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H135772 <br /> LAWRENCE LIVERMOnc NATIONAL LABORATORY <br /> HAZARDOUS WASTE DISPOSAL REQUISITION ❑ HWM Use Only Page i of <br /> 1.Bw .�f 2. Roo No' r 3. RMMA: 10.Hazardous Outer Container/Retention Tank ID: Overpack? scheduled WasteRun Date: Void Requisition: <br /> J ��)�� ❑ Yes No ,Rperties: [-]Yes Elmo �Q / 9 ❑DATE:_ / I <br /> Toxic <br /> 4.W No: 5. kpla e d 6.Account No: 12.Outer Container 13.Outer Container Size: El HWM Waste Run Initials/Date ^�� <br /> 71 ❑Co si a Type: ❑ 1 gal ❑330 gal <br /> ' ❑Box ❑ 5 gal ❑660 gal ❑Off-Site to LLNL Rro y� <br /> 7.Waste Minimization Efforts Practiced During Generation of this Waste. No ��y / <br /> El Yes, Activity Codes(enter up to four): W W Yy yy ❑ R6acTve� ❑Can ❑30 gal ❑1000 gal ,�� p WTO <br /> J.� <br /> V Commercial Shipment �]rz zy <br /> gal <br /> 11.Waste Form: ED Carboy ❑55 ❑5000 al Ute'V/f"`- <br /> Comments: gal fd ❑Secured Pickup <br /> ❑Solid ❑Drum ❑85 gal ❑1x1x1.5 ft <br /> Did this Waste Minimization effort begin in current calendar year? ❑Yes No Liquid ank-Fixed ❑2x4x7 ft ❑HWM Field Pump Out <br /> Sludge �ank-Portable ❑4x4x7 ft <br /> 8.Profile No: 9.Directorate: � �� 9e � it„D gal E]HWM Generated Waste <br /> H P ❑Gas Other: Other:7� ❑cu ft ❑Sewer: DATE:--J--J—RSDR# <br /> 14.ITEM 15.AQUEOUS ONLY 16.ANALYSIS 17.SOURCE 18.CHEMICAL/PHYSICAL DESCRIPTION 19.QUANTITY <br /> NO. • SAMPLE NO. CODE per nem <br /> H Normality Arrwunt units <br /> l X93tAN NsgD 5>E L �LtLL P_orhtA;a k UP f ! ow &L <br /> QT�e--) PR014 <br /> COMPLE <br /> P.' Ggoc AUG 10 Im <br /> BY <br /> For RMMA Waste *Normality Required if pH s 2 or pH z 12.5 USE CONTINUATION FORM FOR ADDITIONAL ITEMS <br /> 20.Was the waste kept isolated from <br /> any operation that could have 22.Describe other controls used to prevent radioactive contamination: <br /> produced radioactive contamination 23.1 certify,to the best of my knowledge,that the information provided on this requisition is correct.I understand that I may be liable to State and Federal prosecution by intentionally <br /> (using a glove box,vent hood,etc.)? providing false information. <br /> Yes❑ No❑ <br /> (If no,full rad analysis required) Generator Name(Print-Last,First): L-Code: Ext.: Inspected by HWM Print Name-Last,Firs Ext.: <br /> 21.Was the waste exposed to particle P`-y �- S A n� X73 , %� S <br /> beams capable of inducing radioactivity Signature: Employee No.: Date: C� Signature: Employee No.: Date: <br /> E]by activation? Yes No❑ '�✓CXN f107-7 <br /> (If yes,full rad analysis required) <br /> ITEM RCH RCH P Origin Form EPA NO. DTSC NO. MSDS NO. Hazardous Properties Handling Code: By: <br /> Prefix Code Code <br /> T C I R <br /> Date: Loc: <br /> ❑ ❑ ❑ ❑ Chemical Compatibility Code: <br /> ❑ ❑ ❑ ❑ Department Generating Waste: <br /> ❑ ❑ ❑ ❑ HW Requisition Approve Si azure) <br /> ❑ ❑ ❑ ❑ Empl ee No.: Date: <br /> 2' 7- <br /> LL 5344-B(Rev.3/93) 7600-70302 <br /> White—HWM Copy <br />