Requestor Name:

Department:

Date of Request:

Contact Phone:

Room/Lab#:

Building (McD, IBT, DTL, etc.):

Disposition:
Moving
Service/Repair
Surplus (Warehouse)

Hazard (to select more than one item, Windows users hold down CONTROL key and click,
Mac users hold down Command/apple key and click):
Biological Chemical Radiological

Disinfectant used: ----- N/A:

Principal Investigator: ----- Approved:

Additional Comments:

List of Equipment to be cleared (up to 10 pieces):