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Laboratory Safety Manual

Reviewed May 2012  

Appendix I
Examples of Chemical Removal Request Forms

Example of Chemical Surplus Removal Request Form
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  1. Determine if you can neutralize, detoxify or recycle it yourself. If you can, there is no need to fill out this form. Refer to the Laboratory Safety Manual for guidelines.

    Separate solids from liquids.

    Containerize it. Containers shall be compatible with the chemical(s), shall be sturdy, leak-proof, have a tight cap/lid/seal, and clean on the outside. Unless other arrangements have been made, all containers must be 5-gal. or less in volume. Milk jugs or other food containers, thin trash bags, biohazard bags, radioactive bags, 5-gal. thin-walled metal solvent cans, 5-gal. glass carboys are NOT to be used.

    If necessary, attach label HM-95-2 to the containers. {Available from EHS}

    • List ALL the chemical constituents with approximate percentages.Actual Size Heavy metals should be listed in mg/l or ppm if under 0.1%.Do not use abbreviations or chemical symbols. Use common or IUPAC chemical names. If applicable, list trade name and chemical constituents. If necessary, include a copy of the MSDS. For pesticides, list the common name and the chemical name.
    • Refer to the Laboratory Safety Manual for guidelines if you do not know what is in the container. (EHS will not pick up unidentified chemicals, i.e., "unknowns.")
  2. Fill out the Chemical Surplus Removal Request form. Mail, fax or deliver completed form to Environmental Health & Safety Department.

Filling Out the Form

  1. Generator Information. The responsible faculty/staff person is the person who is in charge of the laboratory/maintenance site. The contact person is the person whom EHS would contact about the chemicals.

  2. Identification/Description of the Chemicals.
  • List all components and their respective percentages. Do not use chemical symbols or abbreviations. List physical state and pH, if applicable. (pH paper is adequate.) List number and type of containers. List volume (liquids) or weight.
  • List any hazards associated with this material, e.g., flammable, oxidizer, organic oxidizer, poison, corrosive, water-reactive, pyrophoric, mutagen/teratogen, carcinogen, shock-sensitive, etc.

Other Information

The chemicals must be prepared for pickup before sending this form to EHS. The request will be processed as it arrives. Chemicals that are improperly packaged, labeled, or identified will not be picked up. Pickup can be expected within two weeks of receipt by EHS. This form must be filled out as completely, specifically and legibly as possible (please print or type). Improperly, inadequately, or illegibly prepared forms will be returned for completion/clarification. If you have questions, a request of special urgency, or if EHS has not picked up your chemicals within two weeks, please call EHS at 744-7241.

example of chemical pickkup request form

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