REQUEST FORM

COLLECTION OF HAZARDOUS WASTE / MATERIALS

 

Waste/Materials

Generator:       _________________________    Department:     _________________________

 

Building/Room No:  _____________________    Request Date:  _________________________

 

Telephone No: _________________________    Fax No:            _________________________

 

 

Please list all hazardous waste or hazardous materials, including quantity, to be collected. 

 

Material to be collected                                                                 Quantity

 

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Name of Person Making Request:  _________________________________________

 

 

 

 

OEHSHW Use Only:

 

Date request received:   ___________________.   Date of Collection:  __________________.