REQUEST FOR CHEMICAL REMOVAL EHS use only
Date picked up:_____________
Picked up by:_______________
Date:
 
Dept.:
 
 
Responsible Person:
 		 Contact Person:
 

Phone:
 
Bldg. & Room #:
 		 Location of Chemicals
 
 
Pick-up No.:
Does EHS need to call to schedule pickup?
Yes   No		 Instructions:
Print (landscape view) and send to
EHS, 120 Physical Plant Bldg.;
or FAX to 744-7148
EHS USE ONLY IDENTIFICATION/DESCRIPTION of CHEMICALS
(Do not submit unknowns)		 PHYS.
STATE		 NUMBER, SIZE &
TYPE OF
CONTAINER		 VOLUME or
WEIGHT in
CONTAINER		 pH HAZARDS
             
             
             
             
             
Special Notes or Handling Instructions:  
"I hereby declare that the identification/description of chemicals is accurate and complete to the best of my knowledge and that I have made a reasonable effort to neutralize, detoxify and/or recycle this material."
(Dept. Head Signature) Date:

(Only one certification is needed per request.)   Page _____ of _____