Adem Form 300 - Solid Waste Profile Sheet

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ALABAMA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
SOLID WASTE PROFILE SHEET
(Please Print or Type - Black Ink Only)
Check one:
New Certification
Recertification
Modification to a current certification (attach an explanation of the changes)
GENERAL INFORMATION
Generator
Name:
USEPA ID Number:
Location:
Mailing Address:
County:
Contact
Name:
Telephone:
Title:
Email Address: _________________________________________
Submitted by (if different from above):
Company
Contact
Name:
Name:
Mailing Address:
Telephone:
Email Address: ____________________________________
WASTE INFORMATION
Process Generating the Waste:
Waste Name:
If this waste is subject to the corrective action regulations of 40 CFR Part 280 (underground storage tank program), supply the following:
UST Facility Identification # ___ ___ ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___ ___ ___
UST Incident # UST___ ___ - ___ ___ - ___ ___
If this is petroleum-contaminated waste, what is the source of the contamination (e.g., gasoline, diesel, hydraulic oil, etc.)? ______________
Does this waste contain any of the following (give the concentration)?:
PCBs _____ppm
Cyanides _____ppm
Sulfides _____ppm
Annual Volume _____________
Remediation Waste
CERCLA Cleanup
Process Waste
WASTE PROPERTIES
Physical State:
If the waste is liquid or contains free liquid:
Solid
% Free Liquids:
Bladeable Sludge
pH:
Liquid
Flash Point:
Solid/Liquid Combination
Solidified prior to disposal?
If yes, please see the instruction page
WASTE DISPOSITION
If this is foundry waste, is it disposed (used as fill material) in accordance with ADEM Admin. Code R. 335-13-4-.26(3)?
_______________
Proposed Landfill(s): Name: _____________________________________________
Permit #: _________________
Name: _____________________________________________
Permit #: _________________
CERTIFICATION
I certify under penalty of law that this waste material does not contain regulated medical waste, regulated PCB waste, or hazardous waste which is not conditionally exempt from Division 14
Regulations. I further certify that, at the point of disposal, this waste material will not contain any free liquids. This document and all attachments were prepared under my direction or
supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or
persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate,
and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.
____________________________________________
____________________________________________
Name (type or print)
Signature
____________________________________________
____________________________________________
Title
Date
Profile Number ____ ____ ____ ____ ____ ____
ADEM FORM 300
5/14 m1
Certification Number SW - ___ ___ ___ ___ ___ ___ - ___ ___ ___ ___

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