UNIVERSITY OF MARYLAND, BALTIMORE
RADIOACTIVE WASTE REMOVAL REQUEST FORM

Authorized User:________________________________________________________________________ Dept:____________________________________Contact Person:_________________________________
Phone:______________________________
Location of Waste (Room/Bldg.):___________________________________________________________
Department Safety Officer:_______________________________________________
Date:___________________

CONTAINER #	NUCLIDE	ACTIVITY in (uCi)	CONTAINER TYPE B = BOX J = 1-GAL JAR D = 30-GAL DRUM P = 5-GAL PAIL	PHYSICAL FORM D/S = DRY SOLID LIQ = LIQUID LSV = LIQUID SCINTILLATION VIAL O = OTHER	CHEMICAL TYPE AND PERCENTAGES (FOR LIQUID WASTES ONLY) SCINTILLATION FLUID (BIOSAFE II, HYDROFLUOR, ETC.) ORGANIC (PHENOL, CHLOROFORM, ETC.) WATER, ETC.

REQUEST FOR REPLACEMENT OR ADDITIONAL CONTAINERS:

BOX -

JAR -

30 GAL DRUM -

5 GAL PAIL -

Comments:____________________________________________________________________________

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Declaration: I hereby certify that the above information is accurate to the best of my knowledge and ability to determine that no deliberate or willful omissions of composition or properties exist and that all known or suspected hazards have been disclosed and all infectious organisms/agents have been rendered nonviable.