Collection Program Return Request Form

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COLLECTION PROGRAM - RETURN REQUEST FORM
I have read and agree to with the terms of the Conditions Agreement found
on Collection Program Return Request.

Company Name

Address

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Zip Code             Phone Fax

Contact Name

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Pickup Hours     to Quantity of IBC's

Last Chemical Trade Name/Number (HazMat Only)

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Title

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49 CFR - DOT

Hazardous Material Regulations

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Locations

IMACC Corporation
2303 Dalton Industrial Ct
Dalton, GA 30721-4901
706.270.8635 Ph
706.259.8071 Fax

IMACC Corporation
1236 Industrial Ave
Suite 101
Gastonia, NC 28054
704.874.1210 Ph
704-874.1208 Fax

IMACC Corporation
1435 W. Church St
Jacksonville, FL 32204
904.233.6693 Ph
706.259.8071 Fax

Map Directions
   Dalton
   Gastonia
   Jacksonville