Online Pre-Qualification Questionnaire

Online Pre-Qualification Questionnaire

Please complete the form below and someone will get back to you shortly or download the form, complete it and fax or email it to us, Download Here.

    Transporter Name*:

    Transport Company Phone Number*:

    Transport Company Email*:

    1. Generator Information

     

    Name/Title*:

    Contact First Name*:
    Phone*:
    EPA Number (if applicable):

     

    Permit Number (Industrial wastewater discharge):

    Street Address*:
    State*:

     

    Responsible Party Information (if a third party is representing the generator)

    Responsible Party Name/Title*:

    Responsible Party Phone*:

    Description of general activities conducted at generator’s facility*:

    eWaste Disposal, Inc. may not require laboratory analysis of wastes that are certified to contain no regulated metals, cyanide, toxic organic compounds, sulfides or chlorinated hydrocarbons.

    CERTIFICATION

     
    I certify that the information I have provided in response to the questionnaire contained in the PRE-QUALIFICATION QUESTIONNAIRE are true, correct and complete to the best of my knowledge. I understand that after reviewing the information you have provided, eWaste Disposal, Inc. may require a sample of the waste unidentified in the questionnaire be submitted for analysis prior to acceptance of the waste for treatment.

    Name/Title*:

    Email*:

    Date*:

    Generators and Waste Haulers Please Note:
    We Cannot accept waste water until the physical characteristics and waste water information has been reviewed and accepted. Please complete the separate physical characteristics and waste description for each waste water interceptor locator at this facility.

    PHYSICAL DESCRIPTION AND WASTE WATER INFORMATION SHEET

    Generator's Process Information

     

    GENERATORS PROCESS INFORMATION*: (Detailed description of specific activity which created the waste contained in this interceptor.)

    Samples being submitted were taken from (location and ID number):

    Check one:*
    ClarifierTrapHolding TankOther - please describe below

    Other (describe):

    3. Physical Characteristics and Description of Waste

     

    Select One*:
    LiquidMudSludgeSlurryOther - please describe below

    Other (describe):

    Water Concentration %*:

    Mud Concentration %:

     

    Waste Properties

     

    pH (Select One)*:0-22-44-66-88-1010-1212-14
    Odor (Select One)*:NoneLowMediumHigh
    Color (Select One)*:ClearLightDarkBlack

     

    4. Component Listing

     

    Arsenic*: YESNOMaybe
    Approx (mg./l):
    Cadmium*: YESNOMaybe
    Approx (mg./l):
    Chromium*: YESNOMaybe
    Approx (mg./l):
    Copper*: YESNOMaybe
    Approx (mg./l):
    Lead*: YESNOMaybe
    Approx (mg./l):

     

    Does the waste contain (or could it contain) any measurable amount of total identifiable CHLORINATED HYDROCARBONS?*:YesNo

    Constituent / Concentration (mg./l) - If yes, please list the source and approximate concentrations:

     

    Does the waste contain (or could it contain) any known or suspected TOXIC ORGANIC COMPOUNDS? (Examples: Benzene, Toluene, etc.)?*:
    YesNo

    Constituent / Concentration (mg./l) - If yes, please list the source and approximate concentrations:

     
    Could the waste contain SULFIDES in excess of 0.1 mg/l?*:YesNo

    Constituent / Concentration (mg./l) - If yes, please list the source and approximate concentrations:

     
    Please up-load any additional information regarding this waste stream.

    This includes any analytical or MSDS information that is available.