Non-Hazardous Waste Form

Generator Details

Generator Name

MOE Generator Registration No.

Type of Industry / Business

Site Address

Mailing Address (If different)

Contact Name

Phone

Phone Ext

Fax

Alternative Contact Name

Phone

Phone Ext

Fax

Customer Details (For Billing Purposes)

Customer details are the same as generator details

Customer Name

Mailing Address

Contact Name

Phone

Phone Ext

Fax

Waste Composition / Characterization / Proof of Classification (reg. 2.2.1) [SOR/2014-152]

Common Name of the Waste

Current MOE Class Code (If registered under reg. 347)

LDR Primary Hazardous Waste Number

Additional LDR Haz. Waste Number(s) (If applicable)

TDGA Shipping Name

UN #

Primary Hazard Class

Subsidiary Hazard Class

Packing Group (I, II, III)

Generating Process (Detailed description)

Waste Is

Unused Raw Materials

Spent

Off-Spec Product

Composition of Waste

List all chemicals/compounds. Provide MSDS’s or analytical data if available.

Check box if MSDS provided

Chemical/Compound

Attachments

Please upload related documentation for this waste stream (ie Sample, MSDS, Analysis, TCLP, LEP, Elements by Atomic Spectroscopy, PCB Analysis)

Upload Files

Please check documentation included as attachments for this waste stream

Analysis (please specify)

Other (please specify)

Hazardous Constituents

Check the boxes to confirm each of the hazardous constituents are below the regulatory values for Non-Hazardous waste as per Schedule 4 (Reg. 347/558).

Inorganics (Metals & Anions)

Arsenic

2.5 mg/L

Barium

100.0 mg/L

Boron

500.0 mg/L

Cadmium

0.5 mg/L

Chromium

5.0 mg/L

Cyanide

20.0 mg/L

Fluoride

150.0 mg/L

Lead

5.0 mg/L

Mercury

0.1 mg/L

Nitrate + Nitrite (as Nitrogen)

1000.0 mg/L

Selenium

1.0 mg/L

Silver

5 mg/L

Uranium

10.0 mg/L

Based upon my knowledge of the waste and the process generating the waste, these constituents are not present in the waste above hazardous classification levels.

Dioxins & Furans

Dioxins & Furans

0.0000015* mg/L

*Toxic Equivalent (TEQ)

Based upon my knowledge of the waste and the process generating the waste, these constituents are not present in the waste above hazardous classification levels.

Volatile Organic Compounds (VOC's)

Benzene

0.5 Mg/L

Carbon Tetrachloride

0.5 Mg/L

Chloroform

10.0 Mg/L

1,2-Dichlorobenzene

20.0 Mg/L

1,4-Dichlorobenzene

0.5 Mg/L

1,2-Dichloroethane

0.5 Mg/L

1,1-Dichloroethylene

1.4 Mg/L

Dichloromethane

5.0 Mg/L

Tetrachloroethylene

3.0 Mg/L

Trichloroethylene

5.0 Mg/L

Vinyl Chloride

0.2 Mg/L

Based upon my knowledge of the waste and the process generating the waste, these constituents are not present in the waste above hazardous classification levels.

Extractable Organics

Benzo(a)pyrene

0.001 Mg/L

Cresol

200.0 Mg/L

m-Cresol

200.0 Mg/L

o-Cresol

200.0 Mg/L

p-Cresol

200.0 Mg/L

2,4-Dinitrotoluene

0.13 Mg/L

Methyl ethyl ketone

200.0 Mg/L

Nitrobenzene

2.0 Mg/L

Pentachlorophenol

6.0 Mg/L

Pyridine

5.0 Mg/L

2,3,4,6-Tetrachlorophenol (2,3,4,6-TeCP)

10.0 Mg/L

2,4,5-Trichlorophenol (2,4,5-TCP)

400.0 Mg/L

2,4,6-Trichlorophenol (2,4,6-TCP)

0.5 Mg/L

2,4-DCP

90.0 Mg/L

Based upon my knowledge of the waste and the process generating the waste, these constituents are not present in the waste above hazardous classification levels.

Pesticides & Herbicides

Aldicarb

0.9 mg/L

Aldrin + Deldrin

0.07 mg/L

Atrazine

0.5 mg/L

Azinphos-methyl

2.0 mg/L

Bendiocarb

4.0 mg/L

Bromoxynil

0.5 mg/L

Carbaryl / Sevin / 1-Naphthyl-N Methy Carbamate

9.0 mg/L

Carbofuran

9.0 mg/L

Chlordane

0.7 mg/L

Chlorpyrifos

9.0 mg/L

Cyanazine

1.0 mg/L

2,4-D / (2,4-dichlorophenoxy) acetic acid

10.0 mg/L

DDT (total isomers)

3.0 mg/L

Diazanon

2.0 mg/L

Dicamba

12.0 mg/L

Diclofop-methyl

0.9 mg/L

Dimethoate

2.0 mg/L

Dinoseb

1.0 mg/L

Diquat

7.0 mg/L

Diuron

15.0 mg/L

Endrin

0.02 mg/L

Glyphosate

28.0 mg/L

Heptachlor + Heptachlor Epoxide

0.3 mg/L

Hexachlorobenzene

0.13 mg/L

Hexachlorobutadiene

0.5 mg/L

Hexachloroethane

3.0 mg/L

Lindane

0.4 mg/L

Malathion

19.0 mg/L

Methoxychlor

90.0 mg/L

Methyl Parathion

0.7 mg/L

Metolachlor

5.0 mg/L

Metribuzin

8.0 mg/L

Paraquat

1.0 mg/L

Parathion

5.0 mg/L

Phorate

0.2 mg/L

Picloram

19.0 mg/L

Simazine

1.0 mg/L

2,4,5-TP (2,4,5-Trichlorophenoxy) priopionic acid

1.0 mg/L

Temephos

28.0 mg/L

Terbufos

0.1 mg/L

Toxaphene

0.5 mg/L

Triallate

23.0 mg/L

Triafluralin

4.5 mg/L

Based upon my knowledge of the waste and the process generating the waste, these constituents are not present in the waste above hazardous classification levels.

PCB's

Polychlorinated Biphenyls

0.3 mg/L

Based upon my knowledge of the waste and the process generating the waste, these constituents are not present in the waste above hazardous classification levels.

Other Compounds

Nitrilotriacetic Acid (NTA)

40.0 mg/L

Nitrosodiummethylamine (NDMA)

0.0009 mg/L

Based upon my knowledge of the waste and the process generating the waste, these constituents are not present in the waste above hazardous classification levels.

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