BREVARD COUNTY

SOLID WASTE MANAGEMENT DEPARTMENT

HOUSEHOLD HAZARDOUS WASTE PARTICIPANT

CERTIFICATION

NAME:
ADDRESS:
CITY/ZIP:
PHONE NUMBER:
DATE & TIME:

 PLEASE CHECK (/) ALL THAT APPLY

ANTIFREEZE PAINT THINNER
AUTOMOTIVE BATTERY PESTICIDES
ADHESIVE POOL CHEMICALS
BATTERY ACID ROOF COATING
CORROSIVES SOLVENTS
DIESEL FUEL TRANSMISSION FLUID
FERTILIZERS BRAKE FLUID
GASOLINE WOOD PRESERVATIVE
HOUSEHOLD CLEANERS OTHER (LIST BELOW)
INSECTICIDES  
LATEX PAINT  
MOTOR OIL  
OIL PAINT  
PAINT REMOVER  

I certify that the waste I am delivering to the Household Hazardous Waste Collection Center is from a household and not generated by a business of any kind.

_____________________________________________________________

Signature

Approved by:___________________________________

                                                                                                                                        HHWPCRT

                                                                                                                                                                                          6/1/95