Laserfiche WebLink
RECEIVED <br /> DEC 0 4 2015 <br /> ENVIRONMENTAL Client Sample ID <br /> Sample Hazard Assesy y,[fPARTMEN 843 Outdoor Work <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 T ❑ Acid ❑ <br /> Tritium ❑ <br /> Inhalation ❑ Base El <br /> Beryllium Reactive [] <br /> (powder sample X0.10%Be;slurry, ❑ Oxidizer <br /> liquid,or solid sample>0.10%Be xzer ❑ <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 /> a25% high explosives by mass? <br /> None of the hazards listed above are present in the sam le. <br /> ET—Check here, if WDR is not available. <br /> I certify, to the best of my knowledge, tha# information provided ao&opis accurate and complete. <br /> Authorized Reviewer(Print Name): Authorize viewer Signa e): <br /> CHAD DAVIS Date: 11117115 <br /> For Sample Use Only <br /> Required Radioactivity Information Yes No Comments <br /> Is 1 are the sam les otentiall radioactive? ❑ X 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 mR/hr 30 cm 1 ft ? [_1 [:1 <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): AU�d Sampler(si re): <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 [ No 11/17/15 20219 <br /> If yes, enter sample into Rad <br /> inventory. Total activity: <br /> WGS 0152 Expiration Date: 712/16 <br />