Mercury Switch Log Sheet
Name of your business:
  
Address:
  
Contact person / phone:
  
Date of transport to switch recycler:
  
      
 
No. of Switches Removed
Vehicle Identification Number (VIN)
(Please use only one digit per box)
All vehicles 1980 and newer must have 17 digits in the VIN.
Vehicles older than 1980 will have less than 17 digits.

Light
Switches (#)
ABS
Switches (#)
                                     
                                     
                                     
                                     
                                     
                                     
                                     
                                     
                                     
                                     
                                     
Total (both columns)
    

I certify that the switches identified on the log sheet are from motor vehicles dismantled in (insert State name) ____________________________.
I certify that only mercury switches are in this container and no other type of waste.
Signature:
Printed Name: