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CrV RHWM Haztrack Waste Disposal Requisition Certification p q Requisition #: ( Q �Y Workplace Start Date: RMMA Certitication (Waste Other): Req. Tract, C Container Identification #: Workplace End Date: _ RMMA: O Yu i4: No 'Building: ( Room: j, PKE# (ifapplicable): y 2- CCInit Shipping Init: nit` is, Date: Waste Description: Qr See WDR or Electronic File Verifier Cergficition: Chemist Certification (Waste Custom 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. Container Verifier Chemist Signature: 'Container Use: 0 -.On-site use only gI Acceptable for off site use Container Manufacturer Serial NoJBateh No. Employee #: Initial: Date: Generator Ccrtlfication: I e.rtify, to the best of my knowledge that the information provided on;the above requisition is correct. I understand that I may be liable to:State and Federal prosecution by intentionally providing false I have obtained this information by: 29 Direct knowledge of the generating process 0,. Analytical Data 0: Obtaining information from others knowledgeable of the waste oroeess Was waste possibly exposed to process resulting in radioactive contamination? O Yes �m No Was waste exposed to radioactive inducing particle beam? Zd Generator RCA Certification (Waste Other): O NTS Certified ❑ On -Site Date: WGS0088 (1 Z103) Name (Print): (v . Container Verifier Signature: ffigralft� Rad Survey (mR/hr) (if applicable): Phone: Employee #: —Date Contact: (3y'@ I Metcr. eutron @Contact Radiological Appendix (Waste Other): Readings less than values in the ES&H Manual, Doc. 20.0. O Contains> 10 grams ❑ Do not store in Appendix.D (i.e., items may be transferred on-site) fissionable material fissile &tray Performed by (Print): i RCA initials: Performed by i Norm Rad Screening Conducted: OYes ❑No ❑N/A Background Reading on 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 Phone: Employee #: Date: I Phone: Employee #: Date: Scale Calibration Certification: ❑ Estimated Weight ❑ Weighed on calibrated scale certified by WCP Tare Weight: Gross Weight: --- Date Weighed Date Weighed: Scale Serial #: Scale Scrinl Cal. Due Date: Cal. Due Date: Initials: Packaging Procedure Followed: OWCP-8 OWCP-20 0EX-404 ❑WPT-104 ❑ Other 0 Packaging Inst. # 0 Other/Describe: • •