New Submission

Instructions: Complete this form within thirty (30) days of HHW Temporary Event. For assistance, call John Patrone (919) 280-4814.

Facility/Event Host Details

HHW ID Number*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Event Host*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Contact Person*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Mailing Address Street*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
City*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
State*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Postal/Zip Code*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
County*field type drop-down
Phone*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Email*field type email

Materials Collected

Indicate type and quantity of material accepted for treatment and its destination.

	Quantity*field type number	Units*field type radio button	Material Treatment*field type drop-down	Destination Address or Contractor*(?)field type multi line
Batteries (all types)	Quantity*field type number	Units*field type radio button UnitsPounds	Material Treatment*field type drop-down	Destination Address or Contractor*(?)field type multi line
Compressed Gases	Quantity*field type number	Units*field type radio button UnitsPounds	Material Treatment*field type drop-down	Destination Address or Contractor*(?)field type multi line
Corrosive Material	Quantity*field type number	Units*field type radio button UnitsPounds	Material Treatment*field type drop-down	Destination Address or Contractor*(?)field type multi line
Electronics (all types)	Quantity*field type number	Units*field type radio button UnitsPounds	Material Treatment*field type drop-down	Destination Address or Contractor*(?)field type multi line
- Amount that is TVs	Quantity*field type number	Units*field type radio button UnitsPounds	Material Treatment*field type drop-down	Destination Address or Contractor*(?)field type multi line
- Amount of TVs that is CRT	Quantity*field type number	Units*field type radio button UnitsPounds	Material Treatment*field type drop-down	Destination Address or Contractor*(?)field type multi line
- Amount of Computer Equipment	Quantity*field type number	Units*field type radio button UnitsPounds	Material Treatment*field type drop-down	Destination Address or Contractor*(?)field type multi line
- Amount of Computer Equipment that is CRT	Quantity*field type number	Units*field type radio button UnitsPounds	Material Treatment*field type drop-down	Destination Address or Contractor*(?)field type multi line
- Amount of Other Electronics	Quantity*field type number	Units*field type radio button UnitsPounds	Material Treatment*field type drop-down	Destination Address or Contractor*(?)field type multi line
Flammable Liquids	Quantity*field type number	Units*field type radio button UnitsPounds	Material Treatment*field type drop-down	Destination Address or Contractor*(?)field type multi line
Flammable Solids	Quantity*field type number	Units*field type radio button UnitsPounds	Material Treatment*field type drop-down	Destination Address or Contractor*(?)field type multi line
Fluorescent Lightbulbs	Quantity*field type number	Units*field type radio button UnitsPounds	Material Treatment*field type drop-down	Destination Address or Contractor*(?)field type multi line
Oxidizing Material	Quantity*field type number	Units*field type radio button UnitsPounds	Material Treatment*field type drop-down	Destination Address or Contractor*(?)field type multi line
Paints (all types)	Quantity*field type number	Units*field type radio button UnitsPounds	Material Treatment*field type drop-down	Destination Address or Contractor*(?)field type multi line
Poisonous Material (pesticides, etc.)	Quantity*field type number	Units*field type radio button UnitsPounds	Material Treatment*field type drop-down	Destination Address or Contractor*(?)field type multi line

Uncommon Materials Collected

List waste type and pounds collected for each.

field type richtext

Certification

I certify that the information supplied is accurate and correct to the best of my knowledge and belief.
Signature*field type signature
Email*field type email

Household Hazardous Waste Collection Event Report

Facility/Event Host Details

Event Details

Materials Collected

Uncommon Materials Collected

Certification