Request for Radioactive Disposal

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^* Required Information

Request for Radioactive Waste Disposal

Name of Principal Investigator

First Name

Last Name

Name of Person Preparing the Form

First Name

Last Name

Email of Person Preparing the Form

Contact Phone Number

Location of Waste (Building & Room Number)

Full Container Pickup

How many containers to pickup?

1) Pickup Type

1) Mixed Waste Chemical Description (for type MX)

Examples: Methanol in water; 50% Phenol & 50% Chloroform

1) Lead Waste Description

Pigs Bricks Sheet

Other:

1) Is Lead Contaminated?

Yes No

Survey results must be provided at time of pickup.

1) Number of Lead Waste Pieces

1) Approximate Weight of Lead Waste

1) Type of Animal Waste Container

Animal Carcasses Animal Litter/Bedding Tissues Vials/Samples

1) Container Number

1) Isotope(s) Used

1) Activity (mCi)

2) Pickup Type

2) Mixed Waste Chemical Description (for type MX)

Examples: Methanol in water; 50% Phenol & 50% Chloroform

2) Lead Waste Description

Pigs Bricks Sheet

Other:

2) Is Lead Contaminated?

Yes No

Survey results must be provided at time of pickup.

2) Number of Lead Waste Pieces

2) Approximate Weight of Lead Waste

2) Type of Animal Waste Container

Animal Carcasses Animal Litter/Bedding Tissues Vials/Samples

2) Container Number

2) Isotope(s) Used

2) Activity (mCi)

3) Pickup Type

3) Mixed Waste Chemical Description (for type MX)

Examples: Methanol in water; 50% Phenol & 50% Chloroform

3) Lead Waste Description

Pigs Bricks Sheet

Other:

3) Is Lead Contaminated?

Yes No

Survey results must be provided at time of pickup.

3) Number of Lead Waste Pieces

3) Approximate Weight of Lead Waste

3) Type of Animal Waste Container

Animal Carcasses Animal Litter/Bedding Tissues Vials/Samples

3) Container Number

3) Isotope(s) Used

3) Activity (mCi)

4) Pickup Type

4) Mixed Waste Chemical Description (for type MX)

Examples: Methanol in water; 50% Phenol & 50% Chloroform

4) Lead Waste Description

Pigs Bricks Sheet

Other:

4) Is Lead Contaminated?

Yes No

Survey results must be provided at time of pickup.

4) Number of Lead Waste Pieces

4) Approximate Weight of Lead Waste

4) Type of Animal Waste Container

Animal Carcasses Animal Litter/Bedding Tissues Vials/Samples

4) Container Number

4) Isotope(s) Used

4) Activity (mCi)

5) Pickup Type

5) Mixed Waste Chemical Description (for type MX)

Examples: Methanol in water; 50% Phenol & 50% Chloroform

5) Lead Waste Description

Pigs Bricks Sheet

Other:

5) Is Lead Contaminated?

Yes No

Survey results must be provided at time of pickup.

5) Number of Lead Waste Pieces

5) Approximate Weight of Lead Waste

5) Type of Animal Waste Container

Animal Carcasses Animal Litter/Bedding Tissues Vials/Samples

5) Container Number

5) Isotope(s) Used

5) Activity (mCi)

6) Pickup Type

6) Mixed Waste Chemical Description (for type MX)

Examples: Methanol in water; 50% Phenol & 50% Chloroform

6) Lead Waste Description

Pigs Bricks Sheet

Other:

6) Is Lead Contaminated?

Yes No

Survey results must be provided at time of pickup.

6) Number of Lead Waste Pieces

6) Approximate Weight of Lead Waste

6) Type of Animal Waste Container

Animal Carcasses Animal Litter/Bedding Tissues Vials/Samples

6) Container Number

6) Isotope(s) Used

6) Activity (mCi)

7) Pickup Type

7) Mixed Waste Chemical Description (for type MX)

Examples: Methanol in water; 50% Phenol & 50% Chloroform

7) Lead Waste Description

Pigs Bricks Sheet

Other:

7) Is Lead Contaminated?

Yes No

Survey results must be provided at time of pickup.

7) Number of Lead Waste Pieces

7) Approximate Weight of Lead Waste

7) Type of Animal Waste Container

Animal Carcasses Animal Litter/Bedding Tissues Vials/Samples

7) Container Number

7) Isotope(s) Used

7) Activity (mCi)

8) Pickup Type

8) Mixed Waste Chemical Description (for type MX)

Examples: Methanol in water; 50% Phenol & 50% Chloroform

8) Lead Waste Description

Pigs Bricks Sheet

Other:

8) Is Lead Contaminated?

Yes No

Survey results must be provided at time of pickup.

8) Number of Lead Waste Pieces

8) Approximate Weight of Lead Waste

8) Type of Animal Waste Container

Animal Carcasses Animal Litter/Bedding Tissues Vials/Samples

8) Container Number

8) Isotope(s) Used

8) Activity (mCi)

9) Pickup Type

9) Mixed Waste Chemical Description (for type MX)

Examples: Methanol in water; 50% Phenol & 50% Chloroform

9) Lead Waste Description

Pigs Bricks Sheet

Other:

9) Is Lead Contaminated?

Yes No

Survey results must be provided at time of pickup.

9) Number of Lead Waste Pieces

9) Approximate Weight of Lead Waste

9) Type of Animal Waste Container

Animal Carcasses Animal Litter/Bedding Tissues Vials/Samples

9) Container Number

9) Isotope(s) Used

9) Activity (mCi)

10) Pickup Type

10) Mixed Waste Chemical Description (for type MX)

Examples: Methanol in water; 50% Phenol & 50% Chloroform

10) Lead Waste Description

Pigs Bricks Sheet

Other:

10) Is Lead Contaminated?

Yes No

Survey results must be provided at time of pickup.

10) Number of Lead Waste Pieces

10) Approximate Weight of Lead Waste

10) Type of Animal Waste Container

Animal Carcasses Animal Litter/Bedding Tissues Vials/Samples

10) Container Number

10) Isotope(s) Used

10) Activity (mCi)

Empty Container Delivery

How many empty containers to deliver?

1) Container Delivery Type

1) Mixed Waste Chemical Description (for type MX)

Examples: Methanol in water; 50% Phenol & 50% Chloroform

1) Type of Animal Waste Container

Animal Carcasses Animal Litter/Bedding Tissues Vials/Samples

1) Quantity to be Delivered

1) Isotope(s) to be used:

2) Container Delivery Type

2) Mixed Waste Chemical Description (for type MX)

Examples: Methanol in water; 50% Phenol & 50% Chloroform

2) Type of Animal Waste Container

Animal Carcasses Animal Litter/Bedding Tissues Vials/Samples

2) Quantity to be Delivered

2) Isotope(s) to be used:

3) Container Delivery Type

3) Mixed Waste Chemical Description (for type MX)

Examples: Methanol in water; 50% Phenol & 50% Chloroform

3) Type of Animal Waste Container

Animal Carcasses Animal Litter/Bedding Tissues Vials/Samples

3) Quantity to be Delivered

3) Isotope(s) to be used:

4) Container Delivery Type

4) Mixed Waste Chemical Description (for type MX)

Examples: Methanol in water; 50% Phenol & 50% Chloroform

4) Type of Animal Waste Container

Animal Carcasses Animal Litter/Bedding Tissues Vials/Samples

4) Quantity to be Delivered

4) Isotope(s) to be used:

5) Container Delivery Type

5) Mixed Waste Chemical Description (for type MX)

Examples: Methanol in water; 50% Phenol & 50% Chloroform

5) Type of Animal Waste Container

Animal Carcasses Animal Litter/Bedding Tissues Vials/Samples

5) Quantity to be Delivered

5) Isotope(s) to be used:

6) Container Delivery Type

6) Mixed Waste Chemical Description (for type MX)

Examples: Methanol in water; 50% Phenol & 50% Chloroform

6) Type of Animal Waste Container

Animal Carcasses Animal Litter/Bedding Tissues Vials/Samples

6) Quantity to be Delivered

6) Isotope(s) to be used:

7) Container Delivery Type

7) Mixed Waste Chemical Description (for type MX)

Examples: Methanol in water; 50% Phenol & 50% Chloroform

7) Type of Animal Waste Container

Animal Carcasses Animal Litter/Bedding Tissues Vials/Samples

7) Quantity to be Delivered

7) Isotope(s) to be used:

8) Container Delivery Type

8) Mixed Waste Chemical Description (for type MX)

Examples: Methanol in water; 50% Phenol & 50% Chloroform

8) Type of Animal Waste Container

Animal Carcasses Animal Litter/Bedding Tissues Vials/Samples

8) Quantity to be Delivered

8) Isotope(s) to be used:

9) Container Delivery Type

9) Mixed Waste Chemical Description (for type MX)

Examples: Methanol in water; 50% Phenol & 50% Chloroform

9) Type of Animal Waste Container

Animal Carcasses Animal Litter/Bedding Tissues Vials/Samples

9) Quantity to be Delivered

9) Isotope(s) to be used:

10) Container Delivery Type

10) Mixed Waste Chemical Description (for type MX)

Examples: Methanol in water; 50% Phenol & 50% Chloroform

10) Type of Animal Waste Container

Animal Carcasses Animal Litter/Bedding Tissues Vials/Samples

10) Quantity to be Delivered

10) Isotope(s) to be used:

Special Notes or Handling Instructions

Certification*

I hearby declare that the identification and activity of the waste is accurate and complete to the best of my knowledge and that I have made every effort to minimize our wastes streams.

Certification*

Wipe test results are attached to the container

Certified by

First Name

Last Name