Liberty Environmental Solutions Quote Request Form

Quote Request Form

1. Generator Information		2. Billing Information
Name:		Name:
Facility Address:		Mailing Address:
Mailing Address:		City/ST/ZIP:
City/ST/ZIP:		Contact Name:
Technical Contact:		Phone Number:
Phone Number:		Fax Number:
Fax Number:
US EPA ID Number:

3. Waste Stream Common Name:

4. Process Generating Waste:

5. Anticipated Volume:	Type:	Frequency:
6. Packaging Size:	Type:
7. Physical State:
8. Color:	Odor:

9. 100% CHEMICAL COMPOSITION (Do not abbreviate chemical names)
Chemical	Exact%	Range%








10. Paint Filter Test Pass Fail

% Free Liquids	% Water

11. pH	Specific Gravity	Density

12. Flash Point	BTU/LB

Flammable Solid Yes No

13. Viscosity

14. MATERIAL IS:	YES	NO
Air or Water Reactive
Unstable
Radioactive
Shock Sensitive
Pyrophoric
Explosive
Ethiological

DOES THIS MATERIAL CONTAIN OSHA:

Carcinogens Pesticides Herbicides

15. Metal Content TCL
		mg/L	mg/L EPA Limit
Arsenic	(As)		5.0
Barium	(Ba)		100.0
Cadmium	(Cd)		1.0
Chromium	(Cr)		5.0
Lead	(Pb)		5.0
Mercury	(Hg)		0.2
Selenium	(Se)		1.0
Silver	(Ag)		5.0

16. ADDITIONAL CONTENTS (Specify Units)

Cyanides Phenols Sulfides

Toluene Ethyl benzene Xylene

PCB's

17. ORGANIC CONTENT - TCLP EXTRACT ONLY -
Does the waste contain any of the following at or above the concentrations specified?

	EPA LIMIT				EPA LIMIT
	(mg/L)	YES	NO		(mg/L)	YES	NO
Benzene	0.50			Hexachlorobenzene	0.13
Carbon Tetrachloride	0.50			Hexachlorobutadiene	0.50
Chlordane	0.03			Hexachloroethane	3.00
Chlorobenzene	100.0			Lindane	0.40
Chloroform	6.00			Methoxychlor	10.00
o-Cresol	200.00			Methyl Ethyl Ketone	200.00
m-Cresol	200.00			Nitrobenzene	2.00
p-Cresol	200.00			Pentachlorophenol	0.70
Cresol	200.00			Pyridine	5.00
2,4-D	10.0			Tetrachloroethylene	0.70
1,4-Dichlorobenzene	7.50			Toxaphene	0.50
1,2-Dichloroethane	0.50			Trichloroethylene	0.50
1,1-Dichloroethylene	0.70			2,4,5-Trichlorophenol	400.00
2,4-Dinitrotoluene	0.13			2,4,6-Trichlorophenol	2.00
Endrin	0.02			2,4,5-TP Silvex	1.00
Vinyl Chloride	0.20

The proceeding constituent composition is based upon:

An attached Waste Analysis

KNOWLEDGE of the hazard characteristic of the waste in light of the materials or process used.

18. Is the waste hazardous per 40 CFR 261.3? Yes No

19. Other Hazardous constituents per 40 CFR 261 Appendix VIII (Specify ppm or wt.%)

20. Special Handling Instructions ( Include extra page)

I certify and warrant that all information as appears in this form and any attachments and supplements is true, accurate, and that all known or suspected hazards have been disclosed. I further certify and warrant that this identification is the result of an analysis of a representative sample obtained and analyzed in accordance with the procedures specified by the U.S. Environmental Protection Agency (SW-846).

I agree to abide to the payment terms of the facility.

Authorized Signature: _____________________________

Title:______________________________ Date:________________

Printed Name: