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steriCycle, # LhYUPubY!eh7dl SiI�l16Ai Work Order# Reviewed by: Date: Approval#: Azide Evaluation Form Generator Name: Generator Code: Generator Address: Contact Name: Generator Phone: Contact Phone: Important! Upon discovering an item requiring evaluation,do not remove it from the storage location. Only handle the container if necessary to gain access to the labeling information. You should make every attempt not to handle the container(s). If you need to handle the container to gain information,do so with extreme care. The following list outlines the Azide chemical families and examples of Azides within those groups Acryl Azides (t-Butyl Azidoformate,Ethyl Azidoformate) Alkyl Azides (Methyl Azide,Ethyl Azide) Aryl Azides (Phenyl Azide) Heavy Metal Azides (Silver,Lead,Copper) Hydrazoic Azides (Hydrogen Azide) Virgin/Sealed Material? Yes No or Spent? Yes No has the container ever been opened?(confirm with customer) Yes No If Yes,enter the date opened: Is the material Dry? Or in Solution? List All constituent(s)and their percentages: 1. Azide % 2. % 3. % 4. % S. % 6. % Is there any evidence of crystalliztion,cloudiness,wisp-like structures,discoloration,solid mass or any other indication of contamination? Yes No If yes,describe: If in a clear container,what is the color of the material? Has the container been under pressure,bulging,ect.?(confirm with customer) Yes No Container Information Is the product in the original manufacturer's container? Yes No Manufacturer: Purchase Date: Lot Number: Expiration Date: Container size: Volume/Weight remaining in container: Container Type: Glass Plastic Metal Other Cap Type: Glass Plastic Metal Other Cork Condition of Container: Rusted Bulging Dented Other Storage Conditions(confirm with customer) Was the material... Stored or spilled on metal? Yes No Unknown Spilled and placed back in container Yes No Unknown In contact with a spatula or scoop which may have been containated? Yes No Unknown