Hazardous Waste Pickup Request

(*) Required Fields

Date of Accumulation Start:

Date Container Filled:

Date you wish the waste taken:

If waste container is leaking or damaged to call 284-5112 or 278-7422 immediately for prompt pickup

Contact Person:

(*)

Contact Email:

(*)

Phone Number:

(*)

Location the waste is being stored
Building/Structure Name	(*)
Room Number or Description of location	(*)

Approximate amount of waste to be collected:

(*)

Generator fund source:

State Funded Foundation (Non-State Funded) (*)

Comments: