Permit Request • CampusOptics

This form is to be completed by the Principal Investigator (PI)/Responsible Person of the lab that is being decommissioned or by the designee. Environmental, Health and Safety (EH&S) will use the completed checklist during the laboratory decommissioning inspection to verify that all hazards have been removed from the laboratory and/or that ownership of remaining hazards has been appropriately transferred to another party. This process should be started at least three months before vacating the chemical-use room/laboratory to allow ample time to dispose of all materials properly. Upon completion of a successful decommissioning inspection by EH&S, you will be issued a Laboratory Decommissioning Clearance Authorization.

Below, please write in today's date for "Permit Start Date" and the decommissioning date for "Expiration Date". Note that all fields below are required.

To schedule a hazardous waste pickup use this link.

Attach Chemical List, photos and any support documents in the "Add Supporting Documents" section at the bottom of the form.

Requester Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Permit Date & Time

Start Date* Required

Start Time* Required

Expiration Date* Required

Expiration Time* Required

Location

Name* Required

Additional Location Details

General Information

Dean/Chair/Director Name* Required

Dean/Chair/Director Email* Required

Department* Required

Reason for Decommissioning* Required

Radioactive Materials

If radioactive materials and/or x-ray producing device was present or used, A-State’s Radiation Safety Officer was contacted and a closeout survey completed.* Required

If a laser was present or used in the lab, A-State’s Radiation Safety Officer was contacted and a Laser Permit Amendment form has been completed.* Required

If biological material was present or used, A-State’s Office of Research Compliance (ORC) was contacted.* Required

Controlled Substances/Chemical Compounds

All controlled substances have been discarded or relocated appropriately. Abandonment of a controlled substance is a violation of the Drug Enforcement Agency's (DEA) requirements. (NOTE: Special procedures may be required by the DEA and by the Food and Drug Administration.)* Required

All chemical compounds, reagents, and samples were removed from refrigerators, freezers, cold rooms, storage rooms, closets, etc., including common areas. In shared laboratories, all PI's/Responsible Persons must agree upon what id disposed, transferred, and /or left behind.* Required

All chemicals targeted for hazardous waste disposal were removed by the following EH&S guidelines. Under no circumstances may any hazardous chemical be disposed of down drains or into regular trash receptacles.* Required

Usable chemicals were transferred to another person in your department and/or location on the A-State campus and that department representative will be responsible for the proper storage, usage and disposal of the materials. Fill out the Chemical Inventory Template noting the name(s), location and amount of material being transferred.* Required

Glassware

All glassware was cleaned and packed according to the Departmental Instructions. * Required

All non-contaminated broken glassware was placed in a lined, sturdy box that was taped shut and labeled "BROKEN GLASS", and placed in the dumpster for regular trash disposal.* Required

Broken glassware that was contaminated has been decontaminated as appropriate for the hazard prior to disposal in the dumpster and/or has been disposed as per EH&S guidelines.* Required

Sharps

Non-biohazards sharps were collected in either a sturdy, puncture resistant container and encapsulated, or in a purchased sharps disposal container (defaced to remove the biohazard label) with a locking lid. The sealed container was placed in the dumpster for proper disposal.* Required

Sharps (needles, scalpel blades, razor blades, broken glass, pipette tips, Pasteur pipettes, etc.) contaminated with biohazardous materials were disposed per EH&S guidelines.* Required

Compressed Gas Cylinders

All compressed gas cylinders were returned to suppliers. If cylinders are non-returnable, EH&S was contacted for removal. * Required

Laboratory Equipment

All lab equipment (fume hoods, biological, safety cabinets, refrigerators, incubators, ovens, etc.) and areas where chemicals or biological agents were used or stored (e.g., cabinets, shelves, benchtops, etc.) were cleaned or decontaminated with soap and water, a 5% calcium or sodium bicarbonate wash, 10% bleach, or another approved disinfectant, as appropriate for the respective chemical and/or biological agent(s) used.* Required

If the Biological Safety Cabinet will be relocated, it was decontaminated per the EH&S requirements.* Required

All trash and debris have been removed from floors, bench tops, cabinets, drawers, and fume hoods* Required

Prior to discarding laboratory equipment, the following items were removed: a. capacitors or transformers (in high-voltage generating equipment) b. mercury from lab apparatus c. mercury switches and thermometers d. refrigerant fluids containing chlorofluorocarbons (in freezers and refrigerators) e. Radioactive sources and chemicals* Required

The only items remaining are those requested by the new tenant and they are tagged with his/her name.* Required

No items/equipment have been left in the hallway.* Required

All emergency contact information and signage for specific hazards were removed* Required

Add Supporting Documents

Add files to upload as supporting documentation along with your permit request.

Files