Environmental Health & Safety Department - Chemical Storage and Distribution Facility (CSDF)
Use this form if you would like the EH&S Department to ship DOT regulated materials. Contact the Chemical Hygiene
Officer for clarification regarding whether or not your particular shipment will be considered to be DOT regulated. The CSDF
will prepare all packages for Hazmat shipping and your Banner Index account will be charged for packaging materials, labels,
customs fee, and shipping costs. Please allow 7-10 business days for processing and destination arrival.
Requestors, please complete the following fields before submission.
Submission Date
First Name
Last Name
Advisor/Supervisor's Name
CSM Dept.
Requestor's Email
Requestor's Phone No.
Billing / Payment Information
Banner Index No.
or Fund Code
Org. Code
5483 Prog. Code
Description of materials to be shipped
Chemical name, product name,
CAS number, UN number, concentration, etc.
Known hazards of material to be shipped. (e.g. flammable liquid,
solid or gas, corrosive, pyrophoric, toxic, etc.)
Amount of material to be shipped and container
description. (e.g. 500mL in glass bottle)
Shipping Information - Destination Name, Address, and Phone number. (PO Box or APO's are not allowed)
Recipient's Name
Recipient's Organization
Recipient's Phone No.
Recipient's Email
Street Address 1
Street Address 2
City, State, and Zip Code
Preferred Service
Packages are insured for a minimum of $100.00 by default.
Total Declared Value of Package (USD)
Additional insurance incurs additional costs
Additional Instructions
or Comments.
Check www.FedEx.com for details regarding shipping services, their terms and conditions, and weather or other related delays.
FedEx Express ships Priority 1 only. FedEx Ground deliveries are 5-7 business days in continental US.
Requestor Certification Statement
The Requestor certifies that the hazardous materials being offered for shipment are chemically compatible with the container being supplied for transport and
that the chemical contents of the containers being offered for transport (listed above) are accurate to the best of their knowledge.
Requestor's signature: ___________________________________________________ Date: ________________
After completion, print, sign, and date before submission of all
Questions? Contact the Chemical Hygiene Officer at the CSDF.
Print Form
materials to be shipped at the CSDF (Coolbaugh Hall, Room 030).
(303) 273-3555 ShipHazmatForm2013a.PDF