Date: 05/25/2013

CCT: Name:

Department: Building: Room:

Phone Number: Supervisor:

Container Type: Select One Plastic Metal Paper Glass Used or Unused: Select One Used Unused Solid/Liquid/Gas: Select One Liquid Solid Gas

Container Size (ml): Radioactive: Select One No Yes

Chemicals / Percent (must equal 100%)

1. Chemical/Percent:
2. Chemical/Percent:
3. Chemical/Percent:
4. Chemical/Percent:
5. Chemical/Percent:
6. Chemical/Percent:
7. Chemical/Percent:

Comments:

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