Hazardous Waste Form

Your Company Name

Clinic address

Post Code

Site Contact Name and Details (This should be a person who is based at the premises concerned)

Title

First Name

Last Name

Phone

If you require sharps boxes collecting please List the size and quantity of each type

What days and times are you open for deliveries

1L Bin - qty

2.5L Bin - qty 2.5

5L Bin - qty

7L Bin - qty

11L Bin - qty

Orange bags - qty

Type of Business

(please tick to confirm) and go to Customer Declaration
I confirm all the waste collected is from a non-medical activity and therefore non-hazardous, consignment Notes don’t apply. (Please note Cytotoxic/static & Dental waste is always hazardous and you require a different form)

What is your PA Association Membership Number (must be completed) If you are unsure you can check the PA Register - Click Here

Name

Date