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Sample Transportation Determination <br />Section I FEB fi 9 2011 <br />Requester Alexander Blane-Zimberq Phone # 22549 <br />Requisition # / Sample ID W356466 ENVIRONMENTAL HEALTH <br />DEPARTNIENT <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 />2 1000 mL amber glass bottled _ 0 <br />1 500 mL poly bottle(s)0 <br />E <br />ral <br />- 0 --- <br />Tota! 0 <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 Blane-Zimberg Date 11/17/16 <br />Signature - .. _� -� - - ---- - - -- - --- - <br />Section II (WSAP Coordinator -- complete and return to Requester if not DOT regulated) <br />DOT Regulated? ❑ Yes �� IR No <br />Determined by (Print) cik"w aA ✓tS to / <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. Instruction Max Net Qty <br />Special Provisions ERG # <br />Packaging <br />❑ Rad Info. Attached <br />COC # a6,6 I <br />WCG 0140 <br />See WIC 153 <br />Effective Date: 10/06/16 <br />Expiration Date: 10/06/19 <br />