Name:

Department/Location:

Phone Number:

Date

Instructions for use;

1. Technical or Common Name or hazardous ingredients and proportions
2. Physical State being either Solid, Liquid or Gas (ie S/L/G)
3. Container Size in Kg or Litres ie. 20Kg
4. Number of containers
5. Container condition being either Good, Fair or Poor ie (G/F/P)
6. Container material being either Glass, Plastic or Metal ie (G/P/M)
7. NSW EPA Category - refer EPA document 'Information Sheet for Obtaining Consent….'
8. United Nations Number if known (refer either label, MSDS or ADG Code)

Chemical or Technical or Trade Name	Physical State	Container Size	No. of Containers	Container Condition	Container Material	EPA Category	UN No.