UniversityofGuelph EnvironmentalHealthandSafety
Revision:November2006
Equipment Decontamination and Decommissioning Report
(For equipment that has been used with or contains hazardous materials)
The e
q
ui
p
ment listed above is a
pp
roved for dis
p
osal
,
reuse or relocation:
De
p
artmentChair
Date
EHSRe
p
resentative
Date
Decontamination:
Completed?
Yes
Notrequired
Ifnotrequired,explainwhy:
Icertifythatthispieceofequipmenthasbeendecontaminatedordoesnotrequiredecontamination:
Printedname
Signature Date
Decontaminatedwith:
Comments:
Ifrefrigerantswerepresent,attachreclaimformconfirmingremoval.Reclaimformno.:
Typeofequipment:
Ownerofequipment:
Department:
Serialnumber/I.D.number:
Originallocationofequipment(bldg&roomno.):
Futurelocationo
f
equipment(bldg&room no.) i
f
applicable:
Equipmenttobedisposed?
Yes
No
This equipment was used with the following hazardous materials:
Biological
Chemical
Radioactive
Other
Pleasespecify:
Thisequipmentcontainsorhascontainedthe following hazardous materials as part o
f
itsdesign(e.g.CFCs, pump oil,
asbestos,etc.):
PrintForm
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome