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RECEIVED <br /> DEC 04 2015 <br /> W0Ap ENVIRONMENTAL Client Sample ID <br /> a <br /> Sample Hazard Asses �T EPARTMENT 874 DUS Bin <br /> seV.a <br /> This form is required for all samples <br /> Qualifying Constituents _ <br /> Hazard Type Yes Comment Hazard Type Yes Comment <br /> Radiological Solvents <br /> Alpha _ Corrosive <br /> Beta ❑ Acid ❑ <br /> Tritium El _ <br /> Inhalation El Base ❑ <br /> Beryllium Reactive ❑ <br /> (powder sample<0.10%Be;slurry, ❑ <br /> liquid,or solid sample>0.10%Be) Oxidizer ❑ <br /> Biologically Active ❑ Ignitable ❑ <br /> Materials _ <br /> Does the sample contain (Fed.Or State-defined)Acutely or Extremely Hazardous ❑ <br /> Material? <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 /> N None 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): Authorirzm <br /> CHAD DAVIS Date. 11/17/15 <br /> For Sam ler Use Only <br /> Required Radioactivity Information Yes No Comments <br /> Is 1 are the sample(s) potentiallyradioactive? ❑ ® If no, skip to name and signature. <br /> Is the exterior of sample containers verified free of El <br /> contamination? _ <br /> Were rad levels detected during sampling? If so, record ❑ ❑ Betalgamma (cpm) BKG (cpm) <br /> highest readings detected. Alpha (cpm) BKG (cpm) <br /> Dose mRlhr <br /> Does the sample(s) exceeds 5 mRlhr 30 cm 1 ft)? El <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): ized 5ampl gna urej: <br /> DOUG VILLELA Date: 11/17/15 <br /> A612 RADIONUCLIDE INVENTORY CONTROL AND SAMPLE ACCEPTANCE <br /> Prior to transporting samples to A612 facility the WSAP Coordinator must complete the section below <br /> Does the total activity for this set of <br /> samples exceed 1 uCi: WSAP Coordinator(signature): Date: RHWM COC#: <br /> Yes [X No 11/17/15 20219 <br /> If yes, enter sample into Rad <br /> inventory. Total activity: (bE b <br /> WG5 0152 Expiration Date: 712116 <br />