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DEC 0 4 2015 <br />0 HEALTH DEPARTMENT Client Sample ID <br />°° ' Sample Hazard Assessment 875 Machine Shop <br />Q <br />Rev. 2 <br />This form is re uired for all sam les <br />_ _ Qualifying Constituents <br />Hazard T e Yes Comment <br />Hazard T e <br />Yes <br />Comment <br />Radiological <br />Solvents <br />Corrosive <br />If no, skip to name and signature. <br />Is the exterior of sample containers verified free of <br />contamination? <br />Alpha <br />If yes, enter sample into Ra <br />Beta ❑ <br />Acid <br />❑ <br />❑ <br />Tritium ❑ <br />Inhalation <br />Base <br />❑ <br />Beryllium <br />(powder sample <0.10% Be; slurry, ❑ <br />liquid, or solid sample >0.10% Be) <br />Reactive <br />❑ <br />- - <br />Oxidizer <br />❑ <br />I certify, to the best of my knowledge, that information provided above is accurate and complete. <br />Biologically Active ❑ <br />Materials <br />Does the sample contain (Fed. Or State -defined) Acutely or Extremely <br />Material? <br />Ignitable <br />Hazardous <br />❑ <br />❑ <br />❑ <br />Does the sample contain high explosives? <br />Does the sample contain >10 mg non -primary initiating or secondary explosives, or <br /><25% high explosives by mass? <br />® None of the hazards listed above are present in the sample. <br />® Check here, if WDR is not available. <br />I certify, to the best of my knowledge, that information provided is accurate and complete. <br />Authorized Reviewer (Print Name): <br />CHAD DAVIS <br />Authori viewe Signa re): <br />Date: 11/17/15 <br />For Sam ler Use Only <br />Required Radioactivity Information <br />Yes <br />No <br />Comments <br />Is / are the sample(s)ppotentially radioactive? <br />❑ <br />N <br />If no, skip to name and signature. <br />Is the exterior of sample containers verified free of <br />contamination? <br />❑ <br />If yes, enter sample into Ra <br />Were rad levels detected during sampling? If so, record <br />highest readings detected. <br />❑ <br />❑ <br />Beta/gamma (cpm) BKG (cpm) <br />Alpha (cpm) BKG (cpm) <br />Dose mR/hr <br />Does the sample(s) exceeds 5 mR/hr @ 30 cm 1 ft)? <br />❑ <br />❑ <br />Does the total activity exceed 1 microCurie? <br />❑ <br />❑ <br />Comments: <br />I certify, to the best of my knowledge, that information provided above is accurate and complete. <br />Authorized Sampler (Print Name): <br />DOUG VILLELA <br />Authorized Sampler (signature): <br />Date: 11/17/15 <br />A612 RADIONUCLIDE INVENTORY CONTROL AND SAMPLE ACCEPTANCE <br />Prior to transporting samples to A612 facility the WSAP Coordinator must complete the section below <br />Does the total activity for this set of <br />samples exceed 1 uCi: <br />WSAP Coordinator signature): Date: <br />RHWM COC #: <br />❑ YesNo <br />11/17/15 <br />20219 <br />If yes, enter sample into Ra <br />inventory. Total activity: <br />WGS 0152 Expiration Date: 7/2/16 <br />