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';c E, <br />' <br />l <br />Version 4.3 <br />10,25,2005 <br />Sample Hazard Assessment <br />Client Sample ID <br />t ��'•'15 <br />For Authorized Reviewer Use Only <br />Use Only <br />Qualifying Constituents <br />Qualifying Constituents <br />YES <br />• .? ',;s��.�' jrr� '€� ` <br />A `, <br />�^�,,, , ri ��� `' '� w i<t �� "� +;r" � .�.0 u3 <br />�l�es ��� t z �t�Hazr�T�" e' <br />-<,�, 4 <br />�sr <br />�,�„ - r <br />o <br />�azrd� <br />Radtolotca"`y A <br />(z �, �+ : ,��❑ <br />❑ y kCor�os vex <br />❑ Acid <br />❑ Base <br />a <br />xrN,E Ss�ti <br />Alpha <br />, y <br />Beta <br />❑ <br />Tritium <br />❑ <br />❑ <br />1ti � N,�arf,... ,,F �a srd -.= `�" .. �' '✓j� P`"c <br />Exceeds 5 mR/hr <br />30 cm 1 ft <br />El <br />,r-- a1dL't°„ m.c,�.� .�. '�,1 . r+ti <br />x +' �, r <br />�Y <br />a„ Z•. <br />NOXI <br />r <br />_� 1 Ita a <br />❑ <br />Sy <br />I��.cttvelll�(sz <br />saw <br />T3des41 ;con n (Fedi rs5 a <br />rh� <br />As rillT ?x <br />e of nedj cu e Mt�reM ely tai do <br />h� <br />I certify, to the best of my knowledge, that information provided above is accurate and complete. <br />Authorized Sampler (Print Name): <br />.T {hA <br />�oe d e- costal gh e os <br />D' e e_cont iROD° <br />r.; <br />.'t 1 W <br />s� s` _ ,� <br />1 �yrvrr�c�f r" <br />n ry� ft t'fi o onda a losrves o <2b <br />Date: <br />-z 5-- -C)4 <br />.c <br />2� <br />X11 <br />> f <br />-�f�- . <br />`' <br />tPs� t x r agj,4� <br />_ 'Q'•t-.— _3s <br />None of the hazards listed above are present in the sample. <br />❑ Check here, if WDR is not available (For RHWM use only). <br />1 certify, to the best of my knowledge, that information provided above is accurate and complete. <br />Authorized Reviewer (Print Name): <br />AuthorizedReviewer (Si ature): <br />Date: <br />L <br />e xz� U <br />For Sampler <br />Use Only <br />SHA is not required for. <br />Qualifying Constituents <br />YES <br />NO <br />1. Berms <br />2. Retention Tanks <br />3. PE Samples <br />Comments <br />Was Hazard Assessment Control (HAC) necessary? <br />❑ <br />121 <br />Per Sample Basis: Are rad levels detectable by meter? <br />❑ <br />❑ <br />[�j Check if N/A <br />Exceeds 30,000 CPM <br />❑ <br />❑ <br />Exceeds 5 mR/hr <br />30 cm 1 ft <br />El <br />❑ <br />Exceeds 1 microCurie <br />❑ <br />❑ <br />Comments: <br />I certify, to the best of my knowledge, that information provided above is accurate and complete. <br />Authorized Sampler (Print Name): <br />ori <br />d Sam r ig ature): <br />Date: <br />-z 5-- -C)4 <br />iia <br />For CES Use Only <br />RHWM personnel must notify CES PEL, or desi nee, if rad levels exceed 1 microCurie for approval to submit sample. <br />SHA is not required for. <br />5. Research Samples <br />SHA Received by <br />Date: CES COC #: <br />1. Berms <br />2. Retention Tanks <br />3. PE Samples <br />6. Preconstruction Soils <br />7. Environmental Soils <br />8. Trip or Field Blanks <br />(initials): <br />p 8 �/ <br />4. Field or Bulk Gammadi <br />For document control purposes, user SHALL ensure that all roorkiug copies are ideutical to current electrouic <br />LttpJ/rorutu-eus.l/ul.you/16d_oidy/ces/QA_docVList_oj QA_Docs.6bu/ <br />