Download Site History Physical Address: Business Activity: Soil Storage

For Facility Use Only
I.D. #
RECO BIOTECHNOLOGY
SOIL DATA AND CERTIFICATION SHEET
Date:
Generator Information
“The name you know”
Richmond, VA
Customer Information
Name:
Address:
Name:
Address:
Contact:
Telephone:
Contact:
Telephone:
Site History
Physical Address:
Soil Storage Method:
Petroleum Type:
Estimated
Quantity in
Tons:
Business Activity:
Source:
Please fill out the applicable information below and sign the Certification. No soil may be delivered until facility approval
and facility manifests are issued for soil shipment. Please attach the appropriate analysis for the selected source type and
check all applicable boxes.
Soil Contaminated From Leaking Petroleum
Underground Storage Tanks (USTs):
* Double click boxes to mark
Sampling Protocol and Location:
Soil Contaminated with Petroleum From
Sources Other than USTs:
EPA SW-846
*Total Petroleum Hydrocarbon (TPH)
418.1 or 8015
Required for Non-Virgin Petroleum or Optional:
*Benzene, Toluene, Ethyl Benzene
Method 5030/8020
and Xylene (BTEX)
*Total Organic Halogens (TOX or EOX)
Standard Methods
*TCLP or Total RCRA Metals
Standard Methods
Virgin Petroleum
Testing Laboratory:
Telephone Number:
Non-Virgin Petroleum
Certification:
This is a complete and accurate description of the soil; no willful omissions of information have been made and all known or
suspected hazards have been disclosed. I/We further certify that the soil is contaminated only with petroleum or
petroleum products from a known source and that the soil to be remediated does not meet the definition of a hazardous
waste according to 40 CFR Part 261 and the Virginia Hazardous Waste Management Regulations. All required analysis
reports are attached.
Generator’s Authorized Signatory:
Print Name:
_______
________
Date:____________________
Title: ____________________
P.O. Box 25189, Richmond, VA 23260
710 Hospital Street, Richmond, VA 23219 – PHONE (804) 644-2800 FAX (804) 644-1335