Chemical Transfer Form

Chemical Name or Constituents: % Composition (if applicable), No Trade Names (unless constituents are included), No Acronyms

ATTENTION:Improperly labeled, unlabeled, radioactive, and infectious substances cannot be accepted using this form. Unknown materials requiring professional laboratory testing may be analyzed at the generators or department’s expense. Chemical waste will not be collected if labeled or packaged as a biohazard.

Generator

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Phone Number* Required

First Name* Required

Last Name* Required

Location

Campus, Building, or Outdoor Area

Additional Location Details

Space* Required

Additional Location Details

Container 1

Accumulation Started Date

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Container Contents

Type

Percentage

Department* Required

Budget Purpose

Check all that apply

Teaching

Research

Select the best date for the pickup

FOR OFFICE USE ONLY: RCRA Code

FOR OFFICE USE ONLY: DOT Hazard Class

Waste and Form Preparer Certification (type your name)* Required

Please specify the best time for the pickup

8-10

10-12

12-2

2-4

Fiscal Officer Certification

Generator

Location

Container 1

Container 0