Recycling Order Form

Pickup Information

Pickup Name: * Address: * City * State: * Zip Code: * Phone * Fax Requested Pickup Date: * Date Sent: * Site Hours to Time Zone Pickup Site Contact:

Generator Location

Company Name: * Physical Address: * City * State: * Zip Code: * Phone * Email: *

Same as Pickup Location

Bill to Information

Company Name: * Physical Address: * City * State: * Zip Code: * Contact Phone * Email: * Purchase Order:

# of Pieces Type/Size/Watt Description of Waste Quantity (lbs, lamps, etc) # of 4' Pallets # of 8' Pallets If ballasts are being picked up, please indicate the type: PCB Non-PCB

Container Type & Size Qty: Notes

Is This a Pack and Pull? Yes No

Hazardous Waste Yes No

Manifest Required? Yes No

Is there a loading dock? Yes No

Is a lift gate needed? Yes No

Is pallet shrink wrapped? Yes No

Is jack/dolly needed? Yes No

Is forklift available? Yes No

Accessible by 69' trailer? Yes No

Certificate of Recycling Required? Yes No

Your submission has been received. A representative will be in contact with you shortly.