Hazardous Material(s) Name(s) and Concentration(s):
(Chemical Name)
DOT Proper Shipping Name (Chemical Name):
UN/NA#:
Acutely Hazardous:	Corrosive:				Waste Category:
Toxic:	Quantity:				Extremely Hazardous:
Ignitable:				Flammable:
EPA Waste #:				Form (solid/liquid):
Container:
Safety Handling Instructions, If Any (per MSDS):
Prepared By:			Dept.:
Dept. Generating Waste:			Bldg./Room:
Phone:
Initial Accumulation Date:
Signature :
RM/EHOS USE ONLY
State Waste ID #:		EPA ID#:
Hazardous Waste Vendor:
Notes: