Request for Hazardous Waste Disposal

Part 1

Budget Centre/Dept
Contact Name / Date
Phone number / Fax number
Location of Waste

Include room number and four digit building number

Purchase order number / Account Number
Number of sheets in Part 2

To Hospitality and Accommodation Services:

Please arrange for collection and disposal of the waste listed in Part 2 overleaf.

The waste meets the following conditions, as appropriate:

·  containers are sound, leakproof and sealed by a secure closure;

·  each container or item of equipment is durably labelled with the proper name of the substance(s), and the hazard warning symbol(s) depicting the major hazard(s) assigned under the CHIP[*] regulations and, where required, the room number and four digit building number;

·  the Hazardous waste content equipment is sealed against accidental release;

·  potentially unstable substances have been appropriately stabilised.

Name / Signature
Budget Centre Hazardous Waste Co-ordinator

For Use by Hospitality and Accommodation Services

Confirmation of proposed date for removal of waste

Waste Series ID Number / Consignment Note Code
Date for Removal / Name of HAS Contact / Phone

For Use by Budget Centre/Department

Confirmation of removal of waste

I confirm the waste removed matches exactly the waste listed in Part 2

Date waste Removed / Budget Centre Contact
Name / Signature


Part 2

Waste Details

Substance/Material/Equipment Name / Class
(see below) / Type
(see below) / Conc./
amount / Form (see below) / Container
Number / Type / Size
Form / Physical Form, L = liquid; P = powder; S = solid; M = mixed
Class / Hazardous Waste Classification (H number)#
Type / 6 digit code#

# From Lists of Wastes Regulations 2005, see GUIDANCE/11/HWGA/05

Sheet Number / 1 / of

For Use by Hospitality and Accommodation Services

Waste Series ID Number / Consignment Note Code


Waste details (cont.)

Continuation Sheet / of
Substance/Material/Equipment Name / Class
(see below) / Type
(see below) / Conc./
amount / Form (see below) / Container
Number / Type / Size
Form / Physical Form, L = liquid; P = powder; S = solid; M = mixed
Class / Hazardous Waste Classification (H number)#
Type / 6 digit code#

# see GUIDANCE/11/HWGA/05

For Use by Hospitality and Accommodation Services

Waste Series ID Number / Consignment Note Code

HSU\Library\Documents\Health and Safety Policy\hs15\hs71pf.doc

Revised November 2005

8.10.08

1

[*] The Chemicals (Hazard Information and Packaging for Supply) Regulations (as amended)