Surplus Equipment Decontamination Form
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1Surplus Equipment
DECONTAMINATION FORM
Date:
Department name:
Contact Person:
Phone Number
Item Description:
UT Tag No:
Serial Number:
Item Location:
This equipment has been thoroughly cleaned and contains no radioactive, chemical,
or biological residues.
BIOHAZARDS:
Not used Used, but decontaminated, method:
HAZARDOUS CHEMICALS:
Not used Used, but decontaminated, method:
RADIOACTIVE MATERIALS:
Not used Used, but decontaminated, method:
Statement of Safety:
I certify that I, (please print)
Have thoroughly cleaned
and/or decontaminated this equipment and tested it for radiation level, eliminating any
potential hazard(s) from bio-hazardous materials, radiation, or chemicals.
Signature:
Date:
(Signature of technician or designee)
PLEASE SUBMIT COPY OF COMPLETED FORM WITH YOUR REQUEST FOR
SURPLUS PROPERTY PICK-UP.
ATTACH ORIGINAL DECONTAMINATION FORM TO EQUIPMENT TO BE
PICKED-UP.
8/10/06
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Parent category: Business