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r r � `V n73 i-1 l , / -11 ,,, <br />/1/ 3 15-7 �W <br />MES <br />SHA <br />Qualifying Constituents <br />Client Sample ID <br />;X W. <br />Version 4.3 <br />10/25/2005 <br />Sample Hazard Assessment <br />Co r�ULI <br />21, <br />M. <br />R <br />*w <br />❑ <br />For Authorized Reviewer Use Only <br />Qualifying Constituents <br />Qualifying Constituents <br />4.ai Ny g-,-,7g{,a. 4"'��� <br />c Wiv3fr��'t'�i <br />�rti rl = <br />NO j <br />s 4 "�l�n �Y'��� <br />az d T a <br />Ift <br />e.s� <br />Co r�ULI <br />21, <br />M. <br />R <br />*w <br />❑ <br />r ' <br />Alpha ❑ <br />Exceeds 30,000 CPM <br />,osiaNix <br />M ONE <br />x y <br />Beta ❑ <br />❑ <br />Acid <br />❑ <br />Exceeds 1 microCurie <br />Tritium ❑ <br />❑ <br />Base <br />❑ <br />I certify, to the best of my knowledge, that information rovided above is ccurate and complete. <br />[Z d3ID aha �.:n : y :H� '�c. i ` <br />N� w <br />° .'a - 3 y} <br />1kir" <br />xb�.tjt+ <br />4��'�' tae <br />tjlOW er SdnHfrJ{t .i o-tj S�ar�t©�p�f3� <br />t Mpl, {Ci 1"�icG+^fr.x� t!'$J'+� +- � �c <br />n Fe or, State define el r. Ext eine J alzar' <br />R� c�i+i"G�„ti�''a`isirt5ary` <br />�? ��ii�� ? <br />olas. a en�a�7 ,c <br />s <br />.. .i'�.r�d r +best <br />l; I M a1�r <br />e T i <br />o thr1e �iir Ra ott �ht�a r e and rm IoFie rt -0 25 a <br />t <br />n <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 />I certify, to the best of y kn wledge, that information provided above is accurate and complete. <br />Authorized Reviewer (P 'nt ame): <br />L�2 I I, ;�L <br />Authorized Rev' we (Sign e): <br />� <br />Date: <br />_ . ua7 <br />For Sampler <br />Use Only <br />Qualifying Constituents <br />YES <br />NO j <br />Comments <br />Was Hazard Assessment Control (HAC) necessary? <br />❑ <br />21, <br />(initials): <br />Per Sample Basis: Are rad levels delectable by meter? <br />❑ <br />❑ <br />t_1 C=heck if N/A <br />Exceeds 30,000 CPM <br />❑ <br />❑ <br />3. PE Samples <br />Exceeds 5 mR/hr <br />30 cm 1 fl <br />❑ <br />❑ <br />I <br />Exceeds 1 microCurie <br />❑ <br />❑ <br />Comments: <br />I certify, to the best of my knowledge, that information rovided above is ccurate and complete. <br />Authorized Sampler (Print Name): <br />uthoriz Sampler ign <br />Date: <br />1l^i7-o 7 <br />For CES Use Only <br />RHWM personnel must notify CES PEL, or designee, 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: <br />CES COC #: <br />1. Berms <br />6. Preconslruction Soils <br />(initials): <br />2. Retention Tanks <br />7. Environmental Soils <br />% <br />3. PE Samples <br />8. Trip or Field Blanks <br />��, 3 —Q 7 <br />I <br />4. Field or Bulk Gamma <br />I <br />For donuneut control purposes, userSHALL rusore that all tuorking copies are identical to currant electronic <br />IdtpJ/miuru•aus.l6d.gov/tbrl ordy/ce.VQA_docvtist_of_QA Docs.Irhal <br />