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WXA1? <br />A- <br />Rev. <br />Sample Hazard Assessmeiff 8 c 9.201 <br />2 ENVIRnKmAr=KITAl <br />Client Sample ID <br />T1,T2,T3,T4 <br />This form is required for all samp%ii-1-illi I+� <br />Qualifying Constituents <br />Hazard Type Yes Comment <br />No <br />Hazard Type <br />Yes <br />Comment <br />Radiological <br />Solvents <br />Is the exterior of sample containers verified free of <br />contamination? <br />❑ <br />Alpha ❑ <br />Corrosive <br />Were rad levels detected during sampling? If so, record <br />highest readings detected. <br />❑ <br />Beta ❑ <br />Acid <br />❑ <br />❑ <br />Tritium ❑ <br />Inhalation ❑ <br />Base <br />❑ <br />❑ <br />Beryllium <br />(powder sample <0.10% Be; slurry, ❑ <br />liquid, or solid sample >0.10% Be) <br />Reactive <br />❑ <br />Oxidizer <br />El <br />Au orized Sampler <br />Biologically Active ❑ <br />Materials <br />Ignitable <br />❑ <br />Does the sample contain (Fed. Or State -defined) Acutely or Extremely Hazardous <br />Material? <br />❑ <br />Does the sample contain high explosives? <br />Does the sample contain >10 mg non -primary initiating or secondary explosives, or <br /><25% high explosives by mass? <br />❑ <br />None of the hazards listed above are present in the sample. <br />Check here, if WDR is not available. <br />certify, to the best of my knowledge, that information IpLQvided ab accurate and complete. <br />Authorized Reviewer (Print Name): <br />CHAD DAVIS <br />Authoriz Revi r,( ignatur : <br />Date: 5/28/15 <br />For Sampler Use Only <br />Required Radioactivity Information <br />Yes <br />No <br />Comments <br />Is / are the sample(s)ppotentially radioactive? <br />❑ <br />® <br />If no, skip to name and signature. <br />Is the exterior of sample containers verified free of <br />contamination? <br />❑ <br />❑ <br />5/28/15 <br />Were rad levels detected during sampling? If so, record <br />highest readings detected. <br />❑ <br />❑ <br />Beta/gamma (cpm) BKG (cpm) <br />Alpha (cpm) BKG (cpm) <br />Dose mR/hr <br />_ <br />Does the sample(s)exceeds 5 mR/hr 1 30 cm ft ? <br />❑ <br />❑ <br />Does the total activity exceed 1 microCurie? <br />❑ <br />❑ <br />Comments: <br />I certify, to the best of my knowledge, that inform rovided above is accu to and complete. <br />Authorized Sampler (Print Name): <br />DOUG VILLELA <br />Au orized Sampler <br />(s'gnature): <br />Date: 5/28/15 <br />M, <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): <br />Date: <br />RHWM COC #: <br />El Yes ® No <br />5/28/15 <br />20005 <br />If yes, enter sample into Rad <br />inventory. Total activity: <br />WGS 0152 Expiration Date: 7/2/16 <br />