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Special Waste Characterization Form

  1. GENERATOR/HAULER INFORMATION:

  2. Are you a Waste Generator or Hauler?*

  3. Name of individual submitting request

  4. Material generated outside Santa Rosa County?*

  5. Method of Payment:*

    Credit/Debit Cards must be in name of person presenting for payment or if company card must match logo on disposal vehicle

  6. MATERIAL INFORMATION

  7. Disposal Request:*

  8. Example: Sand blast media, domestic sludge, petroleum contaminated soil, etc..

  9. ASBESTOS DISPOSAL ONLY

  10. Asbestos Disposal?*

  11. Asbestos Disposal Only:

  12. PHYSICAL / CHEMICAL CHARACTERISTICS

    (Not required for Asbestos Disposal)

  13. Laboratory Testing Documents

    Please fill in Constituent levels in waste below. LRL = less than regulatory limit

  14. (Explain if more than one)

  15. Attach laboratory analysis and MSDS (if applicable), constituent must equal 100%

  16. STATUS

    (Not required for Asbestos Disposal)

  17. Resource Conservation and Recovery Act (RCRA) Haz-Waste

  18. Has the waste been Treated?

  19. Has the waste been Diluted?

  20. Bio-hazardous

  21. Does waste contain Herbicides?

  22. Does waste contain Pesticides?

  23. Does waste contain PCB's?

  24. Does waste contain Solvents?

  25. Certification:

  26. I certify that the information furnished on this application is true and accurately describes the material that is being disposed of at the Santa Rosa County’s Central Landfill and that the materials is not a hazardous waste, nor does it exhibit characteristics of hazardous waste as defined by federal, state or local regulations.*

  27. Leave This Blank:

  28. This field is not part of the form submission.