Request a Reclaim Shipment Pickup First Name*Last Name*Email* Company Name*Pick Up Address*Address Line 2City*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 NumberCustomer Number*30# Empty CylindersEmpty 30# Cylinders, lbs.30# Cylinders with Refrigerant30# Cylinders with Refrigerant, lbs.50# Empty CylindersEmpty 50# Cylinders, lbs.50# Cylinders with Refrigerant50# Cylinders with Refrigerant, lbs.125# Empty Cylinders125# Empty Cylinders, lbs.125# Cylinders with Refrigerant125# Cylinders with Refrigrant, lbs.240# Empty Cylinders240# Empty Cylinders, lbs.240# Cylinders with Refrigerant240# Cylinders with Refrigerant, lbs.1000# Empty Cylinders1000# Empty Cylinders, lbs.1000# Cylinders with Refrigerant1000# Cylinders with Refrigerant, lbs.Pallets*Pallets, lbs.Pick Up Date* Dock Hours (Optional)Is a Lift Gate Required?*YesNoNeed More Tags?*YesNoTotal Number of PalletsCylinders per PalletEstimated Total Shipping WeightAverage Gross Pallet WeightSpecial Instructions This iframe contains the logic required to handle Ajax powered Gravity Forms.
