IHD Solids Management, LLCWASTE MATERIALS DATA/GENERATOR

CERTIFICATION

14070 43rd St. NWAlexander, ND 58831

Phone: (701) 774-8514Fax: (701) 774-8515

Required information for the FACILITY OWNER/GENERATOR: Bill to this Entity? Yes/No Company Name:      Mailing Address:      City:       State:       Zip:      Phone:       Fax:      Cell:       E-mail:      Purchase Order Information:     DESCRIBE THE PROCESS THAT PRODUCED THE WASTE:           Required information for the SITE/ORIGIN LOCATION NAME:Site Name:      Physical Address:      City:       State:       Zip:      

Section:      Township:      /North Range:       W E ¼, ¼ Section:     

MATERIAL DESCRIPTION (Check all that apply)Estimated Volume:       Tons or Cubic Yards

Waste from crude oil or natural gas exploration or production (E & P Wastes)Waste from crude oil or natural gas pipeline or trucking transportation releaseFloor Drain or sump sludge from automotive repair or carwash facilityWaste from refined petroleum (gas or diesel) if so:

Underground storage tank (UST) release

Aboveground storage tank (AST) release

Surface spill

Non Petroleum Contaminated waste (describe):      Asbestos Waste (describe):      

GENERATOR CERTIFICATION Deliveries can not contain any listed or toxicity characteristic hazardous waste(s). The following natural gas or crude oil production and transportation wastes shall be analyzed for Naturally Occurring Radioactive Material (NORM),

specifically, 226 Radium, 228 Radium and 210Lead concentrations by a state-approved laboratory prior to acceptance at this facility:1. Accumulated materials, including: solids, scale, sediment, production sand, emulsion, sludge and other tank bottoms from storage facilities,

separators, heater treaters, vessels, tanks, and production impoundments, that hold product or exempt waste;2. Pipe scale, hydrocarbon solids, hydrates, and other deposits removed from tubular goods, piping, casing, filters, filter bags, clean-out traps and

other equipment;3. Pigging wastes from gathering lines; 4. Filter Socks and Proppant from E&P and deep well injection activities; and5. Any waste material suspected to contain technologically-enhanced concentrations of NORM or likely have accumulated NORM in concentrations

exceeding five (5) picocuris per gram as a total of Radium 226 and 228 or Lead 210. IHD does not accept household garbage; putrescible waste; animal carcasses; waste grain; seed; elevator screenings; sludge and liquids (except as

specifically permitted); unrinsed pesticide containers; lead-acid batteries; waste oil; PCB waste/oil; ignitable waste such as solvent, paint and fuels; corrosive waste such as acid and alkali; reactive waste; hazardous materials; septic tank waste or infectious waste.

IHD may collect samples of waste that is suspect as non-conforming and to verify the characteristics through laboratory analysis of the samples. IHD may “pass through” any costs due to non conforming wastes including but not limited to laboratory fees; transportation fees and disposal fees of

non conforming wastes to a permitted disposal facility.Radchem testing is OR is not required (owner/generator to complete). Read bullet 2 above or call us!As the owner/generator or agent of the owner/generator, I hereby certify that I understand the information supplied above, and that the waste meets these criteria before being delivered to the Facility. Furthermore, I certify that am fully aware of the waste management and transportation requirements of North Dakota. I also certify that to the best of my ability and belief, the information provided above is true and correct:Generator Signature: Date:      Printed Name:       Phone:      Required information for the CONTRACTOR/HAULER: Bill to this Entity? Yes/No Company Name:      Mailing Address:      City:       State:       Zip:       IHD Use Only: Accept___ Reject___ Job #_____________________

**This Certification must be submitted for approval in advance of deliveries**Please include any applicable chemical analysis results with this form

IHD Solids Management, LLCWASTE MATERIALS DATA/GENERATOR

CERTIFICATION

14070 43rd St. NWAlexander, ND 58831

Phone: (701) 774-8514Fax: (701) 774-8515

Received By: Date:

**This Certification must be submitted for approval in advance of deliveries**Please include any applicable chemical analysis results with this form