Waste Information Profile

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

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

Area Code Phone Number
Generator Address: *

Street Address

Street Address Line 2

City State

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

Area Code Phone Number
Fax Number:

Area Code Fax Number
Address:

Street Address

Street Address Line 2

City State / Province

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

Yes No
Waste Description (choose one): *
How was the wastewater generated (process)? *
Method of Shipment: *

Tanker Vac Truck Tote/Drum
Transportation Company:
Anticipated Volume: *
Transport Frequency *
Has a sample been sent to Patriot? *

Yes No
Is this material an EPA Hazardous Waste per RCRA 40 CFR §261? *

Yes No
Analytical Attached: *

Yes No
Analytical Attachment:

Browse Files

Cancel of
SDS Attached: *

Yes No
SDS Attachment:

Browse Files

Cancel of
Color: *
% Solids: *
pH: *
Flashpoint: *

Below 140F Above 140F
Odor: *

None Mild Strong
Dimethyl Sulfoxide (DMSO): *

Yes No
PCBs: *

Yes No
Cyanides: *

Yes No
Glycol: *

Yes No
Grease: *

Yes No
Oils: *

Yes No
Additional Compounds: *

Ammonia Sulfides Phenols None of the above
Halogens: *

Fluorine Chlorine Bromine Iodine N/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

Month Day Year
Should be Empty:

General Information:

Billing Information:

Waste Water Profile:

Certification: