Request a Reclaim Shipment Pickup First Name* Last Name* Email* Company Name* Pick Up Address* Address Line 2 City* State* Zip Code* Phone*HAZMAT Contact Info* The telephone number of a person who is knowledgeable of the refrigerant's hazardous material and has comprehensive emergency response & incident mitigation information for that material CHEMTREC Number Customer Number* 30# Empty CylindersHiddenEmpty 30# Cylinders, lbs.30# Cylinders with RefrigerantHidden30# Cylinders with Refrigerant, lbs.50# Empty CylindersHiddenEmpty 50# Cylinders, lbs.50# Cylinders with RefrigerantHidden50# Cylinders with Refrigerant, lbs.125# Empty CylindersHidden125# Empty Cylinders, lbs.125# Cylinders with RefrigerantHidden125# Cylinders with Refrigrant, lbs.240# Empty CylindersHidden240# Empty Cylinders, lbs.240# Cylinders with RefrigerantHidden240# Cylinders with Refrigerant, lbs.1000# Empty CylindersHidden1000# Empty Cylinders, lbs.1000# Cylinders with RefrigerantHidden1000# Cylinders with Refrigerant, lbs.Pallets*HiddenPallets, lbs.Pick Up Date* MM slash DD slash YYYY Dock Hours (Optional) Is a Lift Gate Required?* Yes No Need More Tags?* Yes No Total Number of PalletsCylinders per PalletEstimated Total Shipping WeightHiddenAverage Gross Pallet WeightSpecial Instructions
