EMERGENCY RESPONSE*

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Liquid Industrial By-Product Re-Approval Notice Form

Liquid industrial by-product re-approval notice Form

Thank you for selecting Liquid Industrial By-Products, Inc. (LI) as your environmental management partner. To extend an expiring by-product approval or in the event that a by-product stream or process has changed, the generator may use this form to re-approve the by-product profile.

Please select one of the following options:

Generator Certification:

I certify and warrant to Liquid Industrial By-Products (LIBP) as follows: (1) all of the information contained on this by-product Re-approval form and attachments, if any, is accurate and complete as of the date of execution and, if re-approved by LIBP, will remain accurate as of the date of any and all pick-ups or delivery to LIBP; (2) the by-product is non-hazardous as defined in applicable federal, state or local statutes, rules, or ordinances; (3) this certification and warranty are based on my personal knowledge of the stream, the information presented, or my inquiries of the person(s) responsible for providing such information; and (4) I am authorized to execute this Re-approval on behalf of the generator identified on this form. I agree to contact LIBP, if there are any future changes in the nature of the by-product(s) sent to LIBP. 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.

Clear Signature
MM slash DD slash YYYY

For Liquid Industrial use only


Approved to extend

Not approved to extend 		New expiration date: ___________________________

Reason: ________________________________________

Please return completed document to Liquid Industrial By-Products, Inc.