Environment, Health and Safety

Regulated Waste Pick-up Request

GENERATOR INFORMATION
Generator Name/Contact Person:	e-mail:	Phone:
Department OR Trade:	Building where Waste is located:	Room:

Waste Origin: Academic Lab Research Lab Maintenance Construction Other

Classification: Unused Waste Mixture Spent Product

One or more of the containers listed below contains: PCBs Radioactive Materials Biohazardous Materials None of the Above

Tag #	Container Type	Container Size	Physical State	Waste Description

~ OR ~

Attach the alternate list of waste containers which includes all required information:

Click here to download the template (.xlsx format) for the alternate list of waste containers

Clicking the "Submit Request Now" button below will e-mail a copy of this form to Larry Page and will display a copy of the form that you can print for your records.
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Last Modified 3/11/13