Online Radioactive Waste Removal Request Form
Please fill out the following form and print and sign the confirmation page. Thank you.
Authorized User
*
Authorized Number
*
Department
*
Contact Person
*
Email
*
Phone
Location of Waste (Room/Bldg.)
*
Container Number
Nuclide
Activity in (µCi)
Assay Date
Container Type
B = Box
J = Jar
D = 30 Gal Drum
P = 5 Gal Pail
Physical Form D/S = Dry Solid
LIQ = Liquid
LSV = Liquid
Scintilliation Vial
O = OTHER
Chemical Type and Percentages
(for liquid waste ONLY)
None
Box
Jar
Drum
Pail
None
Dry Solid
LIQ
LSV
Other
None
Box
Jar
Drum
Pail
None
Dry Solid
LIQ
LSV
Other
None
Box
Jar
Drum
Pail
None
Dry Solid
LIQ
LSV
Other
None
Box
Jar
Drum
Pail
None
Dry Solid
LIQ
LSV
Other
None
Box
Jar
Drum
Pail
None
Dry Solid
LIQ
LSV
Other
None
Box
Jar
Drum
Pail
None
Dry Solid
LIQ
LSV
Other
None
Box
Jar
Drum
Pail
None
Dry Solid
LIQ
LSV
Other
None
Box
Jar
Drum
Pail
None
Dry Solid
LIQ
LSV
Other
Request for additional containers:
Box
Jar
30 Gal Drum
(120 Liters)
5 Gal Pail - Open Top (for LSV) (20 Liters)
5 Gal Pail - Closed Top (for Liquids) (20 Liters)
Comments
Declaration:
I I hereby certify that the above information is accurate to the best of my knowledge and ability to determine that no deliberate or willful omissions of composition or properties exist and that all known or suspected hazards have been disclosed and all infectious organisms/agents have been rendered nonviable.