| Processor:_______________________ | Data Entered:_______________________ |
| Date:_______________________ | T:__________R:____________ |
| Dangerous Waste Transfer Record |
| Transfer Date:_______________________ |
| Transporter Name:_______________________ |
| Transporter Signature:_______________________ |
| Destination: Chemical Stores Bldg._____ Treatment Center______ Recycling Center_____ |
| Other:_________________________________________ |