New Submission

A household hazardous waste I.D. number shall be required to ship collected materials off-site for treatment and/or processing.
Please check the appropriate box and fill in the blanks.

Facility/Event Host Details

Facility/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

On-site Contractor*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.
Phone*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Email*field type email

Company Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
ID Numberfield type single line
Input blocked. Maximum character limit of 12 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.
Phone*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Email*field type email

Company Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
ID Numberfield 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.
Phone*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Email*field type email

Physical Location of Event/Facility*field type multi line
Date of Temporary Event (if applicable)*field type date
Event Start Time*field type time
Event End Time*field type time
Materials to be Collected*field type multi line
Very small quantity generator (VSQG) waste should not be accepted.
Materials to be Recycled*field type multi line
Additional Commentsfield type multi line

I certify that the information supplied is accurate and correct to the best of my knowledge and belief, and that this facility will only accept household hazardous waste. I am authorized to make this request on behalf of the operator at the location given.
Signature*field type signature
Datefield type date
Date will be captured on form submission
Email*field type email