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.

Requester Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Name* Required

Additional Location Details

Container 1

Accumulation Started Date

Container Type* Required

Barcode

Amount

Unit

Container Contents

Current Total: 0%

Type

Percentage

Suggested Waste Codes

None

Waste Characteristics

EPA Guide

Ignitable • D001

Corrosive • D002

Reactive • D003

Toxic

Waste Codes

Department* Required

Weight of waste

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

Requester Info

Location

Container 1

Container 0