Chemical Waste Pick-Up Request Form

When filling out the form, please fill in the information for all the fields on the form up to and including your Room Number. These include:

Your Phone Number
Your Director's Name
Your Department
Your Name
Your Building
Your Room Number

Your e-mail address is optional.

Phone: Lab Director: Department:
Your Name: Your e-mail:

When selecting your building click on the dot in front of your building's name. Only one building can be chosen. If you accidentally click on the wrong one just click on the correct name and the computer will correct the mistake for you. Be sure to fill in your room number in the box following your building name.

Building & Room Number
Chemistry Cobb Hall Corner Building Gilmer Hospital East Hospital West Jordan Hall	Materials Science MR-4 Multi-Story Old Med. School Physics Thornton Other

From there select any containers you need to have picked up, and any empty containers you require to be dropped off at your lab.

When selecting containers to be picked up or dropped off simply click on the arrow on the select bar of the required container size and choose the number of containers desired.
note: If there are more than 20 containers of one type to be picked up we ask that you call OEHS and discuss the pickup with one of our personnel.

Waste Containers
Pick-Up < 500 ML. (1 Pt.) bottles 1 liter (1quart) bottles 2 liter (0.5 gallon) bottle 4 liter (1 gallon) bottle 2.5 gal. (8 liter) carboy 5 gal. carboy 5 gal. metal can Laboratory Waste Box Broken Mercury Thermometer other:	Replace 4 Liter Carboy Lab Wate Box Sponge

Waste Containers

Pick-Up

< 500 ML. (1 Pt.) bottles

1 liter (1quart) bottles

2 liter (0.5 gallon) bottle

4 liter (1 gallon) bottle

2.5 gal. (8 liter) carboy

5 gal. carboy

5 gal. metal can

Laboratory Waste Box

Broken Mercury Thermometer

other:

Replace

4 Liter

Carboy

Lab Wate Box

Sponge

If waste tickets or stickers are needed, click on the corresponding box below. Any or all of these may be chosen at once.

Need Waste Tickets
Need Hazardous Waste Stickers (small)
Need Hazardous Waste Stickers (large)
Need Lab Glassware Stickers

If your containers are labeled and ready to be picked up, check the appropriate button below. Otherwise please designate the date when they will be ready.

labeled and ready
will be ready on

If there are any comments or additional explanations required, they can be written in the "comments" section below.

Comments:

After you have completed the form, click the "Submit Request" button below, and we'll do the rest.

If for any reason the On-Line Request Form is not functioning properly, please call in your pick-up requests to our office at 982-4911.

This form created by Adam P. Peters. e-mail to app5a@virginia.edu