EH&S Material Pick-Up Request

Pre Waste Pick-Up Self-Audit (Each Item must be True before EH&S will pick-up waste) *

	True	False
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):
Department: *
Contact Person: *

First Name Last Name
Contact Phone #: *

Area Code Phone Number
Contact Email:
example@example.com
Location: *
Room: *
Best Time:

: Hour Minutes AM/PM Option
Material physical state: *

Liquid Solid Gas
How is container labeled? *
Size of Container(s): *
Include units
Number of Containers: *
Approx. Total Vol/Wt:
Include units
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:

Ignitable/Flammable Reactive/Oxidizer Toxic/Poison Corrosive 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. *

Clear
Full Name of Signee *
EH&S Material Management
For EH&S Use Only
EH&S Signature
Date Signed *

Month Day Year
Should be Empty: