A. GENERATOR INFORMATION



A. GENERATOR INFORMATIONB. CUSTOMER/BILLING INFORMATION1. Generator Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????______1. Billing Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2. Address: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????___2. Address: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????City: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????County: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????___ City: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????County: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????State: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Zip: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????_______ State: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Zip: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3. Site Location (if different): FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????____3. Contact Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????______4. Phone Number: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? 4. Contact Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????___5. Fax Number: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5. Phone Number: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????_______6. Payment by cash check or credit card? FORMCHECKBOX YES FORMCHECKBOX NO, please bill my account. If no account is in place, please call 515-323-6515 to apply. 6. Fax Number: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????_____Email Address: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????_____PO # if required by the Bill-To Customer:? ?_________________________ (If a PO # is required to be on the invoices, this # must be provided before waste can be brought in).C. TRANSPORTER INFORMATIOND. AGENT/CONSULTANT INFORMATION1. Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????1. Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????_____2. Street Address: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2. Street Address: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????____ City: FORMTEXT ????? FORMTEXT ?????State: FORMTEXT ?????Zip: FORMTEXT ????? City: FORMTEXT ????? FORMTEXT ?????State: FORMTEXT ????? FORMTEXT ?????Zip: FORMTEXT ?????_____3. Phone Number: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????___3. Phone Number: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????___4. Fax Number: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4. Fax Number: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5. Contact Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????____5. Contact Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????E. WASTE STREAM INFORMATION1. Common Name of Waste: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2. Detailed Description of Process: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3. Physical State at 70F FORMCHECKBOX Solid FORMCHECKBOX Semi-Solid FORMCHECKBOX Liquid FORMCHECKBOX Powder FORMCHECKBOX Other FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4. Odor: FORMCHECKBOX None FORMCHECKBOX Mild FORMCHECKBOX Significant: (describe) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? 5. Color: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????6. Flash Point: FORMTEXT ????? F FORMTEXT ????? C7. Reactive: FORMCHECKBOX NO FORMCHECKBOX YES with FORMTEXT ????? FORMTEXT ?????8. pH Range: FORMTEXT ????? FORMTEXT ?????9. Heat Generating Waste FORMCHECKBOX NO FORMCHECKBOX YES10. Free Liquid: FORMCHECKBOX NO FORMCHECKBOX YES11. Water Content: FORMTEXT ????? % by water12. Does the waste contain U.S.D.O.T. hazardous materials, PCB’s, or asbestos? FORMCHECKBOX NO FORMCHECKBOX YES13. Does the waste contain any etiological agents or untreated medical waste? FORMCHECKBOX NO FORMCHECKBOX YES14. Is the proposed waste a hazardous waste as defined by Federal or State regulations? FORMCHECKBOX NO FORMCHECKBOX YESF. SUPPLEMENTAL INFORMATION1. Attached Document(s): FORMCHECKBOX None FORMCHECKBOX MSDS FORMCHECKBOX Certified Analytical Report FORMCHECKBOX Memo/Letter FORMCHECKBOX Process Knowledge 2. If analytical data is attached, is the data derived from testing a representative sample in accordance with 40 CFR 261 and/or other applicable laws? FORMCHECKBOX YES FORMCHECKBOX NOG. SHIPPING INFORMATION1. Packaging: FORMCHECKBOX Bulk Solids FORMCHECKBOX Bulk Liquids FORMCHECKBOX Drums FORMCHECKBOX Roll-Off FORMCHECKBOX Dump Truck FORMCHECKBOX Tank Truck FORMCHECKBOX Other: FORMTEXT ????? FORMTEXT ????? 2. Estimated Volume: FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Tons FORMCHECKBOX Cubic Yards FORMCHECKBOX Drums FORMCHECKBOX Gallons/weight per gallon: FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMTEXT ?????3. Shipping Frequency: FORMTEXT ????? FORMTEXT ????? per FORMCHECKBOX One Time FORMCHECKBOX Monthly FORMCHECKBOX Yearly FORMCHECKBOX Other: FORMTEXT ????? FORMTEXT ?????4. Disposal Method: FORMCHECKBOX Landfill FORMCHECKBOX Solidification FORMCHECKBOX Bioremediation FORMCHECKBOX Other: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????H. GENERATOR’S CERTIFICATION STATEMENT:I hereby certify that the material named is not a hazardous waste as defined by 40CFR261 or any applicable state law, that all known or suspected hazards have been disclosed, that there are no other economical or environmentally safe ways to manage this material and that all information submitted is complete and accurate. If any of the above information changes, I agree to notify Metro Waste Authority prior to offering the waste for shipment or management.I, FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????(NAME, PLEASE PRINT) COMPANY NAME: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? PRINTED NAME: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????DATE: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? SIGNATURE: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????I. LANDFILL AUTHORIZATION:MWA Authorized Signature: Date:Landfill Manager’s Signature: Date:PLEASE COMPLETE AND RETURN THIS FORM TO:Liquid Waste Special Waste or Other WasteArthur Kern, Business Waste Management Representative Debra Danley, Special Waste RepresentativeRegional Collection Center Metro Park East Landfill1105 Prairie Drive S.W. 12181 N.E. University AveBondurant, IA 50035 Mitchellville, IA 50169Office: 515-967-5512 ext. 434 Office: 515-333-4475Fax: 515-967-1772 Fax: 515-967-7965Email: ake@ Email: dda@ ................
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