Chemical Pick-Up Form

Please complete as much information as possible. Fields with an * are required fields.

* Name:

* Principal Investigator:

* Room #

* Building:

* Email:

Check all that apply:
		Mixed Chemicals
		Unused/Old Chemicals
		Unknown (Please try to identify the chemicals(s) before pick-up)
If unused, can these chemicals be utilized by another laboratory?
Yes		No

List as completely as possible the chemicals you need picked up. If you have more than nine different items to be picked up, you can either fill out additional Chemical Pick-Up Forms online or you may either contact the Environment, Health and Safety Office at ext. 8-1081 or email ehs@kumc.edu to make arrangements for pick-up of larger quantities of chemicals. Laboratory clean-outs should be scheduled with the EHS Office and not communicated via this Form.
	Chemical Name	Container Unit	Container Size	# of Containers (of that size)
1.

2.

3.

4.

5.

6.

7.

8.

9.

Note: All containers MUST be labeled with a Hazardous Waste Label. These labels can be obtained from the KUMC Environment, Health and Safety Office (EHS) Office. Please call EHS Office at 8-1081 or email ehs@kumc.edu to request hazardous waste labels.

Additional Comments:

Last modified: Jan 14, 2013