HazMat's Bulk Shipment Form

HazMat's Bulk Shipment Form
Name of person placing request

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Company Name
Company Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Load Type
EQUIPMENT REQUEST
Tanker

YesNo
RCRA Empty or Commercially Cleaned
Is a Pump Required to Load or Unload?

YesNo
Is an Air Compressor Required to Load or Unload?

YesNo
How Will the Equipment be Used (Pump/Compressor)
Customer Equipment Involved?

YesNo
Volume Shipping
Weight of load in lbs.
Frequency
weekly, bi-weekly, monthly, quarterly, bi-annually, annually.
Manifest

YesNo
BOL

YesNo
Ready to Ship Date

MonthDayYear
Date
Must Ship by

MonthDayYear
Date
Other Special Needs

FittingsDouble ConicalLengths of HoseStraight Bore UnitVapor RecoveryTrailer CapacityIn Transit HeatInsulatedSteam JacketedAny Last Contained Restrictions
Hose Size
Number of Hoses (1 = 20ft.)
Trailer Capacity
(Gallons Needed)
Last Contained Restriction Description
Hazard Class (Please Explain)
DOT SHIPPING NAME / DESCRIPTION
("DOT Shipping Name" should be as it will appear on the manifest or bill of lading)
PICKUP LOCATION
Contact

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Days & Hours of Operation
(example: M-F 8-5pm est.)
DESTINATION FACILITY
Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Days & Hours of Operation
Delivery Slot required

YesNo
Billing Information
Name

First NameLast Name
Address/ PO#

Street Address or PO Box #

Street Address Line 2

CityState / Province

Postal / Zip Code
Any Additional Notes
If needed, credit application must be completed prior to pickup.

Application is available here: HazMat New Client Credit Application
Should be Empty:

HazMat's Bulk Shipment Form

EQUIPMENT REQUEST

PICKUP LOCATION

DESTINATION FACILITY

Billing Information