Waste Information Profile

4927 NW Front Ave Portland, OR 97210 OR CCB# 236005
Profile:
Cust#:
Exp. Date:

MonthDayYear
Rep App:
General Information:
Generator Name (Who is generating the waste):*
Generator Contact:*
Email:*
Phone Number:*

Area CodePhone Number
Generator Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Billing Information:
Click here if this information is the same as the Site/Generator Information
Billing Firm:*
Email:*
Contact:
Phone Number:

Area CodePhone Number
Fax Number:

Area CodeFax Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Waste Water Profile:
Is the load co-mingled?*

YesNo
Waste Description (choose one):*
How was the wastewater generated (process)?*
Method of Shipment:*

TankerVac TruckTote/DrumOther
Transportation Company:
Anticipated Volume:*
Transport Frequency*
Has a sample been sent to Patriot?*

YesNo
Is this material an EPA Hazardous Waste per RCRA 40 CFR §261 or regulated as hazardous in the state of origin?*

YesNo
Analytical Attached:*

YesNo
Analytical Attachment:

Browse Files

Cancelof
SDS Attached:*

YesNo
SDS Attachment:

Browse Files

Cancelof
Color:*
% Solids:*
pH:*
Flashpoint:*

Below 140FAbove 140F
Odor:*

NoneMildStrong
Dimethyl Sulfoxide (DMSO):*

YesNo
PCBs:*

YesNo
Cyanides:*

YesNo
Glycol:*

YesNo
Grease:*

YesNo
Oils:*

YesNoOther
Additional Compounds:*

AmmoniaSulfidesPhenolsNone of the above
Halogens:*

FluorineChlorineBromineIodineN/A
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 Patriot Environmental. Furthermore, I agree that any waste materials managed under any approval issued by Patriot pursuant to this request will be transported, delivered, or tendered to be in conformance with the waste characterization profile. Where Patriot 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:*

Clear
Printed Name:*
Title:*
Acceptance:
Printed Name:
Title:
Date

MonthDayYear
Should be Empty:

General Information:

Billing Information:

Waste Water Profile:

Certification: