Surplus Chemical Clean Out Form

***THIS FORM IS NEW***
This form is ONLY for Surplus Chemical Clean Out (less than 100 chemicals, all unopened and in original manufacturer's containers).  Keep all chemicals properly segregated and in secondary containment until they are picked up by EH&S.

To request Laboratory Clean Out, use this form instead.

* Please state in the comments section at the bottom whether this is a laboratory cleanout or a donation to the surplus program.

This form will be submitted to the Hazardous Waste Program group at Environmental Health and Safety. If you have questions about this form submission, please e-mail to Chris Craig or call 723-0654.

Note: For the best visual effects please use an Internet Explorer browser.
In the Netscape browser some graphics are displayed differently, though the form will do the job intended.

Fields with an asterisk (*) must be filled out, use NA if unknown or not applicable.

Please use the TAB key only to move between the fields.

*Name of person Requesting *Requester's
Phone
*Requester's e-mail *Date:
*Department Name *Room #
*Building Name *Building #

Use the following tips for the submission:

Contents: Generic description of the contents of the container;
(E.g., assorted buffers, non-halogenated solvents, toxic solids,
flammable liquids, acids, mercury containing materials.)
General Condition of the Containers:
(E.g., good)
Number of Chemical Containers:
(E.g., 15)
Hazard Categories:
Mark the appropriate Hazard Category by the checking the check box, using the
chart below as a guide.

Hazard Category
C= Corrosive
F= Flammable
O= Oxidizer
W= Air/Water Reactive
T= Toxic

Item
No.
Contents
General Condition of the Containers
Number of containers
Hazard Category
   
C
F
O
W
 T
1
2
3
4
5
6
7
8
9
10

If you need to add more than 10 items, please complete this form for your first 10 and submit it, then use the Back button in your browser to return to this page and click on the "Clear This Section" button below to clear only this section of the form (keeping your other information), enter up to 10 more items, and submit this form again.

Repeat this process as many times as you need to.
Additional Information or Comments:

Please go over your information before you press Submit to EH&S button.

To clear all fields and start all over again, click on the Reset button below.

After you submit the request you will receive the confirmation of your order, the time and the date of your submission and all items you checked. You can print out this confirmation by using the Browser command on the tool bar: File->Print.


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