Chemical Safety Division
Lab Clearance
Please do not leave any lines blank.
Please call 567-2955 with any questions.
Isotope:
Lab Room #, Building:
Requestor Name:
Department:
Date of Request:
Contact Phone:
Hazard (hold shift key down and click to select more than one): Biological Chemical Radiological
If Radiological, list all known Radioisotopes used (up to 10):
Disposition: Moving Renovating Cleaning
PI (was in lab):
PI (new):
Areas not to be cleared:
Additional Comments:
