Mars Environmental Services

Waste Questionnaire

Section 1: Contact Information -

Name:
Address:
City:
State:
Zip:
Contact:
Email:
Phone:
Fax:
EPA #:

Section 2: Billing Information -

Name:
Address:
City:
State:
Zip:
Contact:
Phone:
Fax:

Section 3: Description of Waste Product -

Common Name:
Process Name:
Is this waste hazardous by EPA standards:	Yes No
State Codes (opt):
EPA Codes(opt):

Section 4: Physical Properties of Waste Product (at 70°F) -

Physical State:	Layers:	Flash Point:	Viscosity, similar to:
Solid Liquid Sludge Empty Container Any free liquids at 70°F? Yes No	Multi Bi-layered Homogenous	<70°F 70 - 100°F 101 - 139°F 140 - 200°F None Exact:	Water Motor Oil Honey Other:

Section 5: Chemical Composition of Waste Product -

Chemical Name:	Min. %	Max. %
	-
	-
	-
	-
	-
	-
	-
	-
	-

Metals:
Total: (PPM)	EP Toxicity: (mg / liter)

Arsenic (As):		Barium (Ba):
Cadmium (Cd):		Chromium (Cr):
Copper (Cu):		Lead (Pb):
Mercury (Hg):		Nickel (Ni):
Selenium (Se):		Silver (Ag):
Zinc (Zn):

Pesticides, Herbicides (ppm):
Edrin:		Lindane:
Methoxychlor:		Toxaphene:
2,4-D:		2,4,5-TP:
Other:

Section 6: Shipping and Handling information -

DOT Hazmat?	Yes No
DOT Shipping Name:
DOT Hazard Class:
DOT ID Number:	PG:
Shipping Method:	Drum Bulk Other:
DOT Shipping Container:
Projected Volume:	Tons: Gallons: Yards³: Other:
Request Amount:	times per: Week Month Quarter Year
Additional Info:

Section 7: Generator Certification Statement -

I hereby certify that as an authorized representative of the generator named above, all information submitted in this and all attached documents is true and/or accurate. Analysis of the waste was conducted in accordance with the approved test methods in 40 CFR 261 on a representative sample as defined in 40 CFR 261.20. To the best of my knowledge, all known (40 CFR 261) and suspected hazardous components have been included in this documentation. All material and packaging will comply with all current regulations.