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					                                                                            Chain of Custody / Declaration Form

1. Client Details                                               2. Waste Details (please provide analysis if available)
                                                                Producer (If different from 1.):
Company:

Address:                                                        Description:


                                                                Quantity:                                   Container type:
Tel.

Fax.                                                            Type of Process:
Contact:

Sales contact:                                                  Specific Process:



3. Material or classes of material likely to be present. Please write ‘Yes’ or ‘No’ for each compound type. Please indicate amounts if known
in % or mg/kg

                     Compounds                              Yes or No                               Compounds                             Yes or No
                                                           or amounts                                                                    or amounts
State (Liquid, Solid,       Type                                            Oxidising Agents
Sludge or Gas):
Flammable Liquid with Flash Point <55oC                                     Reducing Agents

Flammable Liquid with Flash Point <21oC                                     Sulphide

Ammonia                                                                     Sulphates

Formaldehyde                                                                Fluoride

Organic Liquid with Water Immiscible Layer                                  Wax / Greases / Oils

Phenol or derivatives of Phenol                                             Inorganic halogens      Types


Acids       Types                                                           Amines /        Types
                                                                            Amides

Alkalis     Types                                                           Organic         Types
                                                                            Halogens
Detergents                                                                  Glycols

Antibiotics or Medicines                                                    Flocculating or Coagulating Agents

Heavy Solids (Capable of rapid settlement)                                  Cyanides

Asbestos or other harmful fibrous materials                                 Hypochlorite

Sulphur                  Types                                        Pesticides           Types
Compounds
Tick if any of the following metals present in the waste:- Supply Concentrations if known (mg/kg)

Aluminium                                 Copper                                 Molybdenum                         Tungsten
Antimony                                  Iron                                   Nickel                             Vanadium

Beryllium                                 Lead                                   Selenium                           Zinc
Chromium                                  Manganese                              Silver                             Cadmium

Cobalt                                    Mercury                                Tin                                Arsenic

Any other class of compound or substances that you would wish to draw our attention to:




Note: Disposal facility may not accept any materials classified as: Animal By-Products, Clinical Waste, Explosive, Radioactive, Organic Peroxides,
Spontaneously Combustible, or Water Reactive.
4.   Waste Composition

(Please insert waste composition as it will appear on any consignment or waste transfer note)




Risk Phrases
(Please include any R (risk) phrase associated with the waste or its components.)




 5.0 Addition information on the sampling and the waste stream

Location of sampling point (e.g. effluent tank) :                             Capacity of vessel sampled/No of containers:




Method of sampling (e.g. core sample, top, bottom) :                          Number of samples and degree on consolidation:




Operating conditions at time of sampling (e.g. normal operation, shut         Preservation techniques (if applicable)
down, maintenance)




     Is this waste classified as Hazardous Waste?

     Which code is applied from the European Waste Catalogue
     (EWC)?
     Does the composition of the waste vary substantially? If yes
     Why?
     Can you provide a Hazard Data Sheet or Material Safety
     Data sheet for the waste or its principle components?
     Does the waste Smell? If yes give possible causes?

     Does the waste react with other materials to cause Odours?
     If yes which materials?


     Declaration (the form should be signed by an authorised person from the Client Company)

I declare that I have provided the best information available, and I have given an accurate description of the waste. I have not failed to mention any
critical component of the waste, which, (as a consequence of the omission) could cause harm to the health and safety of personnel transporting or
treating it, or harm to the environment.




Signed ………………………………………………….                                                                 Date: ………………………..

Please return a signed copy of this form to Augean Treatment – Cannock, Unit 17 Lakeside Plaza, Walkmill Way, Cannock, WS11 0XE. Fax 01543
467267. Scan a copy to ccs@augeanplc.com
Office Use Only :-
Material Submitted for Analysis                             Initial ……………………..            Date …………………
Material Accepted for Trial                                Initial ……………………..            Date …………………
Material Accepted for Treatment                              Initial ……………………..           Date …………………



Augean Reference Number:




      The information requested above is essential for us to correctly evaluate wastes and it will help us to check our ability to accept waste into
      treatment within statutory requirements. A detailed description is requested, and your full co-operation will allow us to process your enquiry
      efficiently. Please give as much detail about the waste as possible, and where appropriate, name the compounds present. Augean is unable
      to pursue your enquiry unless details of the waste are divulged to our satisfaction, and we will always treat the information with due
      diligence and confidentiality. Please do not hesitate to contact us if you require assistance or clarification when completing this form.
                    AUGEAN USE ONLY: Analysis/Route Codes (tick required analysis suite)

               Route                                  Route                                     Route
              ATF-NH                               Hydrofluoric                                AV-ZOZ
                                                   acid content
             NTF-NH                                Chromic Acid                               AV-ZSRS

             CTF-NH                                   AV-ZOA                                  AV-ZSKF

                  ATF                                 AV-ZOB                                  AV-ZSFA

                NTF                                   AV-ZOC                                  AV-ZSOD

                CTF                                   AV-ZOD                                  AV-ZSWB

             ARP-NH                                   AV-ZOE                                  AV-ZSCS

             NRP-NH                                   AV-ZOF                                  AV-ZSMF

             CRP-NH                                   AV-ZOG                                  AV-ZSDP

             DDP-NH                                   AV-ZOH                                    PEFF

              DDP-H                                  AV-ZOWI                                     PDIG

               NHLF                                   AV-ZOJ                                   PUNOIL

                  HLF                                 AV-ZOK                                  PINTERC

              Cyanide                                 AV-ZOL                                   PTROM

            Hypochlorite                              AV-ZOM                                      ITD


                                                   Specific Analysis Requests

Visual Description:                            Moisture content:                                Odour:

COD (mg/l):                                    Ammonia (mg/l):                                  pH:

Acidity:                                       Alkalinity:                                      Flash Point:

Total Metals (ICP):                            Carbonate:                                       Sulphate:

Chloride:                                      Formaldehyde                                     Phenols:

Nitrate (mg/l):                                Nitrite (mg/l):                                  Oxidising:

Total Cyanide:                                 DOC:                                             Full WAC to ISO
                                                                                                12457:2002
TPH/PAH                                        TOC:                                             Haz/Non-Haz
                                                                                                Characterisation
Other Analyses:




Requested by:                                                                   Date:


The information requested above is essential for us to correctly evaluate wastes and it will help us to check our ability to accept waste into
treatment within statutory requirements. A detailed description is requested, and your full co-operation will allow us to process your enquiry
efficiently. Please give as much detail about the waste as possible, and where appropriate, name the compounds present. Augean is unable
to pursue your enquiry unless details of the waste are divulged to our satisfaction, and we will always treat the information with due
diligence and confidentiality. Please do not hesitate to contact us if you require assistance or clarification when completing this form.

				
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posted:12/20/2011
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