Radioactive Waste Pick-up Request Form

Radioactive Waste Pick-up Request

Complete this request with information from all containers to be picked up.
Use this form for up to 5 containers at a time. If you have more than 5, submit more than one form, or use the fax form.
Remember to complete and sign the tag on the full containers in your lab. Also be sure to note the results of the contamination survey on the tag. If any of these items are incomplete, the container will not be picked up.
Health Physics must receive this form by noon on Tuesday for pick-up on the following Wednesday morning.
Call (303-492-6523) or e-mail Health Physics if you have questions.

Principal Investigator:	Person completing form: Your e-mail address for questions:
Department: Your phone #:	Building: Room:
Date of Request (today's date):	Have wipes been taken on all containers?: Yes No

Total number of containers in this request:

Type of Waste	Container Color	Isotope(s) & Total Activity (mCi)	Constituents	Replacement Containers
CONTAINER ONE: Volume of Container:	Yellow Orange Green	Activity: Activity: Activity:	Highlight this typing and then use this space to enter the items and % by volume in your waste. The percentages must equal 100%. For example -- In a solid: "paper 25%, gloves 75%" -- In a liquid: individual chemicals and total %: "Tris 50%, Water 25%, Ethanol 25%" -- In a Scintillation vial: type of cocktail (flammable vs. biodegradable): "Biodegradable Cocktail (Econosafe) 100%" or "Methanol 50%, Xylene 50%" If this is a Liquid, what is the pH?:	Do you need a new empty container to replace this one? Yes No
CONTAINER TWO: Type of Waste: Volume of Container:	Yellow Orange Green	Activity: Activity: Activity:	If this is a Liquid, what is the pH?:	Do you need a new empty container to replace this one? Yes No
CONTAINER THREE: Type of Waste: Volume of Container:	Yellow Orange Green	Activity: Activity: Activity:	If this is a Liquid, what is the pH?:	Do you need a new empty container to replace this one? Yes No
CONTAINER FOUR: Type of Waste: Volume of Container:	Yellow Orange Green	Activity: Activity: Activity:	If this is a Liquid, what is the pH?:	Do you need a new empty container to replace this one? Yes No
CONTAINER FIVE: Type of Waste: Volume of Container:	Yellow Orange Green	Activity: Activity: Activity:	If this is a Liquid, what is the pH?:	Do you need a new empty container to replace this one? Yes No

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