Section_J_-_Turn-in_Form.pdf

FORT BELVOIR DPW/ENRD

REVISED May 2014 11:09 AM 5/27/2014

Bin Tracking # or e-mail your request to : usarmy.belvoir.imcom.mbx.hazmat@mail.mil

Daytime Phone Email Address Date

Remarks (Additional information for contents of material and percents.)

Name of Organization’s Environmental Compliance Officer (PRINT) Signature of Organization’s Environmental Compliance Officer

Daytime Phone

Name of Organization’s Waste Handler (PRINT) Signature of Organization’s Waste Handler

DateEmail Address

(SECTION 3)

Manufacturer:Product / Item Name:

Container Type:(drum,can,tube, jug, etc.)

I certify that the above item is labeled, marked, packaged and in the proper condition for transportation to Building 1495, Fort Belvoir, Virginia, and that all persons involved with this turn-in have had the Fort Belvoir RCRA Hazardous Waste Permit training. A current Hazardous Waste Management

License (renewed yearly) must be presented at the time of turn-in. All reimbursable organizations authorize the Environmental and Natural Resource Division to request reimbursement for all costs associated with the proper disposal of this waste and do hereby agree to authorize payment of such costs when request for funds is submitted to my organization.

Is the product one of the following? (If so, please provide an MSDS/SDS or lab analytical results/formulary and profile for contents)

Check all that apply:

Number of Containers: Container Size:(1gal, 1oz, etc.)

DoDAAC:Department of Defense Activity Address Code (Example:W99ABR)

Agency’s Funding Code: General Fund Enterprise Business System (GFEBS) or Accounting Processing Code (APC)

NSN / Part #: MSDS Number or Sample I.D and Profile Number:

(SECTION 2)

Generator’s Hazardous Material and Waste Turn-In Request

Phone Number:Organization’s Funding Representative: Funding Representative’s Email:

Directorate of Public Works – Environmental and Natural Resource Division Bldg 1495, 6170 Sharon Lane Rd - Fort Belvoir, VA 22060

Bldg. Number Item storage location if not Bldg. Number Generator’s/Organization’s Name

(SECTION 1)

CALL 703-806-4537 TO SCHEDULE YOUR TURN-IN

Profile Sheet Number

Received By (print & sign)Date Received

CLIN & Container CostCLIN Number Assigned

To be completed by DPW Hazardous Waste / Material Personnel Only

Items Received/Weight Container # Total Disposal Cost Due:

Industrial Concentrate Lab Chemical Chemical Mixture mailto:usarmy.belvoir.imcom.mbx.hazmat@mail.mil?subject=Hazardous%20Waste%20Turn-In%20Request

Sheet1