

f. Amount and Frequency: Indicate the amount of waste in tons, cubic yards, gallons (liquids only), or other units. Also indicate if this is a “one-time” disposal and/or the frequency of disposal.

g. Method of Shipment: Indicate whether the waste is shipped in bulk/loose or if containerized in drums, boxes/bags, or other.

h. Transportation By: Company transporting the waste.

i. Recommended Special Handling: Provide any details to aid in handling the waste such as PPE requirements, incompatibilities, etc.

j. Does the waste contain free liquids?

A waste is considered to contain free liquids if it fails the Paint Filter Liquids Test Method 9095 as described in “Test Methods for Evaluating Solid Waste, Physical/Chemical Methods, EPA Publication SW-846.”

A predetermined amount of material is placed in a paint filter. If any portion of the material passes through and drops from the filter within the 5-min test period, the material is deemed to contain free liquids.

Rumpke cannot accept free liquids unless subject to our solidification program.

k. Pursuant to 40 CFR 261 and applicable state regulations, is this waste a listed or characteristic hazardous waste?

Indicate if the waste listed by the USEPA in 40 CFR 261 or in any state regulations as a P, U, F, or K-listed or a D-listed characteristic hazardous waste.

Federal regulations available at http://www.access.gpo.gov/nara/cfr/waisidx_07/40cfr261_07.html

Rumpke is not permitted to accept any hazardous waste

l. Have Material Safety Data Sheets applicable to the waste been reviewed to determine if the material should be managed as a regulated waste?

When applicable, MSDSs should be reviewed during the waste determination process. Indicate whether this has occurred.

m. Does the waste contain regulated asbestos material?

Indicate whether the waste contain any NESHAP-regulated asbestos containing material.

n. Does the waste generate heat, fugitive dust, or exhibit a strong odor? (please specify)

Indicate if the material would release dust to the air (baghouse dust, flour, etc.), generate heat if wetted or under other conditions, or have a strong odor. If yes, please specify

o. Is this waste a listed DOT hazardous material? (please specify)

Indicate whether the material is a DOT regulated hazardous material. If yes, please specify. Please note Rumpke is not permitted to transport any DOT hazardous materials.

p. Does the waste contain any radioactive material, including NORM?

Indicate if any radioactive material is present, including Naturally Occurring Radioactive Material (NORM).

q. Does the waste contain any concentrations of PCBs?

Indicate if any PCBs (polychlorinated biphenyls) are present, even if at <50 ppm. Please note Rumpke is no permitted to accept any TSCA-regulated waste.

r. Does the waste contain any infectious agents, DEA regulated substances, or FIFRA regulated substances?

Identify if any materials considered infectious/pathenogenic, regulated by the Drug Enforcement Agency, or regulated by the Federal Insecticide, Fungicide, and Rodenticide Act.

s. Is this a CERCLA regulated waste?’

Indicate if the waste originates from a CERCLA regulated facility.

t. Has the waste been treated?

If the waste has been treated to render it non-hazardous, less hazardous, safer to transport, or to otherwise change the physical, chemical, or biological character or composition of the waste?

5. Sampling & Analysis

a. Has a representative sample (or samples) been analyzed to characterize this waste?

If yes, go to 5b and 5c. If no, skip to Section 6.

b. Representative Sample Certification

1. Indicate if the sample was obtained in accordance with 40 CFR 261 or equivalent; 40 CFR 261

available at http://www.access.gpo.gov/nara/cfr/waisidx_07/40cfr261_07.html

2. Indicate sample type

3. Please identify the applicable sample ID names/numbers if an analytical report is submitted.

4. In the cases where multiple samples were obtained, include a description of the sampling

protocol utilized to obtain the sample (including rationale behind the number of samples,

locations of samples, sample types, etc.)

c. Please attach a copy of the final, signed laboratory report with case narrative and chain of

custody. Preliminary reports will not be accepted.

Analytical reports must be complete; partial copies are not acceptable.

The report must be signed by the laboratory reviewer.

The chain of custody must be included.

Preliminary results are insufficient.

Generator’s Waste Review and Certification

Please review the certification, check whether you are an employee of the generator or signing as an agent on behalf of the generator, and sign and date.

If you are an agent signing on behalf of the generator, you must provide proof of authorization to sign upon request.

12.11 Revision	page 2 of 4

Marie Ruebusch

2011-12-20

Rumpke