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RECEIVED <br /> DEC 0 4 2015 <br /> WA1� lENVIRONMENTAL Client Sample ID <br /> o� HEALTH DEP RTMENT 875 Machine Shop <br /> Sample Hazard Assessment <br /> Rev.2 <br /> This form is required for all samples <br /> _ <br /> Qualifying Constituents <br /> Hazard T e Yes Comment Hazard Te Yes Comment <br /> Radiological Solvents IJ <br /> Alpha Corrosive T <br /> Beta Acid ❑ <br /> Tritium ❑ <br /> Inhalation Base <br /> Beryllium Reactive ❑ <br /> (powder sample X0.10%Be;slurry, ❑ Oxidizer liquid,or solid sample X0.10%Be) _ ❑ <br /> Biologically Active ❑ Ignitable ❑ <br /> Materials _ I I I _ <br /> Does the sample contain (Fed. Or State-defined)Acutely or Extremely Hazardous EJMaterial? <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 /> certify, to the best of my knowledge, that information provided qibov4kis accurate and complete. <br /> Authorized Reviewer(Print Name): Authori viewe Signa re): <br /> CHAD DAVIS Date: 1111711 <br /> For Sam ler Use Only <br /> Required Radioactivity Information Yes No Comments <br /> Is 1 are the sample(s)ppotentially radioactive? ❑ Z 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 mR/hr <br /> Does the sample(s) exceeds 5 mR/hr @ 30 cm 1 ft)? ❑ ❑ <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): Authorized Sampler(signature): <br /> DOUG VILLELA Date: 11/17/15 <br /> A612 RADIONUCLIDE INVENTORY CONTROL AND SAMPLE ACCEPTANCE <br /> Prior to transporting samples to A612 facili 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 /> ❑ YesNo 11/17/15 20219 <br /> If yes, enter sample into Ra <br /> inventory. Total activity: <br /> WGS 0152 Expiration Date: 70116 <br />