EH&S Material Pick-Up Request

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

Rows	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:
Generated By (PI):
Department:
Contact Person:

First NameLast Name
Contact Phone #:

Area CodePhone Number
Contact Email:
example@example.com
Location:
Room:
Best Time:

:HourMinutesAM/PM Option
Material physical state:
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:
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

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty: