Southwest Processors Inc. Pre Qualification Questionnaire

Transporter Name*

If you are a Broker put your company name here. This is the person that will be invoiced for the material.

Transport Company Phone Number*

Transport Company Email*

1. Generator Information

Company Name*

This is the Generator of the waste.

Contact Name*

First Last

Contact Phone*

Contact Email*

EPA Number (if applicable):

SIC (standard industrial classification)

Permit Number (Industrial wastewater discharge)

Address*

Street Address City State ZIP Code

Responsible Party Information

If a third party is representing the generator such as a consultant or you are the person filling out the Pre-Qual for someone else at the generator location, your information goes here.

Name / Title

Contact Phone

Description of general activities conducted at generator’s facility*

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

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 for each waste water interceptor locator at this facility.

PHYSICAL DESCRIPTION AND WASTE WATER INFORMATION SHEET

2. Generator's Process Information

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 (please describe below)

Other (describe)

3. Physical Characteristics and Description of Waste

Select One*

Liquid
Mud
Sludge
Slurry
Other (please describe below)

Other (describe)

Water Concentration %*

Mud Concentration %

Other Concentration %

Waste Properties

pH (Select One)*

Odor (Select One)*

Color (Select One)*

Explosive*

YES
NO
Don't Know

Reactive*

YES
NO
Don't Know

Pyrophoric*

YES
NO
Don't Know

4. Component Listing

Does the waste contain (or could contain) ANY of the following

Arsenic*

Yes
No
Maybe

Approx (mg./l)

Cadmium*

Yes
No
Maybe

Approx (mg./l)

Chromium*

Yes
No
Maybe

Approx (mg./l)

Copper*

Yes
No
Maybe

Approx (mg./l)

Lead*

Yes
No
Maybe

Approx (mg./l)

Mercury*

Yes
No
Maybe

Approx (mg./l)

Nickel*

Yes
No
Maybe

Approx (mg./l)

Silver*

Yes
No
Maybe

Approx (mg./l)

Zinc*

Yes
No
Maybe

Approx (mg./l)

Cyanide*

Yes
No
Maybe

Approx (mg./l)

Does the waste contain (or could it contain) any measurable amount of total identifiable CHLORINATED HYDROCARBONS?*

Yes
No

Constituent / Concentration (mg./l)

If yes, please list the source and approximate concentrations

Does the waste contain (or could it contain) any known or suspected TOXIC ORGANIC COMPOUNDS? (Examples: Benzene, Toluene, etc.)?*

Yes
No

Constituent / Concentration (mg./l)

If yes, please list the source and approximate concentrations

Could the waste contain SULFIDES in excess of 0.1 mg/l?*

Yes
No

Constituent / Concentration (mg./l)

If yes, please list the source and approximate concentrations

Please up-load any additional information regarding this waste stream.

Max. file size: 100 MB.

This includes any analytical or MSDS information that is available. If you click "Save and Continue Later" this file will be lost. You can always email us a copy of the analytical after the submittal of the Pre-Qual.

CERTIFICATION

I certify that the information I have provided in response to the questionnaire contained in the PRE-QUALIFICATION QUESTIONNAIRE are true, correct and complete to the best of my knowledge. I understand that after reviewing the information you have provided, Southwest Processors, 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 / Title*

Email*

Date*

SERVING ALL OF SOUTHERN CALIFORNIA

800.900.3366 / 323.269.9876

Southwest Processors, Inc.
4120 Bandini Boulevard
Vernon, CA 90058

Pre Qualification Questionnaire

1. Generator Information

Responsible Party Information

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

Generators and Waste Haulers Please Note:

PHYSICAL DESCRIPTION AND WASTE WATER INFORMATION SHEET

2. Generator's Process Information

3. Physical Characteristics and Description of Waste

Waste Properties

4. Component Listing

CERTIFICATION