Hazardous and Radioactive Materials Request for Disposal Form

Environmental Health & Safety, University of Wyoming
Regulated Materials Management Center

Phone: 307-766-3697

This form is used to generate a request for Hazardous Materials Disposal at the University of Wyoming. Please fill this form out completely! Incomplete requests will not be processed by the computer system.

NOTICE: There may be a charge to you or your department for actual disposal costs of hazardous or radioactive waste. Submitting this form constitutes your agreement to pay for this disposal. If your funding sources will no longer be available 6 to 12 months from this request, contact us for an estimate of your disposal costs.

Responsible Party/Faculty/Staff:
Person preparing this form:
Your office number: Building:
Phone: Date of request:
Your email: Billing Contact:
Waste Generating Activity
The finance folks need to know whether waste is from:
- Waste produced in undergraduate/graduate teaching labs or classrooms.
Athletics - Waste produced by the Athletic Department.
Cooperating Agency - Waste produced by non-University agencies in cooperation with Campus, i.e.   WY Game and Fish, State Vet Lab, WY Coop.
- Waste produced by University support services, i.e. Physical Plant, Student Health.
Supported Research - Waste produced by grant supported research.
Unsupported Research - Waste produced in non-grant supported research.
Location of Waste (Building/Room No.):
Type of Empty Containers Requested Number of Empty Containers Requested

 Please enter the number of items to be disposed of
** For each applicable row below, the description field is mandatory.
Description of Hazardous Materials 
List components and percent compositions of mixtures. A good guess is adequate, however, concentrations could affect disposal costs.
(Ex: 90% Acetone, 10% Water*

Count of Container

 Container Type
jar, etc)

(e.g., gallon, liter, gram, kilogram)

Physical State