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Environmental Health,Safety & Risk
EH&S
TEL NO: (818) 677-2401
FAX NO: (818) 677-5853
MAIL DROP: 8284
Radioactive Waste Pickup Request
Form 104
LINE
I.
REQUEST INFORMATION:
  Pickup Requester: Date: Ext:
  Authorized User: Waste Location:
LINE
II.

INSTRUCTIONS:
 
1.
 Ensure each container has been properly labeled - use CSUN "Radioactive Waste Labels" (Form 107)
2.
 Enter the following information for each container of waste:
 
Container #: Reference number that corresponds to the number used o radioactive waste label.
Radionuclide: Isotope present in waste.
  Note: For multiple isotopes/container, use separate entry for each isotope.
Activity: Activity for the isotope.
Reference Date: Activity reference date
Form: Physical form of the waste. Enter one of the following:
  - Dry - Aqueous liquid - Organic liquid - Scintillation vials - Other (describe)
Quantity: Quantity of waste in each container.
3.
 Mail or fax a copy for the form to EH&S (Mail Code 8284; fax: 5853)
4.
EH&S will call to schedule a waste pickup.
Container #
Isotope
Activity
Ref. Date
Form
Quantity
Notes
             
             
             
             
             
             
             
   
Authorized User Signature: __________________________ Date: _______
~ EH&S USE ONLY ~
Pick-Up Date: _____________________ Picked-up By: ________________________