ehs header
Instructions:
Fill in contact information completely.
For each container (bag, bottle, box, stock vial or drum of scintillation vials):
  Select isotope
  Select waste type.
  If liquid waste, fill in contents.
  Fill in volume of container (drum, bag, jug) in gallons
  Fill in estimated activity for each container
  If this is a stock vial fill in approval number (remember to keep vial in outer 
  container and in locked storage until pick up.


Radiation Waste Pickup Form

Please fill out the following form as completely as possible.


Location Information
Department:
Building:
Room Number:


Principal Investigator Information
Principal Investigator:
Pickup Coordinator:
E-mail Address:
Phone Number:

Chemical Information
Container

Isotope
Dry,
Liquid,
Scintillation Vial, or Stock Vial?

If Liquid, List Chemical Components
(in percent)

Container Volume:
(in gallons)
 

Estimated Activity
in Container:
(in millicuries)

Stock Vial
 Approval Number
1
2
3
4
5
6
7
8


Comments:


 

We will make every attempt to pick-up the waste within 7 business days of receiving this form.  
Please call the Environmental Health and Safety Department at 3-0071 or email us with any questions.

For EH&S Use

Background Reading
Instrument  Model
S/N
Date of Pick Up
Signature