Laboratory Registration Form for the 9th Ave. & Colorado Blvd. Campus

Environmental Health and Safety Department

 

Complete this form for each laboratory space assigned to the Principal Investigator.  Submit by clicking the Submit Button at the end of this page.  You may also download this form, complete and submit to EH&S,  Attn:  Compliance Assistant, Mailstop F-484 .  Contact the Compliance Assistance representative (x40344) with any questions.

Instructions:

1.    This form is used to notify EH&S for Registration of laboratory space as required by state law.

2.    Complete ALL fields.  Home phone numbers are ONLY available to University Police in the event of an emergency (fire, flood, etc.) in your laboratory.  After completion, please e-mail the form to EH&S by clicking on the Submit button below.

3.    Note:  If you have any questions regarding this form, please call the EH&S Compliance Assistant at 724-0344.  This form can also be downloaded as a pdf document.  Click here for the pdf download version of this document.

4.    EH&S will update our Emergency Response Database and room signage as necessary as you submit updates.

Building Room Number Date Completed

Principal Investigator Information:      

Name Email
Department/Division Mailstop
Office Phone Home Phone
Pager

Emergency Contact Information:

Emergency Contact #1
Name (Last Name, First Name, MI)
Office Phone Home Phone Pager
 

Emergency Contact #2
Name (Last Name, First Name, MI)
Office Phone Home Phone Pager
 

Emergency Contact #3
Name (Last Name, First Name, MI)
Office Phone Home Phone Pager

 

Check One (purpose of submitting form):

  Registration of new non-Satellite Accumulation Area (SAA) lab space

  Registration of new Satellite Accumulation Area (SAA) lab space

  Change in room number/Principal Investigator/contact info/other

  Release of SAA - no longer in use

  Change in waste stream type (see below)

 

Check all types of waste you are generating or anticipate generating:

  Radioactive wastes

  Radioactive mixed wastes (radioactive materials mixed with flammable, corrosive, reactive or toxic chemicals)

  Infectious wastes (human blood, bodily fluids, tissues, cell culture, any type of pathogens, recombinant DNA materials)

  Infectious mixed waste (infectious agents mixed with flammable, corrosive, reactive or toxic chemicals)

  Hazardous chemical wastes       

Flammable Liquids Heavy Metals
Solvents Oxidizers
Corrosives Reactives
Poison Liquids or Solids Organic Solvents

  Other (please list)