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Sample Transportation Determination, <br />Section I <br />Requester Tony Calhoun Phone # 4-5262 <br />Requisition # / Sample ID T-1, T-2, T-3, & T-4 <br />FEB 6 9 2017 <br />ENVIRONMENTAL HEALTH <br />DEPAFR TIt, ENT <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 />containers ® Liquid ❑ Solid <br />Weight <br />(in ❑ Swipe <br />rams <br />4 40 mL glass vials <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />Total <br />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) Ch vis Date 5/28/15 <br />Signature 4pg�j� <br />Section II (WSAP Coordinator — complete and return to Requester if not DOT regulated) <br />DOT Regulated? ❑ Yes ® No <br />Determined by (Print) Ch avis Date 5/28/15 <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. <br />Special Provisions <br />Packaging <br />❑ Rad Info. Attached <br />COC # 2()00 5 <br />WGS 0140, Expiration Date: 09/08/17 <br />Instruction <br />ERG # <br />Max Net Qty <br />