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Date*

Contact Person*

Location of DA-110*

Phone Number*

Location of e-waste (Bldg. and Room)*

Do we need to call before pick-up?

Yes

No

Please describe the type and quantity of e-waste to be picked up.*

By submitting this form, I certify that the equipment listed for pickup does not contain any hazardous materials, hazardous waste, regulated medical waste or radioactive materials or waste. If the equipment previously contained any of these materials, the equipment has been properly decontaminated or disinfected. If you are uncertain whether any of the above is accurate, contact the Department of Environmental Health and Safety at 532-5856 for assistance.

I have read the above statement.

Kansas State University

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E-Waste Form