Liquid Industrial By-Product Profile Approval Form Liquid Industrial By-Product Profile Approval Form A. Generator Information (Material Origin)Generator Name:(Required)Site Address: (123 Main St)(Required)Site Address: (City, State Zip)(Required)Technical Contact:(Required)Email:(Required) Phone:ExtCell#:Generator US EPA Site ID #:(Required)To determine if a site ID # exists visit: https://www.egle.state.mi.us/wdspi/Home.aspxNot required for non-hazardous by-products. Use “MILIB” if no site id# is assignedType of Business:(Required)B. Billing Information Same as Generator Already on File Billing Name:Billing Address: (City, State Zip)AP ContactEmail: Phone:PO Number Required?(Required) Yes No Send invoice via:(Required) Mail Email Other Email address to send to:(Required)Other InstructionsC. Contractor/Transporter InformationWill you be having Liquid Industrial By-Products haul the material?(Required) Yes No Transporter Name:(Required)Address: City, State Zip(Required)Contact Name:(Required)Phone:(Required)Transporter USEPA Site ID #:(Required)D. Generator General InformationDoes the Generator have hazardous products onsite?(Required) Yes No If yes, name of product(s)(Required)If Yes, how are they disposed of?(Required)E. By-Product InformationDescription of the by-product & process generating the material (be specific)(Required)Analytical attached: Yes FileMax. file size: 320 MB.Other information attached (such as SDS)? Yes FileMax. file size: 320 MB.Volume Produced (in gallons)(Required)Frequency:(Required) Per Day Per Week Per Month Per Year 1x only Other Expected Shipping Method(Required) Bulk Drums Totes Other F. Regulatory InformationDoes the by-product contain any used oils?(Required)Any oil that has been refined from crude oil or any synthetic oil that has been used and as a result is contaminated by physical or chemical impurities. Yes No If Yes, does the used oil exceed 1000 mg/L of total halogens?(Required)The tote of organic and inorganic halogens expressed as chloride present in a used oil in ppm by weight. Yes No If Yes, please attach supporting documentation on how the generator has complied with the rebuttal requirement(Required)LIBP can assist with this. Attached File(Required)Max. file size: 320 MB.Is this by-product an exempted or delisted “hazardous waste”?(Required) Yes No If yes, please attach any supporting documentation Attached FileMax. file size: 320 MB.Does this by-product contain PCB’s?(Required)Polychlorinated biphenyl is a highly carcinogenic chemical compound, banned in 1978. Yes No Does this by-product contain Reactive Cyanides?(Required)Content that could generate toxic fumes when exposed to mildly acidic conditions. Yes No Does this by-product contain Reactive Sulfides?(Required)Simple salts of sulfides that react vigorously with acids to release hydrogen sulfide gas. Yes No Does this by-product contain Herbicides or Pesticides?(Required)Used to kill undesirable plants or pests. Yes No Does this by-product contain Graphite(Required)The crystalline form of the element carbon. Yes No pH of material(Required)acceptable results are between 2.1 & 12.4G. By-Product Classification (check which applies)Classification(Required) Mixed Solvents Coolants & Water Soluble Oils Water Based Cleaning Solutions Storm Sewer Cleanouts Car Wash Sludges Other By-Products Other Oil Pharmaceutical X-Ray/Photo Cleaning Solutions Sanitary Sewer Cleanouts Grease Trap Wastes PCB Brine Crankcase Oil Antifreeze H. Shipping document informationHow would you like the signed copy of the shipping document sent? With Invoice To generator address to attn of: Untitled To separate address to attn of: Untitled Other: UntitledI. Ongoing Analytical/Periodic TestingLI can provide ongoing analytical period testing (at generator’s expense) for DEQ and Environmental Auditing purposes.(Required) No, I do not require this information Yes, I would like my by-product stream(s) tested. LI Salesperson will contact you to discuss pricing, sampling, and verify details before proceeding. You can discuss frequency & method of sending data at that time. J. Generator Certification (please read and certify by signature)Generator Certification: I certify and warrant to Liquid Industrial By-Products (LI) as follows: (1) all of the information contained on this by-product profile form (Profile) and attachments, if any, is accurate and complete as of the date of execution of this Profile and, if approved by LI, will remain accurate as of the date of any and all pick-ups or delivery to LI; (2) the by-product is non-hazardous as defined in applicable federal, state or local statutes, rules, or ordinances; (3) I have disclosed on this Profile all known or suspected hazards associated with the by-products; (4) this certification and warranty are based on my personal knowledge of the stream, the information presented on this Profile, or my inquiries of the person(s) responsible for providing such information; and (5) I am authorized to execute this Profile on behalf of the generator identified on this Profile. I agree to contact LI, if there are any future changes in the nature of the by-product(s) described on this Profile. I will provide updated information, a new Profile as necessary, and additional information (like SDSs) well in advance of the following required pick-up date, allowing adequate review of the new stream and information. I acknowledge that LI may disclose this Profile to third parties, including governmental agencies: (1) as necessary to provide treatment and/or disposal services; (2) to comply with any applicable federal, state, or local law, rule, or ordinance; or (3) to respond to the request of a governmental agency. I acknowledge that LIWS will rely on this certification and warranty for purposes of making decisions regarding the transportation, treatment and disposal of the by-product as described. The generator identified on this Profile shall forever indemnify, defend, release and hold harmless LI, its officers, directors, shareholders, employees, and affiliates from and against all losses, liabilities, fines, penalties, claims, and costs (including reasonable attorneys’ fees) as a result of or in connection with any violation or alleged violation of any federal, state or local law, rule or ordinance which is caused by or arises out of (1) any breach of this certification and warranty; or (2) any negligent act or omission of the generator. Name (Print):(Required)Date:(Required) MM slash DD slash YYYY Title:(Required)Company:(Required)Certification Signature(Required) Δ
