WASTE GENERATOR PRE-QUALIFICATION ONLINE QUESTIONNAIRE

 

Please fill this form, then press the Submit button at the bottom of the page to electronically send your information to Southwest. Please note that the form is presently not residing on a secure server, so if you have security concerns, you may wish to submit your information in some other format.

If you need assistance with any of the following questions, please email feedback@southwesttreatment.com, telephone (800)900-3366; or fax (323)780-3170.

 

Transport Company / Phone: /

1. Generator Information:

Generator Name:
EPA #: (if applicable)
SIC #: (standard industrial classification)
Permit #: (industrial waste water discharge)
Address:
Address 2: (if necessary)
City, State, Zip:
Company Contact: Name, Title:
Telephone #:
Responsible party information: (if a third party is representing the generator)
Name, Title:
Telephone #:

Description of general activities conducted at generator's facility:

Southwest Treatment Systems, Inc. may not require laboratory analysis of wastes which are certified to contain no regulated heavy metals, cyanide, toxic organic compounds, sulfides or chlorinated hydrocarbons.

CERTIFICATION:

I certify that the information I have provided in response to the questionnaire contained in this PREQUALIFICATION QUESTIONNAIRE are true, correct and complete to the best of my knowledge. I understand that after reviewing the information you have provided, Southwest Treatment Systems, Inc. may require a sample of the waste unidentified in the questionnaire be submitted for analysis prior to acceptance of the waste for treatment.

Name of Applicant: Title:
E-mail address : Date:

 

GENERATORS and WASTE HAULERS PLEASE NOTE:

We cannot accept waste water until the physical characteristics and waste water information has been reviewed and accepted. Please complete the separate physical characteristics and waste description information section below for each waste water interceptor located at this facility.

 


PHYSICAL DESCRIPTION AND WASTE WATER INFORMATION SHEET


2. Generator's Process Information:

Detailed description of specific activity which created the waste contained in this interceptor:
Samples being submitted were taken from (location and ID number):
Check one:
Clarifier
Trap
Holding Tank
Other (describe):

3. Physical Characteristics and Description of Waste:

Physical State (check one):
Liquid
Mud
Sludge
Slurry
Other (describe):
Waste Composition:
Conc.%
Waste Composition:
Conc.%
Water:
Mud:
Other:
Other:
Waste Properties:
pH:
Explosive: YES NO ?
Odor:
Reactive: YES NO ?
Color:
Pyrophoric: YES NO ?

4. Component Listing:

Does the waste contain (or could it contain) ANY of the following:
YES
NO
?
APPROX. (mg./l)
YES
NO
?
APPROX. (mg./l)
Arsenic Mercury
Cadium Nickel
Chromium Silver
Copper Zinc
Lead Cyanide
Does the waste contain (or could it contain) any measurable amount of total identifiable CHLORINATED HYDROCARBONS?
(Check one): YES NO If yes, please list the source and approximate concentrations below:
Constituent / Conc. (mg/l) Constituent / Conc. (mg/l)
Does the waste contain (or could it contain) any known or suspected TOXIC ORGANIC COMPOUNDS?
Examples: Benzene, Toluene, etc.
(Check one): YES NO If yes, please list the source and approximate concentrations below:
Constituent / Conc. (mg/l) Constituent / Conc. (mg/l)
Could the waste contain sulfides in excess of 0.1 mg/l?
(Check one): YES NO If yes, please list the source and approximate concentrations below:
Constituent / Conc. (mg/l) Constituent / Conc. (mg/l)

To submit your completed questionnaire, click the submit button below.