CALPIA E-WASTE RECYCLING/REFURBISHING
CHECKLIST
I completed my DGS STD.152 approved by DGS and/or a LISTfor disposition of assets.
State Agencies - EACH line item must contain> Item Name, Make, Model & Serial Number
I completed Electronic Forms EWR-F004(this packet) and EWR-F014 and e-mailed one (1) copy of each to CALPIA E-Waste at .
I removed ALL individual Batteries, Fluorescent Bulbs, equipment containing Mercury (thermometers etc.). Call CALPIA E-Waste regarding sending any household appliances. Batteries in electronic equipment >Lap Tops, Think Pads or Computers are accepted.
I sanitized my assets. I checked the appropriate box (s). I answered questions 2A and 2B & 2C on page 2 of 4 (How to dispose of my Memory Devices) on the CALPIA Electronic form EWR-F004.
I removed ALLproperty tagsand/or identifying labels, name labels offALL Electronic Equipment being sent to CALPIA E-Waste.
All items are wrapped on a 4-way pallet with no overhang and stacked a maximum of 36” high(unless otherwise discussed with CALPIA E-Waste).ALL Equipment must be palletized.
NO CELL PHONES in my shipment. ALL CELL PHONES HAVE BEEN REMOVED.
ALL palletswill be labeled with CALPIA form EWR-F014. CALPIA E-Waste has the right-to-refuse pick-up/drop-off if they find the LOT is not properly palletized and/or equipment appears hazardous/dangerous to transport.
Authorized Signature/Date (Sign electronically by typing your name)
Note: CALPIA will schedule your pick-up/drop-off when ALLitems are completed on this list.
6/30/17; Rev. D EWR - F004
12/5/17; Rev. E EWR - F004 Page 1 of 5
CALPIA E-WASTERECYCLING/REFURBISHING
- Electronic Equipment: (Agency/Company complete this form)
Attach a copy of DGS 152sindividually listing each item with>Item Name, Make, Model, & Serial Number and/or a LISTof electronics with the same identifying information.
*NO CELL PHONES
Quantity Of: “Supervisor Only” Boxes, Boxes Pallets
#of Boxes # of Pallets Weight
Other (describe):
- A. Customer’s Hard Drive
Hard/Drive Wiping Completed by Customer Prior to sending (Per DGS/SAM/Section 5900/MM12-01)
(MUST Check ONE of the FOLLOWING) (or) CHECK> NO HARD DRIVES SENT
B. Requesting E-Waste – Use In Refurbish Program Once Hard Drives Received:
Hard/Drive>CALPIA can use in the refurbish programRefurbish Will>Re-wipe>WipingFails H/D>SHRED
C. Requesting E-Waste: To – Have Hard Drives Shredded
Hard/Drive>Shred Hard/Drive>Shred-Send Customer Certificate
- Hazardous or Dangerous Materials or Equipment
Description: (include type of equipment) (*CALPIA reserves the right to refuse these items)
Quantity:
#of Boxes # of Pallets Weight
Other (describe):
- Customer Additional Information Pre-Approved By E-Waste: (or)Other Electronics
Description: of item(s)
Quantity:
#of Boxes # of Pallets Weight
Other (describe):
12/5/17; Rev. E EWR - F004 Page 2 of 5
Question #5 is only applicable for pick-ups.
- Pick-up Information : Check All Items Available At Your Pick-up Location
Shipping/Receiving DockForkliftPallet Jack
PalletsShrink Wrap (Other describe) Capability to Receive Big Rig Truck
Other (describe):
Description: (include loading requirements and needs): Where to Park our Vehicle.
REQUIRED INFORMATION FOR ALL PICK-UPS/DROP-OFFS
REQUESTING: Agency/Company Completes This Form
Agency-Company-Organization:
Complete Address:
Cross Street:
Contact Name:
Phone Number:
Fax Number:
E-mail Address:
Additional Comments:
DO NOT WRITE BELOW THIS AREA FOR CALPIA PROCESSING
CALPIA E-Waste Processing Facility:
E-Waste Facility Address: 8681 Younger Creek Dr.Sacramento, CA 95828 OR3100 Wright Rd Camarillo, CA 93010
E-Waste Hotline: (916) 229-3096
Fax: (916) 229-3185
Email:
12/5/17; Rev. E EWR - F004 Page 3 of 5
CALPIA E-WASTERECYCLING/REFURBISHING
The following clothing and items are prohibited at drop-off locations:
-Blue Jeans-Chambray Shirts- Yellow Rain Gear
-Shorts-Athletic Wear-Backless/Strapless/Tank Tops
-Open-Toed Shoes-Firearms- Tobacco
***ALL NON-STATE ISSUED CELL PHONES MUST BE IN LOCKED VEHICLES***
Tips on how to answerquestions from page 2 & 3:
Question 1: A LIST of electronic equipment is needed withItem Name, Make, Model, and SerialNumber especially >CPU’s,(CRT-Devices (old bulky monitors/TV’s), Lap Top, Think Pads, LCD Flat Screen monitors/TV’s, ALL Items with glass and/or viewing screen. For State agencies, a copy of your DGS STD.152 for asset distribution is Preferred.ALLelectronic items on DGS Std. 152MUST BEindividually listed with Item Name, Make, and ModelSerial Number.
*Landline-Phones/Memory Devices:They MUST be boxed separately sealed and labeled with quantity and “Supervising Staff ONLY” on all sides of the box. All Phones must be documented on page 2, Question 1 of this form. NO CELL PHONES ALLOWEDreceived into the E-waste facility. Memory devices and hard drives (not installed in units), memory cards, flash drives, etc., Must be boxed separately and labeled on outside of box “Supervisor Only with Count”.
**Quantity Information: A description of box & pallet quantity for general identification and for estimating the volume in the truck. For example:5-pallets and 25 cardboard boxes. Server Cabinets can remain un-palletized. Avoid using “miscellaneous” or “lot of” if it is a mixture of eight or ten items. Estimated weights are also desirable if available. A pick up is a LOT > one (1) to twenty-four (24) pallets.
CALPIA E-Waste Processing Facility will weigh the e-waste at time of arrival (subtracting pallet and cardboard weight) and will document that weight as Electronic e-waste weight received.
Page 2 Question 2A-2B-2C: Specify how to handle hard drives. CALPIA has a refurbished computer program and would like toutilize your hard drives in this program.CALPIA will sanitize hard drives prior to using in refurbishing and if the hard drive fails the 3-way wiping the hard drive will be shredded.Specify check box if NO hard drives sent, 2B for refurbishor2C to shred hard drives upon request. State agencies are required per the SAM 5900 and MM 12-01 & 12-02 to sanitize assets prior to submitting the std.152.
Question 3: A description of hazardous or dangerous equipment or material is needed for items being shipped that could potentially: cause an accident; exposure or vulnerability to harm, loss, risk or peril; pose a threat to the environment or worker health and safety. These items will be reviewed by CALPIA and will be refused prior to pick-up.
12/5/17; Rev. E EWR - F004 Page 4 of 5
Question 4:List any equipment pre-approved prior to pick up this may be medical equipment orspecial equipmentyou need removed. (Pictures may be needed for approval. Call CALPIA E-Waste Staff prior for approval).
After completing the attached forms, email completed form to the CALPIA E-Waste Facility. It is recommended that you keep all documentation on equipment you are sending for a minimum of two (2) years. The F004, F014, Std. 152 and/or LIST are required prior to each desired pick up.
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