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RECEIVED <br /> DEC 04 2015 <br /> Client Sample ID <br /> C9) <br /> •,; ENVIRONMENTAL 8276 Machine <br /> Sample Hazard ASS TMENT <br /> � Shop <br /> Rev.2 <br /> This form is required"samples <br /> samples <br /> Qualifying Constituents <br /> Hazard Type Yes Comment Hazard Type Yes Comment <br /> Radiological Solvents -ITT- <br /> Alpha Corrosive <br /> Beta Acid <br /> Tritium F1El <br /> Inhalation ❑ Base <br /> Beryllium Reactive [] <br /> (powder sample<0.10%Be;slurry, ❑ OXIdIZ@r <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? T <br /> Does the sample contain ?10 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 a accurate and complete. <br /> Authorized Reviewer(Print Name): Authorize fewer Signatu ): <br /> CHAD DAVIS Date: 11/17/15 <br /> For Sample Use Only <br /> Required Radloactivi Information Yes No I Comments <br /> Is 1 are the sample(s)ppotentially radioactive? If no, ski 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 mRfhr 30 cm 1 ft)? ❑ El <br /> Does the total activity exceed 1 microcurie? ❑ Q <br /> Comments: <br /> I certify, to the best of my knowledge, that information provided above is accurate and complete. <br /> Authorized Sampler(Print Name): A on d Sampler <br /> DOUG VILLELA gate: 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 Coordinat ignature): Date: RHWM CDC#: <br /> ❑ Yes [V No 11/17/15 20219 <br /> If yes, enter sample into Rad <br /> inventory. Total activity: <br /> WGS 0152 Expiration Date: 712116 <br />