PDI WASTE DATA SHEET - R360 Environmental Solutions

R360 Disposal Facilities - Please check your disposal preference
Prairie Disposal Landfill
102C10 52nd St NW
Tioga, ND 58852
(701)664-3383
Prairie Disposal Treating Plant
102C10 52nd St NW
Tioga, ND 58852
(701)664-3383
Chimney Butte Landfill
1217 Highway 85
Fairfiled, ND 58627
(877)827-0851
Smoky Butte Landfill
13310 94th St NW
Fortuna, ND 58844
(877)827-0851
PDI WASTE DATA SHEET
GENERATOR INFORMATION
Fairfield Treating Plant
1488 Highway 85
Fairfield, ND 58627
(701)300-1478
JOB #
Please fill out completely &
Accurately!!
Generator and Bill To one & the Same?
R360 Use Only!
PROJECT INFORMATION
Company:
If not, please fill out Information below Service/Transportation Company (if applicable)
Address:
Customer:
Project Contacts: (Please list 1 or more)
Address:
NAME:
Zip:
City:
PHONE:
Contact:
St:
EMAIL:
Phone:
Zip:
NAME:
Email:
Contact:
PHONE:
Well Name:
Phone:
EMAIL:
Location/Coord:
Email:
Is a Service/Transportation Company
Representative authorized to sign
manifests?
Estimated Amount of Waste:
City:
St:
Rig Name:
AFE#:
Permit#:
PO#:
API#:
YES
NO
TONS
YDS
BBLS
LOAD
WASTE STREAM INFORMATION
WASTE ACCEPTED BY LANDFILLS (Regulated by NDDH)
PLEASE CHECK TYPE OF WASTE & DESCRIBE
WASTE ACCEPTED BY TREATMENT PLANTS (Regulated by NDIC)
PLEASE CHECK TYPE OF WASTE & DESCRIBE
Exploration Waste
Drilling Fluids &
Sludges
Production Waste*
Production Fluids &
Sludges
Remediation Waste*
Completion Fluids &
Sludges
Non Haz Industrial
Waste*
Remediation &
Cleanup Fluids
Inert Waste
Non Paint Filter
Solids
My signature certifies that all information contained herein is true and accurate, and the material described is properly identified, labeled and prepared as indicated. I certify that this waste to the best of my knowledge is not
hazardous or dangerous as defined by the US EPA, or the state of origin. I certify this waste does not contain any regulated radioactive materials, ignitable waste, free liquids, that all known suspected hazards have been disclosed,
and the waste is not a regulated hazardous waste as defined by federal, state or local authority. I also certify that all samples used for analysis of waste are representative of the materials described herein. I understand that all
wastes may undergo inspection upon arrival at the facility and may be refused if the delivered material does not conform to the description herein. Notification will be provided immediately if there is a change in the composition or
process generating this waste stream, prior to offering the waste for management by this facility.
PRINT NAME:
* May require analyticals prior to acceptance!!
GENERATOR
SIGNATURE:
My signature certifies that I am an authorized agent of the Customer named aboved
CUSTOMER
PRINT NAME:
SIGNATURE:
PDI REPRESENTATIVE SIGNATURE:
Please email or fax completed document to pdigate@r360es.com or 701-355-6370
R360 Environmental Solutions * 102C10 52nd St NW * Tioga, ND 58852
Need Directions? Call
Call 701-713-4462
Dial 701-713-4460
701-713-4463
701-713-4461 Questions? Dial
DATE:
DATE: