Spent Carbon Identification Formtom hart2025-09-22T16:03:09-04:00 Download / Print PDF Generator Information Company Name: Address: City / State / ZIP: Site Location Address: Site City / State / ZIP: U.S. EPA ID No.: State ID No.: Contact Name: Title: Phone: Email: Spent Carbon Properties And Composition Mesh Size: Product Base: PelletizedGranularCoalCoconut ShellWoodLignite Product Base, Other: Foreign Material Present: YesNo If Yes, please explain: Odor: StrongMildNone Process Generating Spent Carbon: Ground Water RemediationIndustrial WastestreamSolvent RecoveryChemical ProcessingAir FiltrationFood ProcessingVOC Control Process Generating Spent Carbon, Other: Application Description: Classification Is this US EPS Hazardous Waste?: YesNo If Yes, Waste Code: Is this Carbon a Hazardous Waste as defined by State or Local Regulations:? YesNo If Yes, Waste Code: Generator State Agency Information (If spent carbon is manifested) Agency Name: Agency Address: Agency City / State / ZIP: 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?: YesNo Does the carbon contain PCBs in excess of 50 ppm?: YesNo Does the carbon contain dioxins in the excess of 20 ppb?: YesNo Does the carbon contain any pesticides or herbicides?: YesNo Does the carbon contain any sulfur or cyanide containing compounds?: YesNo Does this carbon contain halogenated compounds?: YesNo Is this carbon subject to land ban regulations?: YesNo Does the spent carbon contain any per- and polyfluoroalkyl substances (PFAS)?: YesNo 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:
