Please fill in the form below and sign certifying you have read and understand the following:

I hereby certify that the below and attached information is true and accurate to the best of my knowledge. I certify that the information and sample submitted is representative to the waste stream being considered. I understand that the determination made by AOC regarding the acceptance and pricing of this waste is based on the information and sample I provided and is subject to change if the incoming stream changes.

* Email Address
Company Name
Facility Address
City, State, Zip
Technical Contact
Position
Phone
Generator EPA ID No.
DOT Shipping Name & Placard
Are there any levels of PCBs
Is this waste mixed with hazardous (RCRA) waste?
Describe the process that generates this waste
Type of waste
Shipping Method
Physical Constituents
Arsenic ppm
Cadmium ppm
Chromium ppm
Copper ppm
Lead ppm
Nickel ppm
Zinc ppm
Flash Point
Gravity
Viscosity
pH
* Certification Signature
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