COMPLIANCE INFO_FILE 12 - Laserfiche WebLink

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, f ;.�..;*,r: L_ n nn #:��l, Identification #: RHWM Haztrack Waste Disposal Requisition Certification Workplace Start Date: QOJL RMMA Certification (Waste Other): Rcq. Tracking Workplace End Date: _ ��w ��29 RMMA: O Yes PIC110 (� G PKE# (if applicable): CC Init. W I Shipping Init: ,ft Initials: Datc: sWastd Description: See WDR or Electronic File '. Contalner Use: ;OOn-site use only Acceptable for off site use f.ci twiner Manufacturer f$enal.No./Batch No. '`.Employee #: Initial: Date: Verifier Cer flcltion: 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): G{j visual inspection the waste is accurately described. %' Container Verifier Chemist Signature: _ Rut;, Name (Print): Phone: Employee f!:6102,78 Daic:'Q Container Verifier Signature: . Rad Survey (mR/hr) (if applicable): Phone:g Employed # , -Date: AY @ Contact: • fly '@ I Meter: outron.@ Contact Radiological Appendix (Waste Other): Readings less than values in the ES&H Manual, Doc. I.V.U. terator Certification: ❑ Contains> 10 grams ❑ Do not store in Appendix.D (i.e., Items may be transferred on-site) rtify, to -the best of my knowledge that the information provided fissionable material fissile array Performed by he above requisition is correct. I understand that I may be liable (Print): fate and Fedora] prosecution by intentionally providing false -': t n. RCA initials; Performed by (Signature):rmi ve obtained this information by: `I)iicet knowledge of the generating process Norm Rad Screening Conducted: phone: Employee #: Date: "Analytical Data ❑Yes ONo ❑N/A :;Obtaining information from others knowledgeable of the waste Scale Calibration Certification: possibly exposed to process resulting in radioactive Reading on Item ion? O Yes k No milliPJhr exposed to radioactive inducing particle beam? phone CL RCA Certification Waste Other): ❑ NTS Certified ❑ On -Site Treatment RCA'Si ature: Phone: Employee #: Date: WGS00S8 (12/03) 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 Assuiaace Program. Container Custodian Name (Print): Container Custodian Signature: Phone: Employee #: Date: ❑ Estimated Weight i ❑ Weighed on calibrated scale certified by WCP Tare Weight: Gross Weight: Date Weighed Date Weighed: ------------- Scale Serial #: Scale Serial if: Cal. Due Date: Cal. Due Datc: Initials: Packaging Procedure Followed: i ❑WCP-g 13WCP-20 ❑EX -404 ❑WPT-104 C3 Other O Packaging Inst # O Other/Describe: F i