Radioisotope Laboratory/Equipment Decommission Request Due to the complexity of testing please allow up to 72 hours for equipment decommisioning. Lab decommision length and cost will be evaluated on a case by case basis. Permit Holder:* Permit Code: Requisitioner:* First Last Phone Number:*Email:* Facilities Coordinator: OEHS Contacted: Yes No Radioisotopes: Tritium (H-3) Carbon 14 (C-14) Phosphorus 32 (P-32) Iodine 125 (I-125) Other(s) *Indicate all isotopes used.Other Radioisotopes:*Please list all other radioisotopesLast Usage Date: Month Day Year Approximate last date of usage:Decommission Choices:* Equipment Laboratory Equipment Type:* Liquid Scintilation Counter Refridgerator(s) Freezer(s) Centrifuge(s) Other *Please describe equipment and quantity for release in the notes section below.Other Equipment:*Please list or describe applicable equipmentEquipment Location:* Leaving Laboratory: Moving into Laboratory: Date of Move:* Month Day Year Renovation: Yes No Reason for Renovations:Full renovationPartial renovationConversion into non-lab areaDate of Renovation:* Month Day Year *Anticipated start date of renovations.Decontamination Performed:* Yes No Action(s): Radiologic wipe test Gieger counter survey Biologicaly disinfected Chemical removal and/or neutralization Other *Please upload all supporting documentationOther Action:*Please describe other action(s):Performed By: Documentation:Accepted file types: jpg, gif, pdf, doc, docx, xls, Max. file size: 100 MB.*Upload wipe test results or other documentationNotes:*All additional information should be entered hereNameThis field is for validation purposes and should be left unchanged.