Non-Hazardous Waste Form

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Generator Details

Generator NameMOE Generator Registration No.Type of Industry / BusinessSite AddressMailing Address (If different)Contact NameEmailPhonePhone ExtFaxAlternative Contact NameEmailPhonePhone ExtFax

Customer Details (For Billing Purposes) - Make dropdown

Customer details are the same as generator detailsCustomer NameMailing AddressContact NameEmailPhonePhone ExtFax

Waste Composition / Characterization / Proof of Classification

Common Name of the WasteCurrent MOE Class Code (If registered under reg. 347)LDR Primary Hazardous Waste NumberAdditional LDR Haz. Waste Number(s) (If applicable)TDGA Shipping NameUN #Primary Hazard ClassPacking Group (I, II, III)Generating Process (Detailed description)Waste Is

Composition of Waste

List all chemicals/compounds. Provide MSDS’s or analytical data if available.Check box if MSDS provided% and Chemical/Compound. If multiple please separate by rowsPhysical StatePhases/LayersLiquid %Sludge %Solid %Powder %ViscosityPourableColourpHSpecific GravityBTU/lbDescribe OdourOdourFlash Point & Boiling Point

Reactivity / Hazardous Characteristics

Is this waste any of the following?Other (please describe)

Shipping Information

Shipping Volume (per shipment)FrequencyContainer TypeDo you require replacement containers?What Types?

Attachments

Please upload related documentation for this waste stream (ie Sample, MSDS, Analysis, TCLP, LEP, Elements by Atomic Spectroscopy, PCB Analysis)Please check documentation included as attachments for this waste streamAnalysis (please specify)Other (please specify)

Hazardous Constituents

Check the boxes to confirm each of the hazardous constituents are below the regulatory values for Non-Hazardous waste as per Schedule 4 (Reg. 347/558).Inorganics (Metals & Anions)Nitrate + Nitrite (as Nitrogen) - 1000.0 mg/LSelenium 1.0 mg/LSilver 5 mg/LUranium 10.0 mg/LBased upon my knowledge of the waste and the process generating the waste, these constituents are not present in the waste above hazardous classification levels.

Dioxins & Furans

Dioxins & Furans - 0.0000015* mg/L*Toxic Equivalent (TEQ)Based upon my knowledge of the waste and the process generating the waste, these constituents are not present in the waste above hazardous classification levels.

Volatile Organic Compounds (VOC's)

Benzene 0.5 Mg/LCarbon Tetrachloride 0.5 Mg/LChloroform 10.0 Mg/L1,2-Dichlorobenzene 20.0 Mg/L1,4-Dichlorobenzene 0.5 Mg/L1,2-Dichloroethane 0.5 Mg/L1,1-Dichloroethylene 1.4 Mg/LDichloromethane 5.0 Mg/LTetrachloroethylene 3.0 Mg/LTrichloroethylene 5.0 Mg/LVinyl Chloride 0.2 Mg/LBased upon my knowledge of the waste and the process generating the waste, these constituents are not present in the waste above hazardous classification levels.

Extractable Organics

Benzo(a)pyrene 0.001 Mg/LCresol 200.0 Mg/Lm-Cresol 200.0 Mg/Lo-Cresol 200.0 Mg/Lp-Cresol 200.0 Mg/L2,4-Dinitrotoluene 0.13 Mg/LMethyl ethyl ketone 200.0 Mg/LNitrobenzene 2.0 Mg/LPentachlorophenol 6.0 Mg/LPyridine 5.0 Mg/L2,3,4,6-Tetrachlorophenol (2,3,4,6-TeCP) 10.0 Mg/L2,4,5-Trichlorophenol (2,4,5-TCP) 400.0 Mg/L2,4,6-Trichlorophenol (2,4,6-TCP) 0.5 Mg/L2,4-DCP 90.0 Mg/LBased upon my knowledge of the waste and the process generating the waste, these constituents are not present in the waste above hazardous classification levels.

Pesticides & Herbicides

Aldicarb 0.9 mg/LAldrin + Deldrin 0.07 mg/LAtrazine 0.5 mg/LAzinphos-methyl 2.0 mg/LBendiocarb 4.0 mg/LBromoxynil 0.5 mg/LCarbaryl / Sevin / 1-Naphthyl-N Methy Carbamate 9.0 mg/LCarbofuran 9.0 mg/LChlordane 0.7 mg/LChlorpyrifos 9.0 mg/LCyanazine 1.0 mg/L2,4-D / (2,4-dichlorophenoxy) acetic acid 10.0 mg/LDDT (total isomers) 3.0 mg/LDiazanon 2.0 mg/LDicamba 12.0 mg/LDiclofop-methyl 0.9 mg/LDimethoate 2.0 mg/LDinoseb 1.0 mg/LDiquat 7.0 mg/LEndrin 0.02 mg/LGlyphosate 28.0 mg/LHeptachlor + Heptachlor Epoxide 0.3 mg/LHexachlorobenzene 0.13 mg/LHexachlorobutadiene 0.5 mg/LHexachloroethane 3.0 mg/LLindane 0.4 mg/LMalathion 19.0 mg/LMethoxychlor 90.0 mg/LMethyl Parathion 0.7 mg/LMetolachlor 5.0 mg/LMetribuzin 8.0 mg/LParaquat 1.0 mg/LParathion 5.0 mg/LPhorate 0.2 mg/LPicloram 19.0 mg/LSimazine 1.0 mg/L2,4,5-TP (2,4,5-Trichlorophenoxy) priopionic acid 1.0 mg/LTemephos 28.0 mg/LTerbufos 0.1 mg/LToxaphene 0.5 mg/LTriallate 23.0 mg/LTriafluralin 4.5 mg/LBased upon my knowledge of the waste and the process generating the waste, these constituents are not present in the waste above hazardous classification levels.

PCB's

Polychlorinated Biphenyls 0.3 mg/LBased upon my knowledge of the waste and the process generating the waste, these constituents are not present in the waste above hazardous classification levels.

Other Compounds

Nitrilotriacetic Acid (NTA) 40.0 mg/LNitrosodiummethylamine (NDMA) 0.0009 mg/LBased upon my knowledge of the waste and the process generating the waste, these constituents are not present in the waste above hazardous classification levels.

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