Mixed Waste Pickup Request

							RSP-MW                     UNIVERSITY OF HAWAII RADIOACTIVE MIXED WASTE PICKUP REQUEST FORM
Revision, 4/04             (WASTE CONTAINING BOTH RADIOISOTOPES AND HAZARDOUS CHEMICALS)

INSTRUCTIONS:
1. Use and place one form for EACH container/bottle.
2. Enter total volume amount. DO NOT fill container/bottle to the top!
3. List isotope(s) and their activity(s).
4. Enter pH value. (We need this value for disposal purposes)
5. Enter chemical name(s) and the percent% each chemical is present in the total volume.
  (example: total volume is 1 gallon, chemical is toluene, 25% (1 quart of 1 gallon is toluene)
6. Permanently LABEL container/bottle with the following: P.I.'s name, Isotope(s) and their activity(s), Date container/bottle
  was sealed.


P.I.:                                 Lab/Location:                                   Phone:

LIQUIDS          pH value:______      Total VOLUME:____________________
Date             Isotope(s) Activity(s) Ship Code(s) Chemical Name(s)                                         Percent%
                                                                                                               0.00%




SOLIDS           pH value:_______     Total WEIGHT:____________________
Date             Isotope(s) Activity(s) Ship Code     Chemical Name(s)                                        Percent%




Date Container/Bottle Closed:____________. I HAVE READ AND UNDERSTAND ALL CONDITIONS ON THIS FORM.

GENERATOR CERTIFICATION: I certify the above waste contains NO UNTREATED biohazardous materials.

PRINCIPLE INVESTIGATOR SIGNATURE:________________________________ Date: ________________

Radiation Safety Program Use Only
Container/Bottle #: _____________________________
RSO Signature:___________________________Date:________________________

24-HR EMERGENCY PHONE NUMBER: (808)956-6911. CONTACT: RADIATION SAFETY PROGRAM, 956-8591.