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KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT (Kansas Department of Health and Environment)

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SW650a – updated 06/10/2013 Page 1 of 3
KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT
Bureau of Waste Management (BWM)
1000 SW Jackson St., Suite 320
(785) 296-0681
GENERATOR LIQUID WASTE PROFILE SHEET
I. GENERATOR INFORMATION
SIC CODE:
GENERATOR NAME:
EPA ID NO:
GENERATOR SITE ADDRESS:
CITY:
COUNTY:
STATE:
ZIP:
GENERATOR MAILING ADDRESS:
CITY:
COUNTY:
STATE:
ZIP:
GENERATOR CONTACT NAME: E-MAIL:
II. WASTE STREAM INFORMATION
NAME OF WASTE:
PROCESS(ES) GENERATING WASTE:
INDUSTRIAL WASTE: POTW WASTE: OTHER WASTE SOURCES:
PHYSICAL STATE: LIQUID SLURRY
METHOD OF SHIPMENT: TANKER DRUM OTHER:
ESTIMATED ANNUAL VOLUME (Gallons/Liters):
FREQUENCY: ONE TIME ONLY WEEKLY MONTHLY
SPECIAL HANDLING INSTRUCTIONS:
HAS THIS WASTE STREAM PREVIOUSLY BEEN AUTHORIZED FOR SUBTITLE D LANDFILL DISPOSAL: YES NO
IF YES, WHAT WAS THE AUTHORIZATION NUMBER?
III. REPRESENTATIVE SAMPLE CERTIFICATION
WAS A REPRESENTATIVE SAMPLE COLLECTED FOR A HAZARDOUS WASTE DETERMINATIN AS PER K.A.R. 28-
31-261
YES NO
SAMPLE DATE:
CHECK ONE: COMPOSITE SAMPLE GRAB SAMPLE
SAMPLERS EMPLOYER:
IV. RD&D LANDFILL INFORMATION
LANDFILL NAME:
LANDFILL ADDRESS:
CITY:
COUNTY:
STATE:
ZIP:
PHONE NUMBER:
E-MAIL:
LANDFILL CONTACT NAME:
PHONE NUMBER:
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SW650a – updated 06/10/2013 Page 2 of 3
V. HAZARDOUS WASTE DETERMINATION INFORMATION
1. pH – Standard Methods, Part 4500-H
+
B. Electronic Method: pH Value ___________
2. Flash Point – EPA Method 1010, Test Methods for Flash Point by Pensky-Martens Closed Cup Tester: See
American Society for Testing Materials (ASTM) Standard D 93-79 or Standard D 93-80: ________
o
F or
________
o
C
3. Other process(es) related characteristics not cited above:
___________________________________________________________
Attach laboratory analytical report(s) (and/or Material Safety Data Sheets for all materials in the process streams)
Does this waste contain regulated concentrations of Polychlorinated Biphenyls (PCB’s) YES NO
Is this a hazardous waste as defined by 40 CFR Part 261 or KAR 28-231-261
YES NO
Is this radioactive waste as defined by federal or state regulations?
YES NO
Is this a regulated medical or infectious waste as defined by federal or state regulations?
YES NO
Is this waste generated at a Federal Superfund clean-up site?
YES NO
Standard Methods refers to Standard Methods for the Examination of Water and Wastewater (latest edition) and
SW-846 refers to EPA’s Test Methods for Evaluating Solid Waste, Physical/Chemical Methods (latest edition).
VI. CERTIFICATIONS
Generator
I hereby certify that to the best of my knowledge and belief, the information contained herein is a true and accurate description of the waste material
being offered for disposal. I further certify that by utilizing this profile, no employee of this company will deliver for disposal, or attempt to deliver for
disposal, any waste which is classified as toxic, hazardous waste, medical or infectious waste, or any other waste material this facility is prohibited from
accepting by law. Our company shall defend, indemnify, and hold harmless the State of Kansas, its officers, agents, and employees, officially or
personally, against all actions, claims, and demands whatsoever which may arise from or on account of this approval for disposal. Notwithstanding, to
the extent that the State of Kansas, KDHE, or any employees thereof, may be liable for any activities arising from this approval for disposal, such liability
would be strictly limited to that provided in the Kansas Tort Claims Act (K.S.A. 775-6101, et seq.). If this is a renewal, the materials and processes that
generate the waste have not changed since the last disposal authorization indicated above, and the information previously provided to KDHE is still
valid.
AUTHORIZED REPRESENTATIVE NAME & TITLE (PRINTED) COMPANY NAME
AUTHORIZED REPRESENTATIVE SIGNATURE DATE
Landfill
I have reviewed the Generator Liquid Waste Profile Sheet (KDHE form SW650a). To the best of my knowledge, this waste is not a hazardous waste.
Therefore, this waste could be accepted at our facility for disposal.
AUTHORIZED REPRESENTATIVE OF LANDFILL NAME & TITLE (PRINTED) LANDFILL NAME
AUTHORIZED REPRESENTATIVE OF LANDFILL SIGNATURE DATE
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SW650a – updated 06/10/2013 Page 3 of 3
Instructions for Completing the Generator Liquid Waste Profile Sheet
If you have any questions about information required to complete this form, please contact
the Special Waste Coordinator at 785-296-1600 or send an e-mail to: kdhe.swda@ks.gov
The Kansas Department of Health and Environment would like to emphasize to our landfills participating in the
RD&D program that they must work with their customers to ensure that accurate waste determinations be
made either by following good representative sampling protocols or by knowledge of process both initially and
whenever necessary based upon changes to the waste stream or BWM requirements.
I. Generator Information - Information must be provided for the location where the waste is generated and
by the individual taking responsibility for the waste disposal request. KDHE will e-mail you a copy of the
special waste disposal authorization letter in portable document format (pdf) if you provide your e-mail
address. If you do not provide your e-mail address, we will mail or fax you a copy of the Special Waste
Disposal Authorization (SWDA) letter. Please note that you may complete this form on-line at our website;
however, you must print the form and submit a signed copy via fax, regular mail or as an e-mail
attachment.
I
I. Waste Stream Information – Provide 1) the name or a brief description of the liquid waste; i.e., oily
wastewater, wastewater sludge”, etc.; 2) a brief, accurate description/name of the process (es) that
produced the waste, i.e., wastewater treatment plant process, type of industrial wastewater process, etc;
3) the physical state; 4) the method of shipment; 4) estimated annual volume in gallons or liters; 5
)
f
requency of generation; 6) special handling instructions; and 7) information regarding prior disposal for
Subtitle D landfill disposal.
II
I. Representative Sample Certification – All analytical data provided are from a Kansas Department of
Health and Environment (KDHE) certified laboratory and are representative of the waste identified for
disposal. When sampling/analysis is required such as when washing down industrial equipment in
a
pr
oduction area or a large tank clean-out, it is important for these liquid waste “determinations” to b
e
bas
ed upon representative samples. This is especially important for large waste streams that have the
potential to change through the course of a project.
I
V. RD&D Landfill Information – Provide landfill name, address, location and contact details.
V.
Hazardous Waste Determination Information - Provide 1) liquid wastewater characterization
information as defined by pH, flash point, and other process related characteristics; and 2) provide
laboratory analytical report/s and/or Material Safety Data Sheets for all chemicals in the process streams
including the parameters required for this profile. The laboratory reports need to indicate and certify
whether the environmental characterization analyses were performed by a KDHE certified laboratory with
certifications for these types of analyses. If you have questions whether analyses are required or what
analyses are required, please contact the Special Waste Coordinator at 785-296-1600 or send an e-mail
to: kdhe.swda@ks.gov. Also, provide answers to the five questions regarding waste type
characterization at the end of this section.
VI
. Certifications (Generator and Landfill) - The certification statement must be signed by an authoriz
ed
r
epresentative of the generator/owner of the waste as well as the landfill.
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Completed 20 July 2020

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