Chemical Collection Request Form

First, verify that all chemicals meet the following conditions (check each item):

Proper labels, available from Environmental Health and Safety (EHS), are affixed to each container and include the full chemical name(s).
Containers are leak-proof, including screw-top containers.
All waste has been identified specifically and completely on the label (for assistance with unknown waste contact EHS).
No radioactive materials are present in the waste stream (including decayed isotopes, uranium salts, etc.). All radioactive waste is handled by Radiation Safety at 66964.

Waste can not be removed if it does not meet the conditions specified above. Removed waste that can not be shipped off site will be returned to the generator for repackaging/remediation.

Does any of the waste contain a DEA controlled substance? If yes, please specify in the comments below.

Next, provide contact information:

Investigator/Supervisor Name:
Department:
Division:
Building:
Room:
Contact Name:
Contact Telephone:
Contact Email:
Confirm Contact Email (Must Match Email Above):

 

Lastly, provide information about the chemical(s) to be collected:

Containers

Phase

State

Chemical Name(s); indicate concentrations,
if applicable (grams/liter, %, ppm, etc.)

Container
Size


To add additional lines, click the "Add More Chemicals to Form" button below.