Form C: Commercial Product Waste Form

HAZARDOUS WASTE

FORM C: COMMERCIAL PRODUCT WASTE FORM

FEDERAL LAW PROHIBITS IMPROPER DISPOSAL.

BOX /

IF FOUND, CONTACT THE NE AREST POLICE, OR PUBLIC SAFETY

:

DATA ENTRY DATE

AUTHO RITY O R THE U.S. ENVIRONMENTAL PRO TECTIO N AGENCY.

CONT. #

DOT SHIPPING NAME:

: L

SCHOOL CODE

LABPACK MN02

:

MANIFEST#

BULK CAN/PAIL

DF CF DM CY

(CSDP USE)

(CSDP USE)

BULK DRUM

GENERATOR: _________________________________________________________________________

ADDRESS:

__________________________________________________________________________

CITY/ST/ZIP:

__________________________ EPA# ____________________________________________

MN

O nly one commercial produc t type per box/cont. Indicate the amount(s ), tes t pH for liquids (multi pH paper is acceptable ) and include water if

applicable. Label e ach item with com ponents, %'s, a mount and pH. Secure ly c lose and pack items(s) in box/cont. (facing up!). Write box/cont. num ber

on box/c ont. Che ck whe ther box/cont. contains solids, liquids or aeros ols. Check whether a labpack (multiple items) or bulk material (pa il or drum).

Product Name:_______________________________________

Manufacturer:_____________________________________

Use:___________________________ MSDS Included: YES NO

Address:_________________________________________

Catalog#___________________________ Age:____________

City,State,Zip________________ Phone_______________

AMOUNT

DRUM

EPA#

DDC

CAS NUMBER

COMPONENT

%

LIQUID

(CSDP USE)

pH=

SOLID

AEROSOL

I certify that the information provided is an accurate identifcation and evaluation of the hazard characteristics of the waste in light of the materials and processes used. The compounds listed are those used in the process

generating the waste or are known byproducts of this process. I understand that program personnel rely on this information to properly classify, transport and dispose of these wastes and that improper information might

violate federal and state law, resulting in civil or criminal penalties. I understandt the guidelines givin in the U of M CSDP packet and ahve followed applicable procedures, including waste minimizatino when practicable.

NAME_________________________________ SIGNATURE _______________________________ DATE________________