EH&S Material Pick-Up Request
Florida Gulf Coast University
For EH&S Use Only:
Pre Waste Pick-Up Self-Audit (Each Item must be True before EH&S will pick-up waste)
Each waste container is in good condition (no leaking/bulging).
All chemical contents and amounts are accurate and clearly LABELED on each container.
Each container is compatible with chemicals inside (GLASS, POLY, METAL).
The accumulation end date is clearly marked on each container.
Each container is kept closed, except when adding waste.
Each container is in secondary containment within the area, and secondary containers are separated according to compatibility.
I have completed the appropriate EH&S Safety course within the last calendar year.
This material is:
Usable/ For Redistribution
Used Product for Recycling
Waste for Disposal
Generated By (PI):
Contact Phone #:
Material physical state:
How is container labeled?
Size of Container(s):
Number of Containers:
Approx. Total Vol/Wt:
Briefly describe the process that produced this waste
(Example: Acetone used to rinse glassware)
Material Identification: Full Chemical Names only
List all constituents and percent of total volume below, including water. No chemical formulas or abbreviations.
This should be considered a hazardous waste because it is:
Listed as hazardous waste in Title 40 Code of Federal Regulations (CFR) Part 261, Subpart D.
By this signature, I certify that all of the information in the above form is accurate to the best of my knowledge.
Full Name of Signee
EH&S Material Management
For EH&S Use Only
Should be Empty: