Spent Activated Carbon Identification Form

Spent Carbon Identification

Generator Information

Company:

Address:

City, State, Zip Code:

Site Location Address:

Site City, State, Zip Code:

U.S. EPA ID No.:

State ID No.:

Contact Name:

Title:

Telephone:

Spent Carbon Properties And Composition

Mesh Size:

Product Base, Other:

Foreign Material Present:

Yes

If Yes, Please Explain:

Odor:

Strong

Mild

None

Process Generating Spent Carbon, Other:

Application Description:

Classification

Is this US EPS Hazardous Waste:

Yes

If Yes, Waste Code:

Is this Carbon a Hazardous Waste as defined by State or Local Regulations:

Yes

If Yes, Waste Code:

Generator State Agency Information

(If spent carbon is manifested)

Agency Name:

Address:

City, State, Zip Code:

List of Contaminants (Organic Compounds and Metals) on spent carbon and range:

Spent Carbon pH:

Spent Carbon Flashpoint:

Regulatory

Is the total adsorbed organic constituents in excess of 35% by weight loading?

Yes

Does the carbon contain PCBs in excess of 50 ppm:

Yes

Does the carbon contain dioxins in the excess of 20 ppb:

Yes

Does the carbon contain any pesticides or herbicides:

Yes

Does the carbon contain any sulfur or cyanide containing compounds:

Yes

Does this carbon contain halogenated compounds:

Yes

Is this carbon subject to land ban regulations:

Yes

Does the spent carbon contain any per- and polyfluoroalkyl substances (PFAS):

Yes

Shipping Information

U.S. DOT Shipping Name and Hazardous Class:

Local Hazardous Waste Number of EPA Codes:

Shipping Amount:

Frequency:

Generator Certification

I hereby certify that all information on this online form contains a true and accurate description of the spent carbon and that the characterization of the spent carbon and classification of the spent carbon as either hazardous or non-hazardous has been made in accordance with applicable analytical testing and in accordance with applicable laws. Generator agrees to defend and hold the reactivator harmless from all liabilities claim losses arising out of or relating to any violation by the generator or client of any statute ordinance, regulation, law or other government requirements relating to the proper characterization and classification of the spent carbon including any applicable regulator requirements pertaining to the generation, storage, and transportation of any spent carbon.

Signature of Generator Authorized Agent (May be typed):

Name of Generator or Authorized Agent:

Title:

Date:

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Spent Carbon Identification Form

Spent Carbon Identification Form

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