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W9�p FFB 9 201 Client Sample ID <br />Sample Hazard Assessment W356453 <br />ENVIRONMENTAL NEALTH <br />Re, 2 EPABIMENT <br />This form is required for all samples <br />Qualifying Constituents <br />Hazard Type Yes CommentHazard Type Yes Comment <br />Alpha Corrosive <br />Required Radioactivity Information <br />Beta - - - - Acid <br />Tritium <br />❑ <br />Inhalation Base <br />Is / are the sample(s)ppotentially radioactive? <br />_ <br />Beryllium Reactive <br />(powder sample <0.10% Be; slurry, ❑ Oxidizer <br />liquid, or solid sample >0.10% Be) <br />[] <br />❑ <br />Biologically Active ❑ Ignitable <br />Materials <br />❑ <br />Does the sample contain (Fed. Or State -defined) Acutely or Extremely Hazardous <br />E]Material? <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 />❑ <br />LJ None of the hazards listed above are present in the sample. <br />❑ ❑ Beta/gamma (cpm) BKG (cpm) <br />Check here, If WDR is not available. <br />Alpha (cpm) BKG 0(cpm) <br />I certify, to the best of my knowledge, that information provided above is accurate and comple—te. <br />Authorized Reviewer (Print Name):i I Authoriz77Tr <br />ure}: <br />CHAD DAVIS atDate: 11/7/16 <br />For Sampler Use Only <br />Required Radioactivity Information <br />Yes <br />No <br />Comments <br />Is / are the sample(s)ppotentially radioactive? <br />If no, skip to name and signature. <br />Is the exterior of sample containers verified free of <br />❑ <br />contamination? <br />Were rad levels detected during sampling? If so, record <br />❑ ❑ Beta/gamma (cpm) BKG (cpm) <br />highest readings detected. <br />Alpha (cpm) BKG 0(cpm) <br />Dose mR/hr <br />Does the sample(s) exceeds 5 mR/hr @ 30 cm 1 ft)? <br />❑ ❑ ; <br />Does the total activity exceed 1 microCurie? <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 />Au lz Sampler (s' natorft <br />DOUG VILLELA <br />Date: 11/7/16 <br />11 <br />A612 RADIONUCLIDE It <br />Prior to transporting samples to A612 facility the WSAP Coordinator must <br />Does the total activity for this set of <br />samples exceed 1 uCi: <br />❑ Yes ❑ No <br />If yes, enter sample into Rad <br />inventory. Total activity: <br />WCG 0152 <br />See WIC 153 <br />RY CONTROL AND SAMPLE ACCEPTANCE <br />WSAP Coordinator (signature): Date: <br />11/7/16 <br />RHWM COC #: <br />Effective Date: 10/06/16 <br />Expiration Date: 10/06/19 <br />