Location(bldg&roomno.):
Department:
Supervisorofroom(PrincipalInvestigator):
Laboratory and Room Decommissioning Report
(To be completed for all laboratories as well as rooms that have contained hazardous materials)
A
B
C
D
E
PrintForm
Step Two: While under my responsibility, this room has contained the following hazardous materials:
Radioactive
Other
Pleasespecify:
In compliance with the University of Guelph Laboratory Safety Program, the following requirements have
been met:
Em
ptiedofradioactivematerials
Wipetest
sandrepresentativesurveyforradioactivityperformedandarebelowthreshold.
Notethatwipetestwillnotdetectfixedcontamination.
Other(specify)
ContinuetosectionE
Supervisorofroom(signature)
ContinuetosectionE
Supervisorofroom(signature)
This room has been decommissioned:
Supervisorofroom‐printedname
Departmentchair‐printedname
EHSRepresentative‐printedname
University of Guelph
Environmental Health and Safety
Revision: December 2006
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signature
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signature
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