Laserfiche WebLink
RECEIVJD <br />DEC 04 2015 <br />WNALp ENVIRONMENTAL Client Sample ID <br />HEALTH DEPA TMENT 8278 Machine <br />0o <br />Sample Hazard Assessment Shop <br />Rev. 2 <br />This form is required for all samples <br />Qualifying Constituents <br />_ <br />Hazard Type Yes <br />Comment <br />Comments <br />Hazard Type <br />Yes <br />Comment <br />Radiological <br />Is the exterior of sample containers verified free of <br />contamination? <br />Solvents <br />El <br />11/17/15 <br />Alpha <br />❑ <br />Corrosive <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 />Beta <br />❑ <br />Acid <br />❑ <br />❑ <br />Tritium ❑ <br />Inhalation <br />Base <br />I certify, to the best of my knowledge, that information provided above is accurate and complete. <br />Authorized Sampler (Print Name): <br />DOUG VI LLELA <br />Beryllium <br />(powder sample <0.10%a Be; slurry, ❑ <br />liquid, or solid sample >0.10% Be) <br />re): <br />Date: 11/17/15 <br />Reactive <br />❑ <br />Oxidizer <br />❑ <br />Biologically ActiveElIgnitable <br />El <br />Does the sample contain (Fed. Or State -defined) Acutely or Extremely Hazardous <br />Material? <br />Does the sample contain high explosives? <br />Does the sample contain >10 mg non -primary initiating or secondary explosives, or <br /><26% high explosives by mass? <br />❑ <br />❑ <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 a accurate and complete. _ <br />Authorized Reviewer (Print Name): <br />CHAD DAVIS <br />Authorize a fewer Signatu ): <br />Date: 11/17/15 <br />For Sam ler Use Only <br />Required Radioactivity Information <br />Yes I <br />No I <br />Comments <br />Is / are the sample(s)ppotentially radioactive? <br />❑ <br />wsAP Coordinat ignature): <br />If no, skip to name and signature. <br />Is the exterior of sample containers verified free of <br />contamination? <br />❑ <br />❑ <br />11/17/15 <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 VI LLELA <br />A on d Sampler (si <br />re): <br />Date: 11/17/15 <br />V'_ v <br />A612 RADIONUCLIDE INVENTORY CONTROL AND SAMPLE ACCEPTANCE <br />Prior to transporting samples to A612 facility the WSAP Coordinator must completed the section below <br />Does the total activity for this set of <br />samples exceed 1 uCi: <br />wsAP Coordinat ignature): <br />Date: <br />RHWM COC #: <br />[:]Yes NA No <br />11/17/15 <br />20219 <br />If yes, enter sample into Rad <br />inventory. Total activity: <br />WGS 0152 Expiration Date: 7/2/16 <br />