HAZARDOUS CHEMICAL PICK UP FORM
Send completed forms to EHS, 4747 Troost, Room 3, KC, MO 64110
1
Submit Form
If you have questions or problems in the completion of this form, please review the instruction sheet for this form or call
EHS, 235-1642 for assistance.
Date: __________ Department/School Name: __________________________________________________________
Generator's name: _______________________________________ Telephone: ___________________________
Print name of person authorizing charges and pickup: ___________________________________________________
Signature of person authorizing charges and pickup: ____________________________________________________
Account Name to be charged: ________________________ MOCODE Number: ______________________________
Location for pickup: Bldg: ___________________ Room: _____________ Other: ___________________________ If
immediate attention is required for the chemicals, please explain: _______________________________________
______________________________________________________________________________________________
Example: You have five glass bottles of benzene, each containing 4 liters. You have determined no future need for the material and add them to a
Hazardous Chemical Pick Up Form on 1/1/96. Note: If you have the same type of chemical but a different volume or weight in each container, then
list each container separately.
Hazardous Chemical Name(s)
If mixed, list all known and the concentration.
EX Benzene
1
2
3
4
5
6
7
8
9
10
Volume (L)
or
Weight (Kg)
Container
20 L
GB
Type
Characteristic
# of
To
5
X
Re
Ig
X
Comments
Co In
2
Hazardous Chemical Name(s)
If mixed, list all known and the concentration.
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
Volume (L)
or
Weight (Kg)
Container
Type
Characteristic
# of
To
Re
Ig
Comments
Co In