EH&S Material Pick-Up Request
Florida Gulf Coast University
Request Date:
/
Month
/
Day
Year
For EH&S Use Only:
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:
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
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.
*
Full Name of Signee
*
EH&S Material Management
For EH&S Use Only
EH&S Signature
Date Signed
*
/
Month
/
Day
Year
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Submit
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