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Lighting Waste Disposal Form

PSE Customer Business Name: _____________________________________

Electric Account Number:  _________  -  _________ 
-  __________  

Project Address: _________________________________ _________________

Installer Business Name: _________________________________

All lamps and ballasts from this project were disposed of in accordance with applicable
federal, state and local waste disposal regulations.


Waste rules include: The U.S. EPA and Washington Department of Ecology</span><span class="Normal--Char" style=" font-size: 11pt;
"></span><span class="Normal--Char" style=" font-size: 11pt;">s Un</span><span
class="Normal--Char" style=" font-size: 11pt; font-style: italic;">iversal
Waste Rules for disposal of lamps containing mercury, and the U.S. Toxics
Substances Control Act and EPA Rules for disposal of ballasts containing PCBs.


A Waste Disposal Certificate is provided. I</span><span class="Normal--Char" style=" font-size: 10pt;
">deally, the certificate documents waste from this s</span><span class="Normal--Char" style=" font-size: 10pt;
">pecific project. Alternatively, it can document fluorescent lighting
waste from previous retrofit projects, provided that the waste was disposed
of within two (2) months of the completion of this project. Either the
PSE customer or the project contractor (or vendor) may provide the certificate.

1. Lamp Disposal

Number of fluorescent LAMPS disposed of:  4-FT _______   
8-FT ________

HID lamp count: Mercury Vapor _____, Metal Halide_____, High Pressure
Sodium ____

Disposal method (check & specify company or
facility):

W    Recycling by certified recycling company: 
________________________________

W    Government Hazardous Waste Facility (specify): 
___________________________

W    Special arrangement at Municipal Landfill. (Provide
copy of permission letter).

2. PCB Ballast Disposal

Number of PCB BALLASTS disposed of:  _____________

W   Hazardous waste recycling company: _________________________________

3. Authorized Signatures

I certify that the above information is true and accurate:

1. Lighting Installer or Vendor   2. PSE Customer

______________________   ________________________

Date:  _________________   Date:  ___________________