Hazardous Waste Management Notification Form

Date material needs to be shipped

Number of shipments/frequency

Contact Name

First Last

Principal Investigator

First Last

Contact Email

Contact Phone

Lab location (Bldg./Rm)

Contents of shipment

Indicate all contents in percent or ppm

Volume

per container/total

Physical Form

liquid/sold/gas

Type/material of container

per container/total

Shipment requires dry ice?

Yes

Destination

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Shipping From

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Department FedEx Number

Shipment Summary

Name

This field is for validation purposes and should be left unchanged.

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