Waste Profile Form

Larson & Associates, Inc.

Filtration Specialists

Generator Information

Name
Street
City
State
Zip
Phone Number

Click here if Site Address is same as above.

Street
City
State
Zip
Phone Number

Waste Description

Volume in Gallons:

Describe the process(s) by which this waste is generated:

Does this waste contain any petroleum products?	YES	NO
Is the waste a characteristic or listed hazardous waste defined by 40 CFR Part 261?	YES	NO
Was the Knowledge of Process used?	YES	NO
If yes, is the sump associated with engine washing or degreasing processes, used oil or used antifreeze spills or disposal, the use or spilling of hazardous chemicals/materials? If no products are present please state such.	YES	NO

Comments:

Was any analyses performed? YES NO. If Yes please attach copies of all analyses performed.

The following certifications are required:

PESTICIDE/HERBICIDE WARRANTY

I hereby certify the following: The waste identified in Section B of this waste profile form does not contain Endrin, Methozychlor, 2,4-D Lindane, Toxaphene, 2,4,5, -TP (Silvex), Chlordane, or Heptachlor (and its Epoxide). These constituents are not used at the location where this waste was generated, nor are they known to be present in the materials of which the above waste is comprised. Hence, there is no reason to suspect their presence in the waste.

Generator’s Initials (Please write your Full Name)