UniversityofGuelph EnvironmentalHealthandSafety
Revision:November2006
Equipment Decontamination and Decommissioning Report
(For equipment that has been used with or contains hazardous materials)
The e
ui
ment listed above is a
roved for dis
osal
reuse or relocation:
De
artmentChair
Date
EHSRe
resentative
Date
Decontamination:
Completed?
Yes
Notrequired
Ifnotrequired,explainwhy:
Icertifythatthispieceofequipmenthasbeendecontaminatedordoesnotrequiredecontamination:
Printedname
Signature Date
Decontaminatedwith:
Comments:
Ifrefrigerantswerepresent,attachreclaimformconfirmingremoval.Reclaimformno.:
Typeofequipment:
Ownerofequipment:
Department:
Serialnumber/I.D.number:
Originallocationofequipment(bldg&roomno.):
Futurelocationo
equipment(bldg&room no.) i
applicable:
Equipmenttobedisposed?
Yes
No
This equipment was used with the following hazardous materials:
Biological
Chemical
Radioactive
Other
Pleasespecify:
Thisequipmentcontainsorhascontainedthe following hazardous materials as part o
itsdesign(e.g.CFCs, pump oil,
asbestos,etc.):
PrintForm