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RECEIVED <br />WXAkLPClient Sample ID <br />Sample Hazard Assessment FEB 0 ?0' W356456 <br />Rev. 2 ENVIRONME <br />DE <br />This form is required for all samples <br />AL HEALTH <br />Hazard Type Yes Comment Hazard Type <br />Radiological Solvents <br />Alpha Corrosive <br />Beta ❑ Acid <br />Tritium <br />Inhalation _ Base <br />Beryllium Reactive <br />(powder sample <0.10% Be; slurry, ❑ <br />liquid, or solid sample >0.10% Be) Oxidizer <br />Biologically Active ❑ Ignitable <br />Materials <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 /><25% high explosives by mass? <br />None of the hazards listed above are present in the sample. <br />Yes <br />I Comment <br />El <br />Date: <br />RHWM COC #: <br />If no, skip to name and signature. <br />❑ <br />❑ <br />❑ <br />inventory. Total activity: <br />❑ <br />El <br />❑ <br />❑ <br />Beta/gamma (cpm) BKG (cpm) <br />❑ <br />Check here, if WDR is not available. <br />I certify, to the best of my knowledge, that information provided above is accurate and complete. <br />Alpha (cpm) BKG 0(cpm) <br />Authorized Reviewer (Print Name): <br />CHAD DAVIS <br />Authorized ewer (Sign e): <br />109n <br />Date: 11/7/16 <br />For Sampler Use Only <br />Required Radioactivity Information Yes No <br />Comments <br />Is / are the sample(s)ppotentially radioactive? <br />Date: <br />RHWM COC #: <br />If no, skip to name and signature. <br />Is the exterior of sample containers verified free of <br />❑ <br />❑ <br />inventory. Total activity: <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 />Does the total activity exceed 1 microCurie? <br />I ❑ <br />❑ <br />Comments: <br />I certify, to the best of my knowledge, that information provided above is urate and complete. <br />Authorized Sampler (Print Name): <br />'ed Sampler ( "gn <br />ure): <br />DOUG VILLELA <br />C/ <br />Date: 11/7/16 <br />LWA <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 Coordinator (signature): <br />Date: <br />RHWM COC #: <br />El ❑ No <br />If yes, enter sample into Rad <br />11/7/16 <br />inventory. Total activity: <br />WCG 0152 trrecuve uaie: -i uiuovi n <br />See WIC 153 Expiration Date: 10/06/19 <br />