Hazardous Waste Pick-Up Request

Complete one form for each container of waste. You may use a single form for multiple containers with the same chemical constituents.

Page 1 of 3 - Personal Information

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Date Date / MM / DD YYYY
Campus

Campus where waste is to be picked up
If Other, Please Specify:
Building (initials)

Building where waste is to be picked up
Room Number

Room where waste is to be picked up
Room Number Extension

Use this field if a room has non-numeric values after the room number (Ex. EC 1650 M1). Only add the extension here.
Requestor Name Requestor Name First Last
Panther ID
Minimum of 7 digits required. Currently Entered: 0 digits.
Requestor Email
Phone Phone - ### - ### ####
Waste Generating Department
Lab Manager/PI Name
Lab Manager/PI Email Address
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Enter Your Email Address *

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