FOR EHS USE ONLY
Extra instructions:
1. All waste in RSO-approved containers only.
2. All dry waste containers must be reasonably full, but not
overflowing, or they will not be taken unless prior arrangements have
been made.
3. Sharps and puncturing objects (e.g. Eppendorf tips) can go into the
dry waste stream (bag), along with other materials, as long as they are
contained in University approved sharps containers.
CONFIRM: Wipe test included
Waste stream composition: only one item per request sheet please.
NOTE: Boxes marked with (*) MUST be completed to ensure the pick-up of waste.
*Radionuclide (isotope) *Chemical Composition
*Unique tag or
identity number
+*Total Activity (µCi or kBq)
- (not concentration)
If undetectable put "background"
Comment: e.g., if "dry"
indicate estimated weight
+"Background " means less than the mimium detectable activity
Indicate desired number of :
Drop off and replacement items:
Jugs: Bins/bags:
Default is 1 to 1 replacement on bins/bags.
Building Name/
Number
Room Number
Location in Room
Location
Radioactive Waste Disposal Request
Date
Submitted by
Phone Ext. or No.
Contact Information
Permit Holder
Permit Number
Type of Waste
Check "ONE TYPE" only: indicate number of units
If Scintillation vials "checked", did any vial contain
more than 100,000 DPM activity"? (Does not apply to 3-H)
NoYes
If yes, those vial(s) must be set aside and disposed separately.
All other forms of nuclear substance and radioactive souce items are considered Extraordinary Rad-Waste and require prior
arrangement with the RSO for disposal.
Dry waste (bags) Liquid (jugs) "Iodine bins" Scintillation vials (flats)
If Scintillation vials "checked", was an "eco-scint"
product used?
Yes
No
If no, i.e. older scintillation fluids, not acceptable.
I hereby certify the above information to be
accurate and correct:
Submitter Signature
Please complete form, print, sign and submit to Environmental Health and Safety via fax 519-824-0364, inter-departmental mail, or in person .
