WKU Environmental Health Safety-Regulated Material Disposal Request


Request for Disposal of Regulated Materials	TAG NUMBER

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CONTAINER INFORMATION	GENERATOR INFORMATION
HOW MANY CONTAINERS?	GENERATOR NAME/CONTACT:	EMAIL:	PHONE:

CONTAINER SIZE UNITS:	BUILDING WHERE WASTE IS STORED:	ROOM:
CONTAINER INVENTORY LIST ATTACHED?	DEPARTMENT OR TRADE:

WASTE ORIGIN	PHYSICAL STATE	WASTE DESCRIPTION	QTY OR %
Academic Lab Research Lab Darkroom Automotive Maintenance Painting Pest/Weed Ctrl Lab Cleanup Other	Solid Liquid Gas
CLASSIFICATION	CONTAINER TYPE
Unused Waste Mixture Spent Product	Metal Plastic Glass Paper
		TOTAL VOLUME OR WEIGHT OF WASTE IN ALL CONTAINER(S), Including UNITS (Lbs, KG, Gallons, Liters)

CERTIFICATION: I certify by my signature below that the above information is accurate and complete to the best of my knowledge. This material has been generated, identified, properly labeled, and stored under my supervision. Unless noted above or on any attachments, this material contains no biohazardous or pathogenic constituents, polychlorinated biphenyls (PCBs), radioactive materials, or other prohibited materials.

Generator's Signature and Date

This form updated: August 24, 2005