Vehicle Type:
Scheduled
,
of
Customer #
Corporate Headquarters
1105 Windham Parkway
Romeoville, IL 60446
Ph: (877) 540-7215
Fax: (815)-676-3086
Vintage Tech Recyclers
A CERTIFIED ELECTRONICS RECYCLER
www.VintageTechRecyclers.com
Vehicle
Load Type:
Red Fields are Required
Leave Time
VT Pick-Up
Driver
rd
Customer Drop-Off
rd
3 Party FTL
3 Party LTL
Equipment Delivery
Equipment Locations:
Company or Organization:
1st Location Address:
Name:
e-mail:
City, State, Zip:
Contact Information
nd
Mailing Address ONLY:
2 Location Address:
City, State, Zip:
City, State, Zip:
County:
Requested Dates:
Type of Organization:
Hours of Operation:
Main Phone:
Alternative Contact:
(
Mobile Phone:
)-
-
to
Name:
Phone:
(
)-
-
In order to provide the best service to you, we ask that you make your equipment counts as accurate as possible.
# of Units
Description
ACTUAL
# Units
Computers
Description
TV’s*
ACTUAL
# Units
Description
Boxes of Miscellaneous
Small
Large
ACTUAL
Monitors-CRT
Small Printers / Fax
Batteries-Power Supplies
Monitors-LCD
Large Printers / Fax
Large Copiers on Wheels
Servers
iMacs
Apple
Laptops
G3s
G4s
G5s
Intels
Large Roll on Item(s)
eMacs
PC
*Televisions are considered small when their screen size is less than 27 inches. Any TV larger than 27 inches is considered large.
1. Describe any large and/or unlisted equipment in detail:
2. Is the equipment palletized?
Yes
No
How tall are the pallets stacked?
Total number of pallets:
3. Describe where the equipment is located:
4. DATA DESTRUCTION : Choose ONE from the 4 choices on page 3 of this document.
5. Are the Hard Drives Removed from the Units?
6. AUDIT:
Yes
Fees: $1 per Item
Yes
No
No
If a choice is not made, VTR does not automatically perform an audit. Thank You.
Time:
Pick-Up Date:
Pick-Up Confirmation
Customer Signature:
VT Representative:
*If no selection is made, VTR automatically performs a FREE Standard Hard Drive Wipe.
Total Number of Hard Drives:
Total Number of
Units to be
Audited:
ESTIMATE
Job Number:
ACTUAL
-
PT#
3
-
_______________________________________________________________________________
By signing you admit that all material received by VTR is to be recycled and that the actual counts are correct to the best of your knowledge.
Your signature releases all received property to Vintage Tech, LLC. Upon receipt Vintage Tech accepts all responsibility for collected assets.
Brendan Wittry
email: bwittry@vintagetechrecyclers.com
**** Customers: Be sure to review the Statement of Work on Page 2 and type in your signature prior to submitting this form.
Effective Date: 07/24/13
Revision # 1
In partnership with:
Statement of Work
Vintage Tech, LLC in partnership with your organization shall provide a responsible electronics recycling service. At this time, we ask
for your assistance to verify that all details listed below are accurate in regards to your services. Vintage Tech would like to ensure a
convenient and efficient experience and if any details appear to be missing, please feel free to contact us at any time. 630.305.0922.
Standard Scope of Services
Vintage Tech Shall Provide:
Your Organization Shall Provide:
A primary contact to coordinate pick-up details.
NIST 800-88 Compliant Data Erasure and Hard Drive Destruction.
e-Stewards and R2 Compliant Material Processing & Recycling
A Certificate of Recycling & Volume Report
A primary contact to coordinate pick-up and/or delivery details.
NON-ACCEPTED ITEMS: In the event that a non-accepted item(s) is received at Vintage Tech facility, the customer will be contacted and given the option to either have the items returned to their facility for a service
charge or to be invoiced for the disposal of the non-accepted item(s).
Specific Instructions for this Customer:
Transportation Fees:
Receiving Department or Facility Plainfield
1 Please correspond with Suzette sschwartz@elkgroveparks.org
2
3
4
5
FREE
Specific Instructions for this Job:
Receiving Department or Facility
1
2
3
4
5
Plainfield
Transportation Fees:
FREE
Payments or Recycling Fee’s
By
Quantity
Material Category
By
Volume
Payment
Fee’s
(Unit Price)
(Unit Price)
Material Category
(Lbs)
0.00
Monitors
0.00
Printers
0.00
N/A
Miscellaneous (or EED’s)
By
Volume
Payment
Fee’s
(Unit Price)
(Unit Price)
(Lbs)
Computers
Televisions
By
Quantity
0.00
0.00
Customer’s Electronic Signature:
Date:
Who referred you to Vintage Tech Recyclers? IEC - Iowa Educators Consortium
By signing you admit that you have received Vintage Tech's Accepted Items List and that the above requirements for both parties are understood.
Effective Date: 07/24/13
Revision # 1
In partnership with:
INFORMATION
Facilities
Corporate Headquarters
1105 Windham Parkway
Romeoville, IL 60446
Mon.-Fri: 9:00 A.M. to 5:00 P.M.
Kansas City Area
4380A Belgium Boulevard
Riverside, MO 64150
Mon-Fri: 8:00 A.M. to 4:30 P.M.
Chicagoland
14110 South Route 59
Plainfield, IL 60544
Mon.-Thurs: 6:00 A.M. to 3:00 P.M.
Fri: 6:00 A.M. to 12:00 P.M.
Detroit Area
4601 Dewitt Road
Canton, MI 48187
Mon-Fri: 8:00 A.M. to 4:30 P.M.
Pick-up Dates
If you request specific days for a pick-up, we will try to accommodate you. However, exact dates may not always be available due to scheduling conflicts.
VTR does not schedule weekend pick-ups.
Pick Up and Processing Fees
1.
2.
3.
All equipment must be ready for pick up prior to our arrival. Please adhere to the following guidelines to keep our cost low, which in turn keeps your
fees low. Each of the following guidelines helps keep our fees at a minimum. If for any reason these requirements cannot be reached, contact a
customer service representative to discuss alternatives prior to pick up.
***Fees will be assessed to the customer if the guidelines below are not met.
a.
Have all equipment disconnected from power and stored in one single area in your facility.
b. Equipment must be stored on the ground floor near an exit to the building.
c.
The exit must have direct access to a driveway or parking lot.
AUDITS: An AUDIT consists of recording brand names and serial numbers of all main items you recycle with us.
a.
Fees for AUDITs consist of $1 per item.
b. *Only main items are recorded* (Computers, laptops, and servers, LCD & CRT monitors, fax machines, copiers and printers.)
Unaccepted Items: If these materials are shipped to a Vintage Tech facility, a charge for processing will be assessed to the customer.
a.
Ballasts
f.
Lithium Batteries
b. Capacitors
g.
Household Batteries: AA, AAA, D, C, etc.
h. VHS Cassette Tapes
c.
Freon Containing Items/White Goods: Refrigerators, Dish
Washers, Stoves, Air Conditioners, Dehumidifiers, etc
i.
Gas Cylinders: fire extinguishers, propane cylinders, etc.
d. Light Bulbs
j.
Medical Equipment: Any material that is considered or has
e. Liquids or Items containing Liquid: gas motors, hazardous
come in contact with biohazard or radioactive material
waste vials, etc.
Data Destruction Services and Associated Fees
All data storage devices recycled with Vintage Tech are wiped and/or destroyed regardless if a SPECIAL data destruction service is requested.
1. FREE Hard Drive Data Wipe
Our facility uses Destruct Data, one of the most advanced data wiping software systems available to securely wipe information from hard
drives. Unless specified otherwise all re-useable hard drives are wiped with Destruct Data free of charge.
2. Hard Drive Wipe with Full Data Erasure Report:
For a fee we offer a full data erasure report from Destruct Data for every hard drive recycled. The full data erasure report form will include
the name of the company/organization, the total number of drives passed/failed, vender, model, capacity, serial number, date of when the
drive was erased, status of the drive erase (pass/fail), erasure description, and health of the drive (if the customer requests it). If you have
any questions about the full data erasure report feel free to contact a customer service representative for more information.
1. Price: $3.00 per drive.
2. Additional $5.00 per drive if a VTR employee removes the drive from the unit.
3. Hard Destruction: On-site hard drive crushing:
For a fee we offer on-site hard drive crushing. One of our trained employees will bring a mobile hard drive crusher to your facility and
individually crush each drive. Limit: 500 Drives per pick-up. Contact a customer service representative for more information.
1. Price: $50.00 setup fee.
2. $3.00 per drive if removed from the computer or server.
3. Additional $5.00 per drive if a VTR employee removes the drive from the unit.
4. Hard Drive Destruction: Off-site Hard Drive Shredding:
For a fee we can provide a hard drive shredding service at our facility using our industrial shredder. This service is offered to all customers
whether dropped off or picked up. Contact a customer service representative for more information.
1. Price: $3.00 per drive if removed from the computer or server.
2. Additional $5.00 per drive if a VTR employee removes the drive from the unit.
Thank you for your time in filling out this form. We appreciate your business and look forward to servicing your recycling needs.
Find out more @
www.vintagetechrecyclers.com
In partnership with:
Effective Date: 07/24/13
Revision # 1