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                                                                                                      For Internal Use Only
                                                  Iowa State University                               Removed | To Whs |>$2000|
                                          Laboratory Equipment Disposal Form
Mail, Fax or Email form to: Environmental Health and Safety
                            2809 Daley Drive / 3660                                                 Date:
                            Fax: 294-9357 Attn: Steve Ziegenfuss
                            Email: sziegen@iastate.edu
                            Phone: 294-7417

Equipment to be disposed:


    ISU #                             Item Description                                   Item Location (Room & Building)
Releasing Department: _________________________________    Principal Investigator: __________________________________
                                                                                            (Print)
Contact Person: _______________________________________________         Phone:
                          (Print)
Contact Person's Location: ______________________________________

    Equipment has never been used with or contained radioactive materials, chemicals (especially perchloric acid), oils, PCBs,
    asbestos, mercury or biological agents.
        Note: Equipment must still be cleaned with detergent.                 Date cleaned:

    Equipment has been used with or contained the following - please check on appropriate line(s):

        ___ Electrical Equipment (X-ray units, transformers, or other items containing oil, capacitors or ballasts, etc.)
            Comments/List:

        ___ Chemicals (list high risk chemicals, perchlorates)
            Comments/List:

        ___ Mercury (Mercury compounds or Mercury-containing components, i.e., switches, lamps, etc.)
            Comments/List:

        ___ Asbestos Containing Items (including asbestos tape or wool, transite, asbestos gloves, etc.; if unsure, call EH&S)
            Comments/List:

        ___ Biological Agents (list agents)
            Comments/List:

        ___ Radioactive Materials (list radioisotopes)
            Comments/List:

            Inspected by EH&S Radiation Safety: Signature___________________________________ Date:

    Appropriate cleaning procedure used (see reverse side):
       List procedure used:
       Cleaning process performed by:
       Print name: _____________________________________ Date: _________________ Phone:

    No known hazard now exists:
        Name/Signature of Dept. Rep.: __________________________________________                  Date:



EH&S Review: Name:     _________________________________________________ Phone:
             Comments:


                 Item approved for disposal.
                                                                           EH&S Signature
Appropriate cleaning procedures can be found at the following sources:

Chemical and Electrical (General, Mercury)
Hazardous Waste Manual (Appendix III of Chemical Hygiene Plan)
 www.ehs.iastate.edu/publications/manuals/hazwaste.pdf (III. Chemical Spill Procedures and IV. Mercury Handling and Spill
Procedures)
Or contact Sean Whalen:
sbwhale@iastate.edu
294-2009

Biological Agents
Biological cleanup procedure at:
http://www.ehs.iastate.edu/publications/manuals/bsm.pdf (Sections F. Disposal and Disinfection and G. Biohazard Spill Cleanup)
Or contact Steve Ziegenfuss:
sziegen@iastate.edu
294-7417

Radioactive Materials
Radioactive cleanup procedure at:
www.ehs.iastate.edu/publications/manuals/rsm2k.pdf (Section M. Emergency and Decontamination Procedures)
Or contact Eric Armstrong:
ekarmst@iastate.edu
294-7666

Asbestos
For asbestos cleanup contact:
John Lathrum
jhlathr@iastate.edu
294-7193




H:\GROUPS\Forms\Biosafety\Laboratory Equipment Disposal Form2 2007.doc