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. E N'E D <br />Sample Transportation Determinate <br />Section I <br />Requester Donald Dearing Phone # 3-5509 FEB 0 9 2017 <br />Requisition # / Sample ID W356456 ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />Waste Type: ❑ Non -hazardous waste or retention tank (not DOT) — Print and sign below and process <br />sample. No further action required. <br />® Hazardous ❑ Radioactive ❑ Mixed ❑ CA Combined <br />Number of Weight <br />containers ❑ Liquid ® Solid (in ❑ Swipe <br />rams <br />125 mL glass 'ars 80 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />Total 80 <br />Print and sign below and forward to the WSAP Coordinator for further review and Section II completion, if <br />necessary. Ensure the WDR or other preliminary characterization information is submitted along with this form. <br />Determined by (Print) Chad Davis Date 11/4/16 <br />Signature r4eZ___1 <br />Section II (WSAP Coordinator — complete and return to Requester if not DOT regulated) <br />DOT Regulated? ❑ Yes ® No <br />Determined by (Print) Chad Davis—Date 11/4/16 <br />Signature <br />If DOT regulated, forward to RHWM Disposal Office for completion of Section III. <br />Section III <br />DOT Information <br />Proper Shipping Name <br />Pass / Cargo / Limited Qty Pack. <br />Special Provisions <br />Packaging <br />❑ Rad Info. Attached <br />COC # ia C 2 <br />WCG 0140 <br />See WIC 153 <br />Instruction <br />ERG # <br />Max Net Qty <br />Effective Date: 10/06/16 <br />Expiration Date: 10/06/19 <br />