University of California, Santa Barbara
Environmental Health and Safety
RADIOACTIVE WASTE PICKUP REQUEST
Upon submitting this form, a copy of this information will be e-mailed to EH&S and a confirming copy will be sent to the e-mail address you enter below. Please enter all information requested. Radioactive waste will not be picked up if the information is incomplete or inadequate. Only EH&S labeled and approved containers will be accepted for disposal.
Pickup Requester:
Request Date:
Campus Telephone #:
E-mail:
Department:
Waste Location (Bldg):
Principal Investigator:
Waste Location (Rooms):
Notes:

DRY OR LIQUID WASTE
Containers
Contents
Radioactivity
Liquid or
solid
Size¹
T½<14
(P-32)
All
Isotopes
T½<90
(S-35)
Physical or
Chemical²
pH³
Nuclide
mCi
Nuclide
mCi
Mixed
Y/N4
# of Liquid replace.
 
# of Solid replace.
 
¹ For dry waste: full or half box; for liquid waste: volume of container 2L, 10L etc.
² For dry waste describe materials in box: paper, plastic, glass etc. For liquid waste describe chemical contents, no formulas or abbreviations please.
   Example description: ethyl alcohol, lauryl sulfate, salt, sodium phosphate, etc.
³ pH if a liquid, pH less than 3 or more than 12, it will be picked up, but it will be considered mixed waste. The pH will be confirmed by Waste Technicians at EH&S. If the pH is not in the appropriate range, you will be informed.
4 Does the item contain hazardous waste other than Radioactivity or is the pH <3 or >12? See certification statement at the bottom of this form.
SCINTILLATION WASTE
Containers
Radioactivity
Vial Size
(milliliters)
Number of
Trays
Scint Fluid Brand Name
Nuclide
mCi
Nuclide
mCi
Nuclide
mCi

OTHER WASTE (Describe)

WASTE CERTIFICATION

 I certify that the radioactive waste I am requesting disposal of herein is accurately described in terms of radioisotope(s), physical form(s), and chemical form(s). I further certify, unless otherwise noted on this document, that this radioactive waste does not contain any other types of hazardous materials and complies with applicable UCSB policies. I understand that if I am uncertain as to these policies or what constitutes "hazardous materials," I may obtain detailed information through the Radiation Safety Office.

I understand that if the items listed above do contain hazardous materials or are outside of the pH range <3, >12 ; they are therefore “mixed waste.” As such, the recharge number above will be recharged the cost of disposal of that item, and not the usual Radioactive Waste recharge fee. I also understand that this disposal cost may be significantly more than the usual Radioactive Waste recharge fee.

 _____________________ Signature__________________________________ Date_____________

Pickup Date:_________ Initial:_____ | Boxes:______ Liquids:______ Trays:_____ | Billing Date:___________


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