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WNAP Client Sample ID <br />pO " Sample Hazard Assessment W356456/ <br />0 Q00280983 <br />Rev. 2 <br />- This form is required for all samples <br />Required Radioactivity Information <br />Qualifying Constituents <br />No <br />_ _ Hazard T_ype <br />Yes <br />_ _ Comment <br />Hazard Type <br />Yes <br />Ra dio/ ical <br />Solvents <br />Were rad levels detected during sampling? If so, record <br />highest readings detected. <br />_Alpha — <br />Beta/gamma (cpm) BKG (cpm) <br />Alpha (cpm) BKG 0(cpm) <br />Dose mR/hr <br />Corrosive <br />Beta <br />- <br />Does the total activity exceed 1 microCurie? <br />Acid <br />❑ <br />- _ <br />Tritium <br />IT <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 />A oriz Sampler ig <br />Inhalation <br />Base <br />_ <br />Beryllium <br />Reactive <br />s.. <br />(powder sample <0.10% Be; slurry, <br />❑ <br />Oxidi, <br />liquid, or solid sample >0.10% Be) <br />Biologically Active <br />❑ <br />Ignitable <br />❑ <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 by mass? <br />-_ <br />7None of the hazards listed above are present in the sample. <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 />Authorized Reviewer (Print Name): <br />Authorize fewer (Si re): <br />Comment <br />FEB 0 9 2017 <br />ENARTME-ENT <br />CHAD DAVIS (�� i Date: 11/17/16 <br />For Sampler Use Only <br />Required Radioactivity Information <br />Yes <br />No <br />Comments <br />Is / are the samplespotentially radioactive? <br />❑ <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 samples 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 />A oriz Sampler ig <br />to ): <br />Date: 11/17/16 <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): Date: RHWM COC #: <br />❑ Yes ® No 11121116 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 />