Chemical Waste Pickup Request

Generator Information

Requestors First Name

Requestors Last Name

Department

Pickup Location Room Number

Pickup Location Building

Requestors Phone Number

Requestors E-mail Address

Principal Investigator First Name

Principal Investigator Last Name

Container Information - Enter a count of the number of containers for each waste type

It is not necessary to enter a 0 in the field where you don't have that waste type. Only a container count is required. It is unnecessary to name all of your chemicals.

Batteries

Lead acid batteries must each have a label attached. All other batteries may be put in a sealed box with one label on the box or label individually. Please provide a count of the number of batteries.

USED OIL - Total number of containers

SOLIDS - Total Container(s) < 100 grams

SOLIDS - Total Container(s) 100 - 500 grams

SOLIDS - Total Container(s) 500 grams - 1 kilogram

SOLIDS - Total Container(s) > 1 kilogram

LIQUID - Total Container(s) < 1 gallon

LIQUID - Total Container(s) 1 gallon

LIQUID - Total Container(s) 5 gallon

LIQUID - Total Container(s) 30 gallon

LIQUID - Total Container(s) 55 gallon

Gas - Total cylinder(s)

Replacement Container(s) Needed?

Contact EHS (5-4626) for prior approval.

Comments and additional descriptions

Certification

HawkID

Check each box below as confirmation of each statement

Container is labeled correctly.

Container is compatible with waste type.

Container is not too full.

Container is clean and free of contamination.

HawkID (If you do not have a HawkID, add your intials)

I hereby declare that the identification/description of waste is accurate and complete, and that I have made a reasonable effort to minimize this waste.

Signed Date

Signed Date: Month

Signed Date: Day

Signed Date: Year