1. BILLING INFORMATION

2. SHIPPING INFORMATION

COMPANY

COMPANY

ADDRESS

ADDRESS

CITY, STATE, ZIP

CITY, STATE, ZIP

3. DRIVER INFORMATION

DRIVER CONTACT

HOURS AVAILABLE

PHONE

WHERE IS WASTE?

2^nd CONTACT

WASTE PACKAGED?

PHONE

PALLETIZED?

IF WASTE IS PALLETIZED, DO YOU HAVE A PALLET JACK/FORKLIFT TO LOAD TRUCK?

YES

NO

HOW HIGH ARE THE PALLETS STACKED?

2’

3’

4’

5’

DO YOU HAVE A LOADING DOCK?

YES

NO

IF YOU DON’T HAVE A DOCK,  IS WASTE ON A LEVEL WITH A DOOR?

YES

NO

IF NO, DO YOU HAVE AN ELEVATOR?

YES

NO

4. PLEASE ENTER YOUR WASTE QUANTITIES BELOW

UNIVERSAL WASTE LAMPS

QUANTITY

MERCURY

QUANTITY

4' and under Fluorescent   

Mercury 8; UN2809; PGIII (Liquid)

Over 4' Fluorescent          

Mercury Contained in Mfg. Articles

Compact Fluorescent        

8; UN2809; PGIII (Devices)

Circular Fluorescent          

ballasts

High Intensity Discharge    

Small Capacitor-Incineration (<9 lbs.)

Shatter Shield                             

Non PCB Ballasts for Recycling

Built in Ballast                 

Non TSCA PCB Ballasts for Recycling

Incandescent                               

PACKAGING

QUANTITY

Broken/Crushed Fluorescent          

2' Lamp Barrel - Deposit (2' in diameter, 2' tall)

Ultra-Violet                                

4' Lamp Barrel - Deposit (2' in diameter, 4' tall)

Neon

4' Lamp Box (holds appx 100 T12s)

ELECTRONIC WASTE

QUANTITY

8' Lamp Box (holds appx 30 T12s)

Computer Monitors

5-gallon UN1H2 Poly Pail

Any other Electronic Equipment

14-gallon UN1H2 Poly Drum

BATTERIES

QUANTITY

30-gallon UN1H2 Poly Drum

Alkaline

55-gallon UN1A2 DOT Steel drum

Mixed (non-sorted)

Gaylord Box

Nickel Cadmium

you may use your own packaging - must be approved.

Lithium, Silver

OTHER UNIVERSAL WASTE ITEMS

QUANTITY

Mercury

type other waste here

Lead Acid

type other waste here

5. OTHER WASTE NOT LISTED ABOVE (PLEASE INLUDE WASTE DESCRIPTION & CONTAINER SIZE)

Container Size/Type of Waste

Quantity

Waste Details (leaking, broken, etc.)