COMPLIANCE INFO_FILE 12 - Laserfiche WebLink

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t Requisition #: ". Container Identification a: Building: Room: or Electronic %"Opy RHWM Haztrack Waste Disposal Requisition Certification Workplace Start Date: — �o � RMNACertlncatlon(Waste Other): Rcq. Tracking -3i 71 i Workplace End Date: RMMA: O Yes EF No Kit( PKE# (if applicable): -y 2 CC Init. Shipping Init: Initials: Datc:. J• + File)Verifier Ccr fieitlon: Chemist Certirrcation (Waste Custom): —' 1 verify to the best ofmy knowledge, the information supplied by waste generator on this form is complete and accurate, andthat by visual inspection the waste is accurately described. Chemist Name Print r C.gntaIner Use: ;iib O,`On-site use only WAcccptablcfor offsiteuse ;.Container Manufacturer t -.Serial No./Batch No. ;•:fix;., Finployee #: Initial: Date: Generator Certification: �.certnfy, to the but of my knowledge that the information provided ti!tthe above requisition is correct. I understand that I maybe liable : t6..§Wc and Federal prosecution by intentionally providing false information. I have obtained this information by: Rl Direct knowledge of the generating process O Analytical Data O Obtaining information from others knowledgeable of the waste I. process RMMA Was waste possibly exposed to process resulting in radioactive contamination? O Ycs No Was waste exposed to radioactive inducing particle beam? O Yes ANo Gencr(print)a': o/�I(C6I Generator Si aturc• PPe. 7 Em Joyce # ,S % yl O Date: 9 _Z I•RC LJ NTS Certified ❑ i RCA Signature: Phone: Em to ec tl; WGSOOS8 (11/03) Treatment Date: Container Verifier Chemist Signature: Nnme (Print): ContainerVerificr Phone: Employee 1): Signature: Rad Survey (mR/hr) (if applicable): Phone: Employee #: r Date; . ®Contact: • (iy'@ I Meter: i _. t Neutron Q Contact Radiological Apperi iix (Waste Other): Readings lass than values In the ES&H Manual, Doc. 20.0, ❑ Contains> 10 grams ❑ Do notstoro'in Appendix D (l.e., items may be transferred on-site) j fissionable material frssila array Performed by (Print): j RCA initials: Performed by (Signature): Norm Rad Screening Conducted: ❑Ycs ONo ❑N/A Phone: Employee f!: Date: Reading on Phone: EmpIo 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 requirements specified in the appropriate LLNL TRU or LLW Program Certification and Quality Assurance Program. Container Custodian Name (Print): Container Custodian Si¢nature: Phone: #: Date., Scale Calibration Certification: ❑ Estimated Weight ❑ Weighed on calibrated scale certified by WCP Tare Weight: Gross Weight: Date Weighed Date Weighed: Scale Serial fl: Scale Serial l:: Cal. Due Date: Cal. Due Date: Initials: Packaging Procedure Followed: 13WCP-8 ❑WCP-20 13EX-404 ❑WPT-104 ❑ Other 0 Packaging Inst. # 0 Other/Describe: 0 •