ASBESTOS WASTE SHIPMENT REPORT FORM

ASN 4
ASBESTOS WASTE SHIPMENT REPORT FORM
PLEASE PRINT OR TYPE. If you have questions, contact your local DEQ Regional Office in Portland 503-229-5364,
Salem 503-378-5086, Medford 541-776-6107, Coos Bay 541-269-2721 ext. 222, Bend 541-633-2019, or Pendleton
541-278-4626.
WASTE GENERATOR: (Contractor, Facility, or Operator)
1. Asbestos removal site name and address: _____________________________________________________________________
Street
City/State
Contact person:
2.
Zip
Phone:
Contractor/Operator’s name and address:
Street
3.
County
Phone:
City/State
Waste disposal site:
County
Zip
County
Zip
Phone:
Street
City/State
4.
Describe asbestos materials:
5.
Containers:
6.
Total quantity (cubic yards):
7.
OPERATOR’S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described
above by proper shipping name and are classified, packaged, marked and labeled, and are in all respects in proper condition for
transport according to all government regulations. All movement of this asbestos-containing material is recorded on this Waste
Shipment Record Form.
Number:
Agent:
Address:
TRANSPORTER(S):
8. Transporter #1: (Acknowledgment of receipt of materials)
Agent:
Address:
Type:
Company:
Phone:
Company:
Phone:
Signature:
9.
Transporter #2: (Acknowledgment of receipt of materials)
Agent:
Address:
Signature:
Date:
Company:
Phone:
Date:
DISPOSAL: (Certification of receipt of asbestos materials covered by this manifest, except as noted in item 11 below.)
10. Waste Disposal Site:
Name and Title:
Date:
Signature:
Phone:
11. DISCREPANCY SPACE: (Add attachments as needed)
(Revised 4/14)
Instructions for using DEQ Form ASN 4
Waste Shipment Report Form
This form is to be used as a permanent record for documenting asbestos-containing waste materials from removal
site to final disposal. The Oregon Department of Environmental Quality (DEQ) regulation that applies to asbestos
waste disposal is found in OAR 340-248-0280 and -0290.
WASTE GENERATOR SECTION
(Numbers below correspond to numbers on the front of this Form)
1.
2.
3.
4.
5.
Enter the name and address of the site where the
asbestos waste was generated. Enter the name and
phone number of the contact person for the
contractor, facility, or operator of the asbestos
waste generation site.
Enter the name, phone number and address of the
person performing the asbestos abatement.
Enter the name, phone number and address of the
disposal site that the waste is taken to.
Describe the materials being removed. (i.e. pipe
insulation, flooring, roofing, popcorn ceiling
material, HVAC system insulation, or nonfriable
asbestos.)
List the total number of containers and their type.
Also enter one of the following container codes
used in transporting each type of asbestos material.
(Specify any other type of container used if not
listed below):
DM
DP
BA
NFC
6.
7.
Metal drums, barrels
Plastic drums, barrels
6 mil. plastic bags or wrapping
Leak-tight containerization for nonfriable
asbestos waste material.
Give an estimate of the total cubic yards of
material.
Print clearly the name of the company and their
authorized signer. This section of the form must
be signed and dated.
NOTE: The waste generator must retain a copy of the
completed disposal form.
WASTE TRANSPORTER SECTION
8.
9.
Transporter #1: Acknowledgment of receipt of
asbestos waste materials. Print agent and company
name, then sign and date.
Transporter #2: Acknowledgment of receipt of
asbestos waste materials. Print agent and company
name, then sign and date.
(Revised 4/14)
NOTE: If there are more than two transporters
attached a new waste shipment form.
DISPOSAL SITE SECTION
10.
11.
List the name of the waste disposal site, print the
name, title and phone number, then sign and date
form. This certifies that you have received the
asbestos material covered by this manifest.
Discrepancy space. This space is used if there is a
discrepancy between the amount of the material
received by the landfill and the amount of material
listed on the waste shipment report form.
NOTE: The waste disposal site operator must retain a
copy of this form.
In addition, asbestos waste disposal regulations require that
the Waste Disposal Site operators take the following
actions:
•
Send a copy of the completed and signed Waste
Shipment Report Form to the Waste Generator as
soon as possible, but no later than 30 days after the
waste has been received at the disposal site.
•
Notify DEQ immediately by telephone of
improperly enclosed or uncovered waste. Submit a
written report to DEQ the following working day,
along with a copy of the Waste Shipment Report
Form.
•
If you discover a discrepancy between the quantity
of waste designated on the Waste Shipment Report
Form and the quantity of waste actually received,
attempt to reconcile the discrepancy with the
Waste Generator. You must report, in writing, to
DEQ within 15 days after receiving the waste any
discrepancies that cannot be reconciled. Submit a
copy of the Waste Shipment Report Form with this
report.