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.

(We may not be able to place all requests in the Surplus Chemical Program. We will try to honor your request for placement in the program, but we must occasionally dispose of some of the surplus-request chemicals as waste and charge your department accordingly.)
Responsible Party/Faculty/Staff:
Department:
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:
Academic - 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.
Services - 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.):
*
Empty container requested? Type? Empty Container Quantity?
 Please enter the number of item 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.
NO CHEMICAL ABBREVIATIONS!
(Ex: 90% Acetone, 10% Water) *

Count of Container

 Container Type
(barrel, 
jar, etc)

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

Physical State

Waste 
or
Surplus