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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.