TECHNICAL SOLUTIONS NORTH AMERICA VSQG CHEMICAL INVENTORY Business/Generator Name: Mailing/Street Address: City, State, Zip Code: Contact Persons: Telephone: County of Business/Residence: Fax: Please weigh your materials (in their containers). The quote will be based on the weight provided. Waste Name/ Number of Container TOTAL Volume Description Containers Size In pounds Sample: Diazinon 3 1-gallon 24 pounds Free Technical Assistance is available to complete this form at 1-715-298-2623. Attach additional sheet(s) if necessary. Explosives and ordnance, radioactive materials, and infectious wastes will not be accepted during this collection event. Please consult Veolia on these items. Please fax or email this completed form to Chris Bahlow at (262) 255-5794 or Chris.Bahlow@VeoliaES.com.