1) | Receiving Facility Name: | phone: | |||||||
Address: | fax: | ||||||||
2) | Customer Name: | phone: | |||||||
Address: | fax: | ||||||||
3) | Property Owner Name (where waste originated): | phone: | |||||||
Address: | fax: | ||||||||
4) | Hauler Name: | phone: | |||||||
Address: | fax: | ||||||||
5) | Consultant Name: | phone: | |||||||
Address: | fax: | ||||||||
6) | Amount of waste: | ||||||||
7) | Original Location of Special Waste: | ||||||||
8) | Activity Which Generated Waste: | ||||||||
9) | Description of Waste. Include any Applicable Dangerous Waste Code: | ||||||||
10) | Does Waste Have Potential to Create Fugitive Dust? | Yes_____ | No_____ | ||||||
If Yes, What is your Plan to Mitigate Dust? | |||||||||
11) | Amount of wastes in pounds or tons: | ||||||||
special waste waste analysis | |||||||||
Customer Must Initial the Appropriate Item. | |||||||||
1. | Wastes were designated through testing | ||||||||
2. | Wastes were designated by other means | ||||||||
Customer Certifies That: | |||||||||
1. | The Waste sampled and intended for disposal under this Certification is special waste as defined in WAC 173 303 040 | ||||||||
2. | The Waste has no free liquids per WAC 173-303-110 (3)(c)(i). | ||||||||
Signature | Date | ||||||||