Spent Carbon ID Sheet

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 Carbon Acceptance Procedure

Instructions for Completion of the Adsorbate Profile Document

Section One - Generator Information

Company Name:
Mailing address:
Telephone Number:
Fax#:
Facility address:
Technical Contract:
Title:
Telephone Number:
Fax#:
Generator:
Date:

Section 2 - Billing Information

Name of STIL's Technical Sales Representative:
Purchase order No.# for Carbon Acceptance:
Bill to Address:
Attention:
Telephone No.:
Fax#:

Section 3 - Regulatory Profile

Is the spent carbon generated at a Superfund Site?                                                Yes No

Has TCLP testing been performed on the spent carbon? If "Yes" send results.        Yes No

Is spent carbon a RCRA Hazardous waste as defined by 40CFR Part 261?           Yes No

If "Yes" list EPA waste code number(s):

If "Yes" list Facility EPA ID#:   Is spent carbon a RCRA Hazardous waste in the facility's state or province? Yes No

If "Yes" list state of provincial wate code number(s):

If "Yes" list Facility EPA ID#:

Is the carbon treating a stream which is subject to Benzene NESHAP Standard (40CFR) Part 61? Yes No Does the spent carbon contain substances subject to the reporting requirments of Section 313 of Title III of the Superfund Amendments and Reauthorization Act (SARA) of 1986 and 40CFR Part 372?

If "Yes" list substances:

Does the spent carbon have any of the following chemicals: Polychlorinated Biphenyls (PCB's): Yes No Dioxins: Yes No 1,2 Dibromo - 3 Chloropropane: Yes No Does the carbon treat an aqueous stream or a vapor stream from an aqueous source? Yes No

List the proper DOT shipping name for the spent carbon.

Section 5 - Carbon Identification and Return Information

Carbon Type	Granular Liquid		Pellet Vapor
U.S. Mesh Size
Carbon Product Name
Calgon Carbon Product?	Yes		No
If "No", indicate type: Coal Base  Coconut Base  Other
Is spent carbon free flowing?	Yes		No
Does spent carbon contain silt, gravel, or other foreign material?	Yes		No

If "Yes" describe:

Adsorption Equipment by:  Service Tech  Customer  Other
Pounds of spent carbon per return in lbs:
Frequency of spent carbon returns:  Times per:  WEEK  MONTH  YEAR
Spent Carbon return via: 55_Gallon_Drum(s)  Super_Sac(s)  Bin(s)  Other
List the principal components and their concentration in the stream (ppm, mg/L, % or other units)
Component	Amount	Unit

Describe the stream and how it is generated:

What is the stream flow rate? gpm cfm

Is the stream treated at elevated temperature? Yes No

If "Yes" Temperature: F C

Is the stream saturated with inorganic salts? Yes No

Section 7 - Safety Profile

(Attach any analyses, toxilogical studies, safety data, MSDS, Etc. that are relevant

Are any of the following types of compounds, materials or conditions present in the spent carbon? If "Yes", describe or identify condition in the column to the right. OSHA Regulated Carcinogens (per 29 CFR 1910)                       Yes No Halogenated Organics                                                                   Yes No Sulfur-Containing Organics                                                            Yes No Pesticides/Herbicides                                                                    Yes No Highly Toxic Organics                                                                   Yes No Radioactivity                                                                                 Yes No Explosive (Self-Igniting or Shock Sensitive) Material                      Yes No Biological or Disease-Causing Agents                                            Yes No Reactive Cyanide or Sulfide                                                           Yes No Odorous Compounds                                                                    Yes No Metals (As, Ba, Cr, Pb, Hg, Se, Cu, Mn, Ni, Zn)                          Yes No Are there any unique safe handling requirments necessary for processing the spent carbon? Yes No If the spent carbon contains propriety chemicals, list acute or chronic hazards associated with or alleged to be associated with human contact or exposure to the material:

Section 8 Certification To be completed by generator of his agent To the best of my knowledge and information, the spent activated carbon to be returned to Service Tech, Inc., for reactivation does not contain PCB's greater than 50 ppm; dioxins above 20 ppb TCDD International Toxicity Equivalents; 1,2 dibromo-3-chloropropane greater than 1.5% by weight; nor it is a characteristically ignitable (for return to Neville Island Plant Only), corrosive or reactive waste.  I certify that this information is complete, accurate and true. Name:       Signature:  Title:          Date:

Spent Carbon Identification Sheet Addendum

This form must be filled out in its' entirety to acceptance of any non-hazardous, non-regulated spend carbon.

1. Please describe in detail how the contaminants entered the liquid stream being treated with the activated carbon.

2.  **If you are claiming that the spent carbon is NOT contaminated with a listed waste according to 40 CFR Part 261.31 or 261.33, on what basis have you made this determination?  Please explain.
3. If a TCLP, or other analytical procedures have NOT been performed on the spent carbon itself, please explain how the determination was made that the carbon is NOT a characteristic waste according to 40 CFR Part 261.21, 261.24.

 

Signature of Generator or Authorized Agent: 

Name of Generator or Authorized Agent: 

**Please refer to CFR 261.11, 261.31, 261.33 for assistance in answering this question.

Activated Carbon Replacement/Service Questionnaire Person Completing Form:  Company:  Site Location:   What type of activated carbon is utilized in this system?  liquid phase, vapor phase, specialty carbon? How many tanks or filter vessels are to be serviced? How much carbon is contained in each tank or filter vessel? Do you want Service Tech. to take away the spent carbon?  Is it hazardous or non-hazardous? Please describe the filter vessels (make/model, steel/fiberglass, approximate dimensions) What type of access is there to the inside of the vessels(18'' or 24'' manway, 12''x16'' ellip. manway) If the vessels are used for liquids, have they been drained?  Will they by drained prior to service? Are the tanks inside:  (shed, building, fenced enclosure)?  Please describe as best as possible. Please describe the flooring/ground cover at and around the tanks (asphalt, concrete, ungraded soil)?   Please feel free to add any additional information in the box below.   Feel free to send any additional information or drawings/diagrams if available.  If you wish to speak to a Service Tech representative, call us at 800.368.0043 Thank you for taking the time to fill out this form.  We look forward to Servicing your filtration equipment!