Material Profile Form
Status : 
Corporate Office: Glenpointe Center East, 3rd Fl, 300 Frank W. Burr Blvd Ste 21, Teaneck, NJ 07666-6712 · (201) 329-7300
SEND SAMPLES TO:   Phibro-Tech, Inc. 8851 Dice Road | Santa Fe Springs, California 90670 · (800) 777-1850
Re-profile Existing ERS No. (leave blank for initial) 
  PURCHASE ORDER # 
FOR PHIBRO-TECH, INC USE ONLY
  A. General Information:
 Generator Name 
 Generator Site Address 
 City 
ST 
Zip 
 Mailing Address: Street or P.O. Box: 
 City       ST   Zip 
 Phone No   Fax No 
 Generator EPA ID Number (Not Required)
 Generator Contact 
 Bill to Company 
 Bill to Contact 
 Bill to Address 
 Email (notification sent to this email) 
  B. Description of Material:
  Generator's Common
   Name of Material 
   Must be Surplus Material as defined in 22 CCR 66266.6 (a)(2)
 C. Bill of lading and Labeling Information:
   RQ               UN/NA No 
  Proper DOT Shipping Name                                                            
   Haz Class  PG 
  D. Characteristics of Material:                                                                                                                                       
ColorOdorSpecific Gravity@70 F 
Flash PointPhysical State at 70 F  pH        
   Comments           
  E. Select Generic Material Type that best describes Material
  F. Metals Total PPM:
  Ag Cr3+  Se   
  As Cr6+  Cu  
  Ba     Hg  Ni  
  Cd     Pb  Zn  
 %
   Chemical Composition (constituents must add up to 100%)
Phibro-Tech cannot accept any material that contains: PCB’s, Cyanides, Pesticides, Phenolics or Dioxins.
 G. Hazardous Characteristics:
Phibro-Tech cannot accept any material that has the characteristics of Infectious or Biological waste, Organic Toxicity, Radioactive, Explosive, Pyrophoric or shock reactivity.
  H. Anticipated Annual Volume:
   Quantity   One time onlyOn-Going
   Container Type (Select all that apply)  
  Drum               
Tote               
Bulk               
 I. Special Handling or Additional Information:  
  • SDS Attached
J. I hereby certify that through generator knowledge and/or chemical analysis, all information submitted in this and all attached documents is complete, accurate, and that all known or suspected hazards have been disclosed. I also certify that the sample submitted with this document was collected using the appropriate sampling technique, so as to be representative of the actual stream. I also certify that the sample is properly classified, packaged, marked, and labeled and that the package is in proper condition for transportation according to DOT regulations.
Authorized Name  Title   Date