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w'g �p Client Sample ID <br />0.Sample Hazard Assessment W353384/ <br />M;� Q00280967 <br />Rev. 2 <br />_ This form is required for all samples <br />Required Radioactivity Information <br />Yes <br />Qualifying Constituents <br />Comments <br />- <br />Hazard T e Yes Comment Hazard Type <br />Yes <br />Comme_nt <br />Radiolo ical Solvents <br />_ _ <br />Alpha ❑ Corrosive <br />Were rad levels detected during sampling? If so, record <br />highest readings detected. <br />Beta_ _ Acid <br />❑ <br />- - -- <br />Tritium El <br />Inhalation Base <br />_ <br />Be IliumR@active <br />❑ <br />(powder sample <0.10% Be: slurry, El <br />Oxidizer <br />Authorized Sampler (Print Name): <br />DOUG VILLELA <br />rized Sampler (s' <br />liquid, or solid sample >0.10% Be) <br />Date: 11/17/16 <br />Biologically Active ❑ Ignitable <br />Materials <br />Does the sample contain (Fed. Or State -defined) Acutely or Extremely Hazardous <br />❑ <br />Material? <br />Does the sample contain high explosives? <br />Does the sample contain >10 mg non -primary initiating or secondary explosives, or <br />❑ <br /><25% high explosives b mass? - <br />ENTAL HEA <br />None of the hazards listed above are present in the sample. <br />-ITCheck <br />Q <br />F= RA RTN4 r KIT <br />here, if WDR is not available. <br />I certify, to the best of my knowledge, that information provided above is accurate and complete. <br />Authorized Reviewer (Print Name): <br />Authorized ewer ature): <br />CHAD DAVIS <br />Date: <br />11/17/16 <br />For Sample 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 />contamination? <br />Were rad levels detected during sampling? If so, record <br />highest readings detected. <br />Beta/gamma (cpm) BKG (cpm) <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 />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 />rized Sampler (s' <br />e): <br />_ <br />Date: 11/17/16 <br />_� <br />A612 RADIONUCLIDE INVENTORY CONTROL AND SAMPLE ACCEPTANCE <br />Prior to transporting samples to A612 facility the WSAP Coordinator must com leted the section below <br />Does the total activity for this set of <br />samples exceed 1 uCi: WSAP Coordinator (signature): Date: RHWM COC #: <br />❑ Yes ❑ No 11/21/16 20617 <br />If yes, enter sample into Rad <br />inventory. Total activity: <br />WCG 0152 Effective Date: 10/06/16 <br />See WIC 153 Expiration Date: 10/06/19 <br />I <br />