Household Hazardous Waste Collection Registration

Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Collection Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Preferred Collection Date and Time

Type(s) of Hazardous Waste for Collection (Select all that apply)

Please list the approximate quantity of each hazardous waste item you will be disposing of (e.g., 2 gallons of paint, 4 batteries, etc.)

Are any of your items leaking or damaged?

If you have leaking or damaged items, please describe them here (leave blank if not applicable)

How did you hear about the hazardous waste collection service?

Signature (Please sign to confirm your registration and agreement)