Wastewater Information Profile (WIP)

Address: *

Third Party Administrator/Broker/Property Owner
Representing Firm:
Click here if this information is the same as the Site/Generator Information
Billing Information:

(If the account is already set up, just include the firm and Email)
Billing Firm: *
Account # (if the account is already setup):
Email: *
Contact:
Title:
Mobile:
Phone:
Fax:

Address:

Site Address

Section 5: Submission
Certification:
I have attached analytical, MSDS or other supporting documents regarding this single source waste stream.
I certify under penalty of law that this document, all attachments and supporting materials were prepared and presented by me or under my direct supervision and that the information provided is a true accurate and complete representation of the waste materials to be presented for evaluation and management by PPV, Inc. Furthermore, I agree that any waste materials managed under any approval issued by PPV pursuant to this request will be transported, delivered, or tendered to be in conformance with the waste characterization profile. Where PPV determines a waste to be non-conforming, the generator shall be responsible for all costs associated with timely return of the waste to generator or for other alternate and lawful management of the non-conforming waste conducted on behalf of the generator.
Relinquished By (please sign digitally): *

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Printed Name: *
Title: *
Date

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PPV Acceptance:
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Date

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