Download Petroleum Contaminated Soil Record Form DATE OF PRIOR

SOLID W ASTE MANAGEMENT SYSTEM
Petroleum Contaminated Soil Record Form
DATE OF PRIOR NOTICE ____________________________ BY __________________________
GENERATOR INFORMATION
Name
__________________________________________________________
Address
__________________________________________________________
Location
__________________________________________________________
Type of Contamination __________________________________________________________
Quantity of Soil
__________________________________________________________
PAINT FILLER LIQUID TEST
Date ______________ Passed ____________ Failed ____________ By ___________________
TRANSPORTER INFORMATION
Name
__________________________________________________________
Address
__________________________________________________________
Equipment used
__________________________________________________________
CHEMICAL AND/OR PHYSICAL ANALYSIS (list and attach copies)
____________________________________________________________________________________
______________________________________________________________________
______________________________________________________________________
TO BE COMPLETED BY COUNTY
DATE RECEIVED __________________________________ BY ___________________________
PLACED IN
Cell 1 ____________________
Cell 2 ____________________
DEPTH OF PLACEMENT ___________________________________________________________
(MAXIMUM DEPTH OF SIX (6) INCHES ALLOWED)
Date of:
st
1 tilling, discing, or turning __________________________ By __________________________
nd
2 tilling, discing, or turning _________________________ By __________________________
Final Disposal
_________________________ By __________________________
LOCATION (describe in reference to site plan)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
RESULT OF THP TEST____________________________________________________________
(ATTACH COPIES OF TESTS)
S:\Website\LF Soil Record Form.doc