UNIVERSITY OF MISSOURI-ST. LOUIS
UNWANTED MATERIAL PICKUP REQUEST
And Container Filling Log
Date Accumulation of Material Began: ______/______/______
Contact EHS for pickup 5 no later than 5 months after Accumulation Start
Date
Container Supervised by:
Lab No./Location of Materials:
Tel. No.
Please fill out completely.
FOR PICKUP, Sign the certification below and E-mail to StruckS@UMSL.edu or
eversj@umsl.edu and we will schedule. For additional information or spill response call 5166363 or 516-6362. In case of emergency, call 516-5155 (Police).
Circle any metals present in this container: Hg, As, Ba, Cd, Pb, Se, Ag.
MATERIAL DESCRIPTION BE
SPECIFIC!
i.e. “Halogenated Solvents” is
NOT acceptable!
QUANTITY OF
MATERIAL
(Kg, L, or % vol.
or wgt.)
COMMENTS / NOTES
Generator Certification: The materials listed above are accurately and completely described, and if they contain any amount
of Arsenic, Barium, Cadmium, Lead, Mercury, Selenium, or Silver, then I have specified this.
Generator:
PRINT NAME
Date ____/____/____ Page ___ of ___
SIGNATURE
(Environmental Health and Safety Form EHS-F1 Revision #4, Revised 02/25/2014)