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.