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:
__________________.