All Containers MUST HAVE a yellow "Radioactive Waste Disposal Record" completed and attached

Authorized User: Date:

Contact Person:

Department: Phone:

Building: Room:
E-mail:
for example--schugh01@louisville.edu

Number of Items on this Pick-Up: 1 2 3 4 5 6 7 8 9 10

Item 1:
Solid lbs
Liquid ml
Liquid Scintillation Vials number of vials
Nuclide: Activity: mCi Chemical Form:

Item 2:
Solid lbs
Liquid ml
Liquid Scintillation Vials number of vials
Nuclide: Activity: mCi Chemical Form:

Item 3:
Solid lbs
Liquid ml
Liquid Scintillation Vials number of vials
Nuclide: Activity: mCi Chemical Form:

Item 4:
Solid lbs
Liquid ml
Liquid Scintillation Vials number of vials
Nuclide: Activity: mCi Chemical Form:

Item 5:
Solid lbs
Liquid ml
Liquid Scintillation Vials number of vials
Nuclide: Activity: mCi Chemical Form:

Item 6:
Solid lbs
Liquid ml
Liquid Scintillation Vials number of vials
Nuclide: Activity: mCi Chemical Form:

Item 7:
Solid lbs
Liquid ml
Liquid Scintillation Vials number of vials
Nuclide: Activity: mCi Chemical Form:

Item 8:
Solid lbs
Liquid ml
Liquid Scintillation Vials number of vials
Nuclide: Activity: mCi Chemical Form:

Item 9:
Solid lbs
Liquid ml
Liquid Scintillation Vials number of vials
Nuclide: Activity: mCi Chemical Form:

Item 10:
Solid lbs
Liquid ml
Liquid Scintillation Vials number of vials
Nuclide: Activity: mCi Chemical Form:

Comments: