1. Requestor Information
Name:
Mailing Address:
City/Town: State: Zip Code:
Business Phone: ext.
Contact Person: Title:
Email:
DEEP USE ONLY
Date Rec’d: _______________
Box #: ______________
Location: ______________
Accession Year: ______________
Accession #: ______________
Date Box Requested: ______________
Date Box Received: _______________
Date Closed: ________________
2. Manifest Information
Manifest Number:
Date Shipped:
Batch Number (if known):
3. Generator Information
EPA ID #:
Site Address:
City/Town:
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