MICRONUTRIENTS, A Division of Heritage Technologies,LLC Micronutrients Use Only    
MATERIAL PROFILE FORM Quote#   Fee  
Ws#   PO  
LOCATION: 1550 Research Way Sample#   Salesman  
Indianapolis, IN   46231
Phone: (317) 486-5880  Fax: (317) 486-5888
New Customer
Recertification
1. GENERATOR INFORMATION     2. BILLING INFORMATION      
Name:         Quote to: Generator         Customer         Other 
 
Address:   Customer          
City, State, Zip:       Address  
Tech Contact   City, State, Zip:        
Phone   Fax     Contact name  
E-mail         Phone     Fax    
US EPA ID         E-mail          
3.MANIFEST MAILING ADDRESS (if Required) 4. OTHER REQUIREMENTS      
Contact name       Regulatory Requirements (if any):    
Company      
Address         Special Requirements:      
City, State, Zip:      
Phone   Fax     Other:          
E-mail                    
                     
5. COMMON NAME                  
6. GENERIC PROCESS GENERATING WASTE
 
Spent alkaline copper etchant    
 
Spent cupric chloride etchant (Chlorine process)
Spent cupric chloride etchant (Oxford process)
  Other:____________________________________________________________________  
7. DOT DESCRIPTION                
        RQ, Corrosive Liquid, Basic, Inorganic, N.O.S., 8, UN3266, PGII, (Ammonium Hydroxide, Copper Chloride Solution), Marine Pollutant, ERG #154
 
        RQ, Corrosive Liquid, Acidic, Inorganic, N.O.S., 8, UN3264, PGII, (Copper Chloride Solution), Marine Pollutant, ERG #154
                   
8. CHEMICAL COMPOSITION:  Using specific chemical names, list all constituents present in the material to be
recycled.  Attach available analysis.  Total composition must equal or exceed 100%.  
        Constituent     Range Units  
                  %  
      %  
                  %  
                  %  
9. METAL/OTHER CONSTITUENTS:  
Specify    Range Units   Range Units   Range Units  
TCLP
Arsenic   ppm Mercury   ppm Iron   ppm  
or Barium   ppm Selenium   ppm Sulfur   ppm  
Totals
Chromium   ppm Silver   ppm Sodium   ppm  
  Lead   ppm Zinc   ppm Other:   ppm  
10. OTHER RELEVANT INFORMATION (hazardous characteristics, special handling, etc)__________________________
____________________________________________________________________________________________________
11. PACKAGING: Container_____ Bulk Liquid ____ Annual anticipated volume (gallons)_______________
Container Type________________ Container Size_______________ Anticipated frequency____________________
   
12. CERTIFICATION  sign and date the certification            
Text Box: I hereby certify that all information submitted herein and attached contains true, accurate and complete descriptions of this material. Any sample submitted for analysis is representative of the material being offered for approval. All relevent information regarding known or suspected hazards in the possession of the generator has been disclosed. I have reviewed the physical facilities, administrative practices, and operational procedures (or have directed the completion of such a review) and based on this review do willingly make this certification. I authorize Micronutrients to obtain a sample from any shipment for purposes of recertification. I will notify Micronutrients if any information on this form changes. __________________________ ___________ _______________________ Signature Date Company