RETURN FORM TO (Safety Officer Use Only) University Police/Safety Officer date recv’d: 337-475-5711 date picked up: mpowell@mcneese.edu picked up by: READ GUIDELINES FOR CHEMICAL AND WASTE DISPOSAL BEFORE FILLING OUT REQUEST FOR DISPOSAL OF CHEMICAL AND HAZARDOUS WASTE FORM RESPONSIBLE FACULTY BUILDING, OFFICE, DEPARTMENT: OR STAFF MEMBER: AND PHONE: PERSON PREPARING DATE OF REQUEST: FORM: BUILDING OFFICE AND PHONE: LOCATION OF WASTE: VOLUME OR (SAFETY OFFICER (SAFETY OFFICER SOLID NUMBER, SIZE, AND TYPE OF WEIGHT IN TOTAL WEIGHT OF IDENTIFICATION OF WASTE USE ONLY) USE ONLY) LIQUID pH CONTAINER CONTAINER EACH WASTE TYPE IN CHEMICALS DOT/EPA ITEM NUMBER GAS (EX. 3 X 1 L Bottle) (ex. 750 ml in each POUNDS (lbs) bottle) DRAW A LINE BETWEEN WASTE TYPES Special Notes or Handling Instructions: Certification: I hereby declare that the identification/description of waste chemicals is accurate and complete to the best of my knowledge and that I have made a reasonable effort to detoxify and/or recycle this material. Printed Name: Signed Name: Date:
(Safety Officer Use Only) date recv’d: date picked up: picked up by: RETURN FORM TO University Police/Safety Officer 337-475-5711 mpowell@mcneese.edu READ GUIDELINES FOR CHEMICAL AND WASTE DISPOSAL BEFORE FILLING OUT REQUEST FOR DISPOSAL OF CHEMICAL AND HAZARDOUS WASTE FORM DEPARTMENT: RESPONSIBLE FACULTY OR STAFF MEMBER: BUILDING, OFFICE, AND PHONE: DATE OF REQUEST: PERSON PREPARING FORM: BUILDING OFFICE AND PHONE: LOCATION OF WASTE: (SAFETY OFFICER USE ONLY) ITEM NUMBER IDENTIFICATION OF WASTE CHEMICALS SOLID LIQUID GAS pH NUMBER, SIZE, AND TYPE OF CONTAINER (EX. 3 X 1 L Bottle) VOLUME OR WEIGHT IN CONTAINER (ex. 750 ml in each bottle) TOTAL WEIGHT OF EACH WASTE TYPE IN POUNDS (lbs) (SAFETY OFFICER USE ONLY) DOT/EPA DRAW A LINE BETWEEN WASTE TYPES Special Notes or Handling Instructions: Certification: I hereby declare that the identification/description of waste chemicals is accurate and complete to the best of my knowledge and that I have made a reasonable effort to detoxify and/or recycle this material. Printed Name: Signed Name: Date:
Request%20for%20Disposal%20of%20Chemical%20and%20Hazardous%20Waste%20Form%20and%20Guidelines-1.docx