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w a c/3 117 Waste Disposal Requisition Waste Type: CID #: Workplace Start Date: , t',6 ONon-Haz (N) OCA Haz (C) ORCRA Haz (H) ❑Universal (UW) Building. #: Workplace End Date: L . .(5 ❑Low -Level (R) OLLW Mixed (F) ❑LLW Combined (S) Room: PKE#/PIW/IGD: ❑NTS LLW (L) OMedical (M) OTRU (T) OTRU Mixed (X) Waste Name: See WDR or Electronic File Tare Weight: Gross Weight: Date Weighed: Date Weighed: Scale Serial #: Scale Serial #: Container Use: ❑ On-site use only �� - lY Acceptable for of site use Container Manufacturer Serial NoJBatch No. Initials: Employee #: Initial: Date: Gator Container Custodian Certification: 11� I certify, to the best of my knowledge that the information provided on the above requisition is correct. 1 understand that 1 may be liable to State and Federal prosecution by intentionally providing false information. I have obtained this information from: ❑ Direct knowledge of the generating process ❑ Analytical Data ❑ Others knowledgeable of the waste process Container Custodian Certification: ❑ . I certify that the waste parcels identified on this requisition are contained in this waste container and have been packaged in accordance with the requirements specified in the appropriate LLNL TRU or LLW Program Certification and Quality Assurance Program, RMMA Certification: Does thisw Lc contain radioactive materials? El Yes Zo ❑ Tome Analyzed RMMA: ❑ Yes No (If Yes and not rad complete below) Was waste possibly exposedto process resulting in radioactive contamination? ❑ Yes Was waste exposed to radioactive inducing particle beams? ❑ Yes Itf No Generator / Custodian Name (Print): Signature: Employee # Df V,5l0: Z;pl Date: WGS0088 (3)15) RMMA Certification: CC Init Shipping Init Rad Survey (mR/hr) (if applicable): Py @ Contact: Py @ I Meter: Neutron @ Contact Py @ 30 cm Readings less than values In the ES&H Manual, Doc. 20.0, Appendix D (Le., Items may be transferred on-sl(e) Performed by (Print): Performed by —(Signature): Employee #: Date: NORM Rad Screening Conducted: ❑Ycs ❑No ❑N/A Background Reading microR/hr : Reading on Item microR/hr : Employee #: Date: Scale Calibration Certification: ❑ Estimated Weight ❑ Weighed on calibrated scale certified by WCP Tare Weight: Gross Weight: Date Weighed: Date Weighed: Scale Serial #: Scale Serial #: Cal. Due Date: Cal. Due Date: Initials: Initials: Bin/SAW/DQO ❑ Yes ❑ No # SAA ❑ WAA ❑ Req Tracking Init Date Verifier Certification: ❑ I verify to the best of my knowledge, the infommation supplied by the waste generator on this form is complete and accurate, and that by visual inspection the waste is accurately described. Name (Print): Signature. _ Employee #: Date: Waste & Documentation Inspected By: Name (Print): Signature: Employee #: Date: Ll 6 Radiological Appendix: Contains > 10 grams CJ Do not store in fissionable material fissile arra RCA initials: RCA Certification: ❑ NTS Certified ❑ On -Site Treatment RCA Name (Print): RCA Signature: Employee #: Date: Chemist Certification: Packaging Procedure Followed: Chemist Name (Print): ❑WCP-8 ❑WCP-20 ❑EX -404 ❑WPT-104 ❑ Other Chemist Signature: ❑Packaging Inst. # ❑Othcr/Describe: Employee #: Date: