Laserfiche WebLink
RECEIVED <br /> DEC U 4 21115 <br /> WNAp ENVIRONMENTAL Client Sample ID <br /> •rc TMENT 874 Machine Area <br /> C, Sample Lazard Asst§Vf� ` <br /> Rev.2 <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 ❑ i <br /> Tritium <br /> Inhalation Base <br /> Beryllium Reactive ❑ <br /> (powder sample X0.10%Be;slurry, ❑ Oxldlzer <br /> liquid,or solid sample>0.10%Be) _ ❑ <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 X10 mg non-primary initiating or secondary explosives, or ❑ <br /> <25% high explosives by mass? <br /> 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 abo-vPjs accurate and complete. <br /> Authorized Reviewer(Print Name): Authoriz a wer( ignat ): <br /> CHAD DAVIS Date: 11/17/15 <br /> For Sample Use Only <br /> Required Radioactivity Information_ Yes No I Comments <br /> Is 1 are the sample(s)ppotentially radioactive? M 2 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 ❑ ❑ Beta/gamma (cpm) BKG (cpm) <br /> highest readings detected. Alpha (cpm) BKG (cpm) <br /> Dose mRlhr <br /> Does the sample(s) exceeds 5 mRlhr ft 30 cm 1 ? <br /> Does the total activity exceed 1 microcurie? Ll I ❑ <br /> Comments: <br /> certify, to the best of my knowledge, that information provided above is accurate and complete. <br /> Authorized Sampler(Print Name): Auth i d Sampler(sign <br /> DOUG VILLELA Date: 11/17/15 i <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 /> El YesNo 11/17/15 202'19 <br /> If yes, enter sample into Ralr <br /> inventory. Total activity: <br /> WGS 0152 Expiration Date: 712116 <br />