Standard Hazardous Chemical Waste Pickup:

This form will be submitted to the Hazardous Waste group at Environmental Health and Safety. If you have questions about this form submission, please e-mail to Tom Finnigan or call ext. 3-8034.

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In the Netscape browser some graphics are displayed differently, though the form will do the job intended.

Fields with an asterisk (*) must be filled out, use NA if unknown or not applicable.

Please use the TAB key only to move between the fields.

*Name of person Requesting *Requester's
Phone
*Requester's e-mail *Date:
*Department Name *Room #
*Building Name *Building #

Are you discarding unused, unopened reagent chemicals?
You may be eligible to participate in EH&S' Surplus Chemical Program.
Materials must be in original manufacturer's container with original label in readable condition.
Please indicate which materials you are donating to this program by placing the word "SURPLUS" in the contents field below.

Container Type Volume/Weight Hazard Category
C= Paper Carton, Box ML. C= Corrosive
P= Plastic Bottle Liter F= Flammable
G= Glass Bottle Gal. O= Oxidizer
M= Metal Can Gm. W= Air/Water Reactive
B= Plastic Bag (must be double-bagged) Kg./Lb., etc. T= Toxic

Use Full Chemical name, please. List all constituents of mixtures. Do not use abbreviations or formulas.

Mark the appropriate Container Type by the checking the check box, using the
chart above as a guide.

Enter the Volume or Weight, using the abbreviations as shown in the chart above.

Mark the appropriate Hazard Category by the checking the check box, using the
chart above as a guide.

Item
No.
Contents
Container Type
Volume/
Weight
Hazard Category
   
C
P
G
M
B
  
C
F
O
W
 T
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10

If you need to add more than 10 items, please complete this form for your first 10 and submit it, then use the Back button in your browser to return to this page and click on the "Clear This Section" button below to clear only this section of the form (keeping your other information), enter up to 10 more items, and submit this form again.

Repeat this process as many times as you need to.

VERY IMPORTANT!

Please check here if this order is related to a previous, recent order. Use the Comments field below to add the explanations about the additional request.

EACH CONTAINER NEEDS TO BE LABELED BEFORE WASTE PICKUP TECHNICIANS ARRIVE FOR PICKUP.

List the names of Principal Investigators (PI's) involved in the project, if known.

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Additional Information or Comments:

Please go over your information before you press Submit to EH&S button.

To clear all fields and start all over again, click on the Reset button below.

After you submit the request you will receive the confirmation of your order, the time and the date of your submission and all items you checked. You can print out this confirmation by using the Browser command on the tool bar: File->Print.