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Sample Transportation Determination <br />Section I <br />Requester Alexander Blane-Zimberg Phone # 22549 <br />Requisition # / Sample ID W353384 <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 _ <br />Weight <br />containers ❑ Liquid ® Solid (in ❑ Swipe <br />orams) <br />3 500 mL glass 'a s 1 _0_1 <br />125 mL g lass 'ars) 09' <br />0 <br />0 <br />0 <br />0 <br />0 <br />— - - - - - Total <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) Alexander Slane-Zimber4 Date 11/17/16 <br />Signature <br />Section II (WSAP Coordinator — complete and return to Requester if not DOT regulated) <br />DOT Regulated? ❑ Yes fK No <br />Determined by (Print) Date ( Zl <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 E=NVIRQNMEH:F E 'r <br />ALTFf <br />D`PAPTti EENT <br />Pass / Cargo / Limited Qty Pack. Instruction <br />Special Provisions <br />Packaging <br />❑ Rad Info. Attached <br />COC # �O <br />WCG 0140 <br />See WIC 153 <br />ERG # <br />Max Net Qty <br />Effective Date: 10/06/16 <br />Expiration Date: 10/06/19 <br />