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RECEIVED <br />Sample Transportation Determination FEB 0 9 2017 <br />Section I <br />Requester Alexander Blane-Zimbera Phone # 22549 ENVIRONMENTAL HEALTH <br />Requisition # / Sample ID W356456 DEPARTMLNT <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 />--- <br />containers � Weight - <br />❑ Liquid ® Solid (in ❑ Swipe <br />- _ - grams) <br />— <br />500 mL glass jar(s) <br />0 <br />0 <br />01 <br />0 <br />0 <br />- <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 Blane-Zimberg Date 11/21/16 <br />Signature <br />Section II (WSAP Coordinator - complete and return to Requester if not DOT regulated) <br />DOT Regulated? ❑ Yes No <br />Determined by (Print) AAV14S Date <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 I Cargo / Limited Qty Pack. Instruction Max Net Qty <br />Special Provisions <br />Packaging <br />❑ Rad Info. Attached <br />COC # 6 <br />WCG 0140 <br />See WIC 153 <br />ERG # <br />Effective Date: 10/06/16 <br />Expiration Date: 10/06119 <br />