Spent Media ID Form

GENERATOR INFORMATION
Company (required)


Address (required)


City, State ZIP (required)


Site Location Address (required)


Site EPA ID No. (if applicable)


SPENT MEDIA PROPERTIES AND COMPOSITION
General Description of Spent Media
Mesh SizePelletizedGranular
Foreign MaterialYesNo
If yes Explain

Process Generating Spent Media
Groundwater RemediationIndustrial Waste StreamChemical ProcessingFood ProcessingPotableSolvent RecoveryAir FiltrationVOC Control

CLASSIFICATION
Is this a U.S. EPA Hazardous Waste:YesNo
Waste Code
Is the media a Hazardous Waste as defined by State or local regulations?YesNo
Waste Code
Generator State Agency Information (if spent media is manifested)
Agency Name and Address:

List of Contaminants (organics and metals) on spent media, please include ranges pH and Flash Point (required)


REGULATORY
Does the spent media exceed the following limits?
Total adsorbed organic constituents in excess of 35% by weightYesNo
Any adsorbed total metals in excess of the following limits:Arsenic (100 ppm) Mercury (50 ppm)Lead (100 ppm)Silver (50 ppm)Chromium (100 ppm) Barium (2000 ppm)Cadmium (100 ppm) Thalium (100 ppm)Antimony (100 ppm) Nickel (100 ppm)Beryllium (100 ppm) Selenium (20 ppm)
Does the media contain PCB’s in excess of 50 ppm?YesNo

Does the media contain dioxins in excess of 20 ppb?YesNo

Does the media contain pesticides or herbicides?YesNo

Does the media contain sulfur/cyanide-containing compounds?YesNo

Does the media contain Halogenated compounds?YesNo

Is the media subject to land ban regulations?YesNo

SHIPPING INFORMATION
U.S. DOT Shipping Name and Hazard Class:

Local Hazardous Waste Number of EPA Codes:

Shipping Amount and Frequency


GENERATOR CERTIFICATION
I hereby certify that all information on this and all attached documents contain a true and accurate description of the spent media and that the characterization of the spent media and classification of spent media as either a hazardous or non-hazardous waste has been made in accordance with applicable laws. Generator agrees to defend and hold the reactivator harmless from all liabilities claim losses arising out of or relating to any violation by the generator or client of any statute ordinance, regulation, law, or other governmental requirements relating to the proper characterization and classification of the spent media including any applicable regulator requirements pertaining to the generation, storage, and transportation of any spent media.I Certify

*By selecting "I Certify" using any device, means, or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.

Digital Signature of Generator or Authorized Agent: (required)

Title (required)



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