Online Pre-Qualification Questionnaire

Transporter Name*:

Transport Company Phone Number*:

Transport Company Email*:

1. Generator Information



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


Permit Number (Industrial wastewater discharge):

Street Address*:


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.


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.




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.


2. 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 - Does the waste contain (or could contain) ANY of the following


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.)?*:

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.