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All responses are required, eventually.

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Questions/Info only visible type will be visible on printing!

Your Name

Work area checkout date

Work area(s): (bldg, room #, bench/hood locations)

Major professor

Where can you be reached after you leave the department?  Include phone and email if possible.

Is all chemical, biological, and radioisotope waste which you have ever produced gone from the department?  (Gone, meaning it has left the buildings.)

Y

N

N/A

If any waste that you produced is being left in the building (as part of shared group waste accumulation containers, e.g.) who is the person responsible for those/that container(s)? 
Name of responsible person:

Are you leaving any "samples" of any sort in the department?
(If yes, attach samples list.)

Y

N

N/A

Have you quenched and disposed all water-reactive and air-reactive chemicals which you purchased, or for which you assumed responsibility at some time?

Y

N

N/A

Are there any gas cylinders in the department that are in your name?  (Check with Chem Stores.)  If yes, complete and attach the gases and reactives list. .
MUST GET SIGNATURE FROM STORES HERE: ______________________________

N

Did you purchase any lectures bottles, air-reactives, or water-reactives that will remain in  the department?  If yes, attach the gases and reactives list.

Y

N

N/A

Can you say with some confidence that you are leaving no chemicals or waste in the department which will cause waste disposal or safety problems in the future?

Y

N

N/A

When did or when will you have returned all keys from BRWN or WTHR?

[Chemistry]  [REM]  [Physical Facilities ]  [Administrative Information Service]  [Purdue University]
http://www.chem.purdue.edu/safety | send comments to: swihart@purdue.edu | last review/update November 16, 1999