Hazardous Waste Pick-up Form

Department of Environmental Health and Safety
Albert Einstein College of Medicine of Yeshiva University
Phone: x4150 http://www.aecom.yu.edu/ehs FAX: x8740

Contact Name : Date:
Principal Investigator: Extension:
Building and Room: Location of Waste:

White area to be completed by the waste generator

 Shaded area to be completed by EH&S

Waste Description
If mixed, list all known chemicals and concentrations

Volume (L) or
Weight (Kg)

# of containers

Type of containers

 .
1. . . O Glass
O Plastic
O Metal
O Box		 O Waste not labeled
O Unsafe
O No Access
O _____________
2. . . O Glass
O Plastic
O Metal
O Box		 O Waste not labeled
O Unsafe
O No Access
O _____________
3. . . O Glass
O Plastic
O Metal
O Box		 O Waste not labeled
O Unsafe
O No Access
O _____________
4. . . O Glass
O Plastic
O Metal
O Box		 O Waste not labeled
O Unsafe
O No Access
O _____________
5. . . O Glass
O Plastic
O Metal
O Box		 O Waste not labeled
O Unsafe
O No Access
O _____________
Special Handling or Remarks:

Please note that each item of waste must have an attached Hazardous Waste label. Any container without a Hazardous Waste label cannot be picked up by the Department of Environmental Health and Safety. Improperly completed forms and labels will cause delays in waste pick up.
Sign at time of pick up

PI/Lab signature:_____________________________________          Date:_________________

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