TSCA Regulated Chemicals Request form

Name(Required)

First Last

Email(Required)

PI / Lab Director(Required)

First Last

TSCA Regulated Chemical(s): Select all that apply.(Required)

Methylene Chloride

Trichloroethylene

Perchloroethylene

Carbon Tetrachloride

Building Name(Required)

Room number(s)(Required)

Proposed Quantity(Required)

Concentration(Required)

Can the procedure be completed within a fume hood or glovebox?(Required)

Yes

Partially

Unsure

Please provide additional details of the proposed operation. Include a description of individual steps that will involve the requested chemical, quantity and concentration used for each step, and what exposure controls are available for each step. Indicate the number of people performing this procedure and their level of experience.(Required)

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Research & Clinical

Haz Waste

Working Safely

Environmental

Construction

Living Safely

TSCA Regulated Chemicals Request form

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