UTD EHS: Chemical Pickup Form

Environmental Management

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-Chemical Pick Up

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Chemical Pickup Form

Container Number: i.e. 1 of 10	Principal Investigator:
Department:	Room: i.e. BE 1.111
Phone:	Waste Type:

LIST ONLY 1 CONTAINER PER FORM
Every container MUST be labeled with percent of EACH chemical, including water.

Amount (ml or g)	% (MUST add up to 100)	Chemical Waste Description (If a mixture, indicate % of each component) NO FORMULAS PLEASE.
At least one amount:	At least one percentage:	At least one waste description:
Amount 2:	Percent 2:	Waste 2:
Amount 3:	Percent 3:	Waste 3:
Amount 4:	Percent 4:	Waste 4:
Amount 5:	Percent 5:	Waste 5:
Amount 6:	Percent 6:	Waste 6:

Container Size:

Indicate if you would like a replacement container. Signify how many containers you would like and the contents that are going to be stored in the container

Containers Needed:

By clicking Submit, I certify that the following information is correct to the best of my knowledge and the chemical(s) are in a proper container for handling and identification.

IMPORTANT: PRINT A COPY OF THIS PAGE AND APPLY IT TO THE WASTE BOTTLE BEFORE PRESSING THE SUBMIT BUTTON.