State of Wisconsin Department of Transportation Lamp and Ballast Inventory
REV 5-30-2023

Pickup Address:

WisDOT Project ID: Click or tap here to enter text.

Facility Name: Click or tap here to enter text.

Address: Click or tap here to enter text.

City:Click or tap here to enter text. State: Click or tap here to enter text. Zip: Click or tap here to enter text.

Requestor Contact Name:Click or tap here to enter text.

Requestor Contact Phone:Click or tap here to enter text.
Requestor Contact Email: Click or tap here to enter text.

BILLTO ADDRESS – Send all invoices to the email address below:

WisDOT BTS-ESS attn: Sharlene Te Beest

PO Box 7986 Room 5 South S513.12

Madison, WI 53707-7986

Contact: Sharlene Te Beest Phone: 608-266-1476 email: dothazmatunit@dot.wi.gov

To arrange for disposal, Email a copy of the completed form to dothazmatunit@dot.wi.gov; your region hazardous waste coordinator and the Hazardous Waste Disposal Vendor contact.

Fixture type	Number of fixtures	Approximate Weight per unit (lbs)
Luminaires, Utility, LED A	Click or tap here to enter text.	30
Luminaires, Utility, LED B	Click or tap here to enter text.	30
Luminaires, Utility, LED C	Click or tap here to enter text.	30
Luminaires, Utility, LED D	Click or tap here to enter text.	30
Luminaires, UnderDeck, LED A	Click or tap here to enter text.	Click or tap here to enter text.
Luminaires, Underdeck, LED B	Click or tap here to enter text.	Click or tap here to enter text.
Luminaires, Underdeck, LED C	Click or tap here to enter text.	Click or tap here to enter text.
Luminaire, High Mast Lighting, LED	Click or tap here to enter text.	Click or tap here to enter text.
Lighting Units, Walkway, LED	Click or tap here to enter text.	Click or tap here to enter text.
Traffic signal, LED module	Click or tap here to enter text.	Click or tap here to enter text.
Pedestrian signal, LED module	Click or tap here to enter text.	Click or tap here to enter text.
Pedestrian signal – 16 inch	Click or tap here to enter text.	Click or tap here to enter text.
Traffic Signal – one section	Click or tap here to enter text.	Click or tap here to enter text.
Traffic Signal – three section	Click or tap here to enter text.	Click or tap here to enter text.
Traffic Signal – four section	Click or tap here to enter text.	Click or tap here to enter text.
Traffic Signal – five section	Click or tap here to enter text.	Click or tap here to enter text.
Tunnel Fixture, LED	Click or tap here to enter text.	Click or tap here to enter text.
Broken Fixtures	Click or tap here to enter text.	Click or tap here to enter text.
High pressure Sodium Lamp	Click or tap here to enter text.	Click or tap here to enter text.
Mercury switches	Click or tap here to enter text.	Click or tap here to enter text.
Ballasts	Click or tap here to enter text.	Click or tap here to enter text.
SUPPLIES
Cubic Yard Boxes - Burlap	Click or tap here to enter text.	NA
Cubic Yard Boxes – Cardboard	Click or tap here to enter text.	NA
Pallets for CY boxes or Burlap boxes	Click or tap here to enter text.	NA
Containers – describe what you need Click or tap here to enter text.	Click or tap here to enter text.	Comments: Click or tap here to enter text.
Other: (describe)	Click or tap here to enter text.	Click or tap here to enter text.

Zone: (refer to zone map below) Click or tap here to enter text.

Containerization:

☐ Items are shrink wrapped on pallets
Number of pallets: Click or tap here to enter text.

☐ Items are contained in Cubic Yard Boxes
Number of boxes: Click or tap here to enter text.
☐ Other – Describe: Click or tap here to enter text.

Loading:

☐ A Fork Lift and operator will be available to assist with pickup – call Click or tap here to enter text. to arrange time and date

☐ No forklift/operator available on site.

Additional pickup /Location instructions:

Click or tap here to enter text.