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■ 4C6149P Stericyclex-- Work Order# Reviewed by: Date: Approval#: Peroxidizable and Polymerizable Compound 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. Chemical Name and composition(list au) 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 Cork Other Condition of Container: Rusted Bulging Dented Other Content Information-Handle the container with extreme caution. Do not open the container without proper training and approval. Virgin/Sealed Material? or Spent? Has the container ever been opened?(confirm with customer) Yes No If Yes,enter the date opened: Are there any visible solids in the container or cap(e.g.crystillization,feathering,etc)? Yes No Is the material inhibited? Yes No If so,with what and the percent? When was the last time it was opened? Was an inhibitor added? Yes No Was it tested for peroxides? Yes No If so,what was the amount? ppm before or after inhibitor added Storage ConditionS(confirm with customer) Was the material... Subject to fire? Yes No Unknown Subject to fluctuations in temperature? Yes No Unknown Subject to thermal or physical shock? Yes No Unknown Stored indoors? Yes No Unknown Subject to direct sunlight? Yes No Unknown Stored outdoors? Yes No Unknown Subject to fluctuations in humidity? Yes No Unknown Name: Company: Signature: Date: