Refrigerator/Equipment Disposal Survey Request

Name *

* +

Department *

Other Department:

Email Address *

Phone Number *

Service Requirement

Number of units to be surveyed? *

Unit emptied and decontaminated with a 10% bleach solution? *

Yes

No

Unit used for radioactive material storage? *

Yes

No

All labels on the unit removed? *

Yes

No

Location Information

Building: *

Off-Campus Location

Room Number(s) *

Site: *

Other Site Location:

Description of the unit(s) *

Urgency Level: *

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