Fillable Hazardous-waste-pick-up-form REQUEST FOR HAZARDOUS WASTE PICK-UP

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Hazardous-waste-pick-up-form REQUEST FOR HAZARDOUS WASTE PICK-UP

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Page 1 of 1 HZW Request form
Rev. 5/31/2019
REQUEST FOR HAZARDOUS WASTE PICK-UP
Date: ___________
TO: Mike Rocke, Environmental Safety Specialist
E-mail: michael.rocke@montgomerycollege.edu Questions? Call: (240) 567-4266
Telephone:_____________________
Fax:___________________________
Li
st of hazardous materials for disposal:
Material
Container
Size/
Volume
Number of
Containers
(Whole no. only*)
Comments
• *Use “Comments” to indicate how full containers are, if desired.
• In order that you may add as many pages as necessary to your list, this document is not protected for forms. (When you reach the last field on this
page, simply use you tab key to automatically add a new row. Do not be concerned that there are no “form fields” in the new cells. Simply type your
data as usual.) After entering your materials for pick-up, be sure to use “SAVE AS” and new name to save a copy on your PC. This will leave the
original, blank copy unchanged for use next time you have hazardous waste for disposal.
• E-mail completed form to the Environmental Safety Specialist.
From:______________________________________
Dept.:______________________________________
Pick-up Location (Campus/Bldg/Rm):______________________________________________________
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Completed 5 April 2020

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