Dea Controlled Substance Disposal Form - Uwm Page 2
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2UW-Milwaukee DEA Controlled Substance Disposal Form
This form must be completed by the registered owner, in full, in order to ensure the disposal of your DEA controlled substance.
Upon completion, include a photocopy of your current DEA license and a substance inventory and send to Environmental Affairs
Engelmann 270. This form may also act as a change of custody document once signed by Environmental Affairs.
Registrant's
Name
DEA Number
Building
Room
Signature: ___________________________
Mailing
Environmental Affairs Representative.
address:
To be signed upon receiving substances during change of custody.
City
State
Zip
Signature:________________________________
Office Phone:
Registrant will fill in columns 1,2, 3 and 4. Environmental Affairs will fill in column 5. Please allow one line per container. Information must
be as specific as possible. Please type or print.
1. Name of DEA Controlled Substance
2. Initial Volume
3. Amount left
4.
5. Weight
for Disposal
(gm, ml, tablets)
In Container
Concentration
Of Container
(gm, ml, tablets)
(lbs)
1.
2.
3.
4.
5.
6.
7.
8.
9
10.
Date Received by Registrant: _____________________
Date Received by En. Affairs________________
Date of Shipment:______________________________
Date of Destruction:________________________
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