APPOINTMENT REQUEST FORM (for Controlled Substance Evidence Destruction) Requesting agency fills in the white sections of this form and email to: controlledsubstancedestruction@state.mn.us 3M will populate the blue sections of this form BCA will populate the green sections of this form Requesting Law Enforcement Today’s Agency: Date: Street Address: Zip County: Phone Number: Code: Contact Rank/Title: Person: Email Phone #: Address: One Container Per Line: Container Size & Source Type EPA #: Barcode ID & Agency -5 or 30 Gal Cont. Dept #: Container Seal# & Address -Metal or Plastic Cont. Container Size & Source Type EPA #: Barcode ID & Agency -5 or 30 Gal Cont. Dept #: Container Seal# & Address -Metal or Plastic Cont. Container Size & Source Type EPA #: Barcode ID & Agency -5 or 30 Gal Cont. Dept #: Container Seal# & Address -Metal or Plastic Cont. Container Size & Source Type EPA #: Barcode ID & Agency -5 or 30 Gal Cont. Dept #: Container Seal# & Address -Metal or Plastic Cont. Container Size & Source Type EPA #: Barcode ID & Agency -5 or 30 Gal Cont. Dept #: Container Seal# & Address -Metal or Plastic Cont. Container Size & Source Type EPA #: Barcode ID & Agency -5 or 30 Gal Cont. Dept #: Container Seal# & Address -Metal or Plastic Cont.
APPOINTMENT REQUEST FORM (for Controlled Substance Evidence Destruction) Requesting agency fills in the white sections of this form and email to: controlledsubstancedestruction@state.mn.us 3M will populate the blue sections of this form BCA will populate the green sections of this form Requesting Law Enforcement Agency: Today’s Date: Street Address: County: Zip Code: Phone Number: Contact Person: Rank/Title: Email Address: Phone #: One Container Per Line: Source Agency & Address Container Size & Type -5 or 30 Gal Cont. -Metal or Plastic Cont. EPA #: Dept #: Barcode ID & Container Seal# Source Agency & Address Container Size & Type -5 or 30 Gal Cont. -Metal or Plastic Cont. EPA #: Dept #: Barcode ID & Container Seal# Source Agency & Address Container Size & Type -5 or 30 Gal Cont. -Metal or Plastic Cont. EPA #: Dept #: Barcode ID & Container Seal# Source Agency & Address Container Size & Type -5 or 30 Gal Cont. -Metal or Plastic Cont. EPA #: Dept #: Barcode ID & Container Seal# Source Agency & Address Container Size & Type -5 or 30 Gal Cont. -Metal or Plastic Cont. EPA #: Dept #: Barcode ID & Container Seal# Source Agency & Address Container Size & Type -5 or 30 Gal Cont. -Metal or Plastic Cont. EPA #: Dept #: Barcode ID & Container Seal#
APPOINTMENT%20REQUEST%20FORM%20Controlled%20Substance%20Evidence%20Destruction%202013.docx