Mn/DOT HAZARDOUS WASTE WORK ORDER


Order Date: Page of



Mn/DOT and Veolia Technical Solutions, LLC are utilizing provisions set forth in State of Minnesota Contract No. 38105 and all amendments to this contract as of December1, 2011.

This document is a written work order pursuant to that contract. This work order authorizes and obligates Veolia Technical Solutions, LLC to undertake the work specified below.

EPA I.D. #:PURCHASE ORDER #:

SITE CONTACT: BILLING CONTACT:

PHONE:PHONE:

ADDRESS:ADDRESS:

FOR Mn/DOT USE / FOR VENDOR USE
Total
Qty / Unit of Measure / Hazardous Waste Commodity Identifier # / Common Name of Waste / Number & Size of Container
1 / Select OneEachQuartGallonYardPounds / Select One76121602 ABANDONED BARREL PICKUP,SERVICE76122003 LABPACK, DISPOSAL76122301 OIL BASED PAINT, DISPOSAL76122301 LATEX PAINT, RECYCLING76122301 PAINT THINNER, DISPOSAL76122301 SOLVENT RAGS76122003 OIL/WATER, DISPOSAL76122003 PARTS WASHER SOLVENT, NON-AQUEOUS, DIS76122003 PARTS WASHER SOLVENT, AQUEOUS, DISPOSA76122302 ANTIFREEZE, RECYCLING76122314 FLUORESCENT/HID, RECYCLING76122304 USED BATTERIES, NICAD/MERC, RECYCLING76122315 PCB CAPACITOR/BALLAST, RECYCLING76122304 COMPUTER ITEMS76121602 NON-SPECIFIC HAZ/REG WASTES
2 / Select OneEachQuartGallonYardPounds / Select One40708029926 ABANDONED BARREL PICKUP, SERVICE40701029908 LABPACK, DISPOSAL40701029909 OIL BASED PAINT, DISPOSAL40617029933 LATEX PAINT, RECYCLING40701029913 PAINT THINNER, DISPOSAL40701029914 OIL/WATER, DISPOSAL40701029915 PARTS WASHER SOLVENT, NON-AQUEOUS, DIS40701029916 PARTS WASHER SOLVENT, AQUEOUS, DISPOSA40619030057 ANTIFREEZE, RECYCLING40609029932 FLUORESCENT/HID, RECYCLING40618029936 USED BATTERIES, NICAD/MERC, RECYCLING40618029939 PCB CAPACITOR/BALLAST, RECYCLING40701000000 NON-SPECIFIC HAZ/REG WASTES
3 / Select OneEachQuartGallonYardPounds / Select One40708029926 SERVICE, ABANDONED BARREL PICKUP40701029908 LABPACK, DISPOSAL40701029909 OIL BASED PAINT, DISPOSAL40617029933 LATEX PAINT, RECYCLING40701029913 PAINT THINNER, DISPOSAL40701029914 OIL/WATER, DISPOSAL40701029915 PARTS WASHER SOLVENT, NON-AQUEOUS, DIS40701029916 PARTS WASHER SOLVENT, AQUEOUS, DISPOSA40619030057 ANTIFREEZE, RECYCLING40609029932 FLUORESCENT/HID, RECYCLING40618029936 USED BATTERIES, NICAN/MERC, RECYCLING40618029939 PCB CAPACITOR/BALLAST, RECYCLING40701000000 NON-SPECIFIC HAZ/REG WASTES
4 / Select OneEachQuartGallonYardPounds / Select One40708029926 SERVICE, ABANDONED BARREL PICKUP40701029908 LABPACK, DISPOSAL40701029909 OIL BASED PAINT, DISPOSAL40617029933 LATEX PAINT, RECYCLING40701029913 PAINT THINNER, DISPOSAL40701029914 OIL/WATER, DISPOSAL40701029915 PARTS WASHER SOLVENT, NON-AQUEOUS, DI 40701029916 PARTS WASHER SOLVENT, AQUEOUS, DISPOSA40619030057 ANTIFREEZE, RECYCLING40609029932 FLUORESCENT/HID, RECYCLING40618029936 USED BATTERIES, NICAD/MERC, RECYCLING40618029939 PCB CAPACITOR/BALLAST, RECYCLING40701000000 NON-SPECIFIC HAZ/REG WASTES
5 / Select OneEachQuartGallonYardPounds / Select One40708029926 SERVICE, ABANDONED BARREL PICKUP40701029908 LABPACK, DISPOSAL40701029909 OIL BASED PAINT, DISPOSAL40617029933 LATEX PAINT, RECYCLING40701029913 PAINT THINNER, DISPOSAL40701029914 OIL/WATER, DISPOSAL40701029915 PARTS WASHER SOLVENT, NON-AQUEOUS, DIS40701029916 PARTS WASHER SOLVENT, AQUEOUS, DISPOSA40619030057 ANTIFREEZE, RECYCLING40609029932 FLUORESCENT/HID, RECYCLING40618029936 USED BATTERIES, NICAD/MERC, RECYCLING40618029939 PCB CAPACITOR/BALLAST, RECYCLING40701000000 NON-SPECIFIC HAZ/REG WASTES
TO BE COMPLETED BY Mn/DOT'S OFFICE OF ENVIRONMENTAL STEWARDSHIP
ECIU IDENTIFICATION NUMBER:
REQUESTED ACTION/S:
ADDITIONAL DATA SHEETS ATTACHED:
SIGNATURE: / DATE:
Summer Allen-Murley - Department Designated Contact Person, 651-366-3635
SEE REVERSE SIDE OF THIS PAGE FOR INSTRUCTIONS TO COMPLETE THIS FORM

Revised 09/12

PICKUP LOCATION: Location name where waste is collected by Veolia Technical Solutions, LLC. E.g., Golden Valley Street address where the waste may be collected. E.g. 12345 Olson Memorial Highway.

EPA GENERATOR I.D. NUMBER: Identification number issued by the EPA, typically a nine digit number preceded by letters. E.g., MND985654321.

DEPARTMENT SITE CONTACT/PHONE: The name of the individual to be contacted regarding this specific waste product. This person should be the contact within your area. Please provide a telephone number where this individual may be reached.

BILLING LOCATION: Street address where the invoice should be sent, if different from the pickup location.

MNDOT PURCHASE ORDER #: MNDOT Purchase Order # as assigned by Purchasing Agent for location. This is not the same as the Central Office assigned ECIU Identification number.

BILLING CONTACT/PHONE: The name of the individual to be contacted on invoicing and payment issues by Veolia Technical Solutions, LLC Treasury.

TOTAL QTY: Quantity, total quantity for line item. For example, two 55 gallon drums total 110 gallons, the number 110 would go there.

UNIT OF MEASURE: Gal, lbs, etc. For example, two 55 gallon drums total 110 gallons, the word gal. would go there.

COMMODITY IDENTIFIER #: Class, sub-class, and item number to purchase hazardous and other waste services. For example: Labpack would be 76122003.

COMMON NAME OF WASTE: The characteristic description of the waste. For example: Oil and Water, Oil Base Paint, Aqueous Parts Washer Solvent, Diesel Fuel, etc.

NUMBER AND SIZE OF CONTAINERS: The exact number and variety of container in which the waste is to be transported. E.g., 5-55 gallon drums; 2-20 gallon plastic pails; etc.

If more than five types of waste are to be disposed, please attach additional pages as needed.

If you have any questions or need further assistance in completing this form, please contact Summer Allen-Murley at 651-366-3635.