COMPLIANCE INFO_FILE 12 - Laserfiche WebLink

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RHWM Haztrack Waste Disposal Requisition Certification 2-2 orj�Tr 1 %-1 - - 4- Requisition #: Workplace Start Date: _ RMMA cerUncation (Waste other): i' Container Identification N: Workplace End Date: ( RMMA: O Yes WNo Building: Room: PKE# (if applicable): 2-7- CC Init. Shipping Init: � 9_MT_ 126 Waste Description: C4 See WDR or Electronic File Verifier Cergficittion: Chemist Certification (Waste Ct I verify to the best of my knowledge, the information supplied by the. waste generator on this form is complete and accurate, and that by Chemist Name (Print): visual inspection the waste is accurately described. ,I I have obtained this information by: % Direct knowledge of the generating process O Analytical Data 01 Obtaining information from others knowledgeable of the waste process Was waste possibly exposed to process resulting in radioactive contamination? O Yes bf No Was waste exposed to radioactive inducing particle beam? Generator # WGS0088 (12/03) Norm Rad Screening Conducted: ❑Yes ❑No ❑N/A Background Reading milliR/hr : Reading on Item milliR/hr Phone: Em to ee #: Date: 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 to specified in the appropriate LLNL TRU or LLW Program Certification and Quality Assivanco Program. Container Custodian Name (Print): Container Custodian Phone: #: Date: Rcq. Tracking initials. Date: + Da Rad Survey (mR/hr) (if applicable): E 9e cQ Contact: • (iy'Q 1 Meter: i Neutron Q Contact Readings las than values In the ES&H Manual, Doc. 20.0, Appendix D (1.e., Items may be transferred on-site) j Performed by (Print): Performed by i (Signature): Phone: Employee M Daic: Scale Calibration Certification: Container Verifier Name (Print): Contalner Use: 0 -'On-site use only ® Acceptable for off site use Container Verifier Signature: Container Manufacturer Serial No./Batch No. Phone: ri oZ — Employee M "4Date: . Employee: Initial: Date: Date Weighed Radiological Appendix (Waste Other): Scale Serial #: Generator Certification: I certify, to the bat of my knowledge that the inforrnation provided on the above requisition is correct. I understand that I may be liable to State and Federal prosecution by intentionally providing false information. O Contains > 10 grams ❑ Do not store'in fissionable material fissile array RCA initials: I have obtained this information by: % Direct knowledge of the generating process O Analytical Data 01 Obtaining information from others knowledgeable of the waste process Was waste possibly exposed to process resulting in radioactive contamination? O Yes bf No Was waste exposed to radioactive inducing particle beam? Generator # WGS0088 (12/03) Norm Rad Screening Conducted: ❑Yes ❑No ❑N/A Background Reading milliR/hr : Reading on Item milliR/hr Phone: Em to ee #: Date: 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 to specified in the appropriate LLNL TRU or LLW Program Certification and Quality Assivanco Program. Container Custodian Name (Print): Container Custodian Phone: #: Date: Rcq. Tracking initials. Date: + Da Rad Survey (mR/hr) (if applicable): E 9e cQ Contact: • (iy'Q 1 Meter: i Neutron Q Contact Readings las than values In the ES&H Manual, Doc. 20.0, Appendix D (1.e., Items may be transferred on-site) j Performed by (Print): Performed by i (Signature): Phone: Employee M Daic: Scale Calibration Certification: ----------------- ❑ Estimated Weight O Weighed on calibrated scale certified by WCP Tare Weight: Gross Weight: j Date Weighed Date Weighed: Scale Serial #: Scale Serial !:: ! i Cal. Due Date: Cal, Due Datc: t Initials: Packaging Procedure Followed: ❑WCP-8 ❑WCP-20 OEX-404 OWPT-104 0 Other O Packaging Inst. # O Other/Describe: 0 •