Microsoft word - customer declaration

2. Waste Details (please provide analysis if available) 3. Material or classes of material likely to be present Flammable Liquid with Flash Point <21oC Flammable Liquid with Flash Point <55oC Organic Liquid with Water Immiscible Layer Mineral Acids (eg Hydrochloric, Sulphuric, Nitric, Heavy Solids (Capable of rapid settlement) Compounds Detail if any of the following metals present in the waste:- Supply Concentrations if known (ppm) Aluminium Any other class of compound or substance that you would wish to draw our attention to: Note : Disposal facility may not accept any materials classified as : Animal By-Products, Clinical Waste, Explosive, Radioactive, Peroxides, Spontaneously Combustible, Water Reactive. 4. Waste Composition (Please insert waste composition as it will appear on any consignment or waste transfer note) Risk Phrases (Please include any R (risk) phrase associated with the waste or its components.) Is this waste classified as Hazardous Waste ? Which code is applied from the European Waste Catalogue (EWC)? Does the composition of the waste vary substantially? If yes Why? Can you provide a Hazard Data Sheet or Material Safety Data sheet for the waste or its principle components? Does the waste Smell ? If yes give possible causes? Does the waste react with other materials to cause Odours? If yes which materials? Chemical Oxygen Demand (COD) of Waste? (if known) Does the material contain any of the following PRESCRIBED SUBSTANCES to the best of your knowledge:- Quantification of materials listed above permits an assessment of discharge levels versus Environmental Quality Standards for discharge to controlled water. Declaration (the form should be signed by an authorised person from the Client Company) I declare that I have provided the best information available, and I have given an accurate description of the waste. I have not failed to mention any critical component of the waste , which, (as a consequence of the omission) could cause harm to the health and safety of personnel transporting or treating it, or harm to the environment. Signed …………………………………………………. Date: ………………………. Please return a signed copy of this form to either Castle Env by fax (0115 944 5225) or by post to Castle Environmental, Crompton Road, Ilkeston, DE7 4BG or email : [email protected] or Castle Environmental, Chemical Lane, Longport, Stoke on Trent, ST6 4PB Fax(01782 839432) email : [email protected] Office Use Only :- Material Submitted for Analysis Initial ……………………. Date ………………… Material Accepted for Trial Initial ……………………. Date ………………… Material Accepted for Treatment Initial ……………………. Date ………………… Initial Material Received Initial ……………………. Date ………………… Crosscheck of Details with initial WTN or Consignment Load Initial………………………. Date…………………. The information requested above is essential for us to correctly evaluate wastes and it will help us to check our ability to accept waste into treatment within statutory requirements. A detailed description is requested, and your full co-operation will allow us to process your enquiry efficiently. Please give as much detail about the waste as possible, and where appropriate, name the compounds present. Castle is unable to pursue your enquiry unless details of the waste are divulged to our satisfaction, and we will always treat the information with due diligence and confidentiality. Please do not hesitate to contact us if you require assistance or clarification when completing this form. SAMPLE REQUEST
Specify organic compound to be identified: Route Analysis (including 3 stage analysis – 1. sample analysis, 2. process model of sample, 3. analysis of process model effluents) NHMS: Please ensure a copy of this document accompanies all samples to be analysed. Please tick or otherwise indicate all required analysis to be performed.

Source: http://www.castle-environmental.co.uk/downloads/CustomerDeclarationForm07.pdf