Mercury and PCB-Containing Material Inventory
			Date
County				Project #	Parcel #
Removed by
		(Contractor)
Delivered to
	(DOT Collection Point)

MERCURY-CONTAINING MATERIALS
Quantity	Description
	2’ fluorescent light bulbs
	4’ fluorescent light bulbs
	8’ fluorescent light bulbs
	mercury vapor light bulbs (bulb coated inside)
	high pressure sodium light bulbs (clear bulb)
	metal halide light bulbs
	thermostats (containing liquid filled capsule)
PCB-CONTAINING MATERIALS
Quantity	Description (Items are to be removed from light fixtures)
	Ballasts
	Capacitors
	Transformers

Note:   The Contractor is responsible for the proper packaging of the above listed materials for transport and delivery to a DOT collection point (arranged through the project engineer).  Packaging requirements are outlined in Section 2.9 of the Agreement for Services.  Copies of this form 1) must accompany the transported materials, and 2) must be given to the project engineer along with the final project documentation.