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H131467 ACCEPTABLE FV 693 <br /> LAWRENCE LIVERMOhr— NATIONAL LABORATORY <br /> _ HAZARDOUS WASTE DISPOSAL REQUISITION ❑ HWM Use Only Page 1 of, <br /> 1.Buildin No: 2. Room No: 3. RMMA: 10.Hazardous Outer Container/Retention Tank ID: Overpack? Scheduled Waste Run Date: Vold Requisition: <br /> Z ❑ YesNo Properties: ❑Yea ONO <br /> ❑DATE: <br /> 4.WAA No: 5.WorkplaceEnd Toxic te: 6.Account No: 72.Outer Container 13.Outer Container Size: Initials/Date <br /> _ � � ❑HWM Waste Run <br /> n/ El r <br /> Gr _ �,�- Type: ❑ 1 gal ❑330 gal ' <br /> 7.Waste Minimization Efforts Practiced During eneration of this Waste? 'MPoD •Ignitable ❑Box ED5 gal El660 gal C3 RTO Off-Site to LLNL ; <br /> ❑Reactive ❑Can ❑ 7 gal ❑750 gal <br /> ❑Yes, Activity Codes(enter up to tour): W W W W Commerclal Shipment / <br /> 11.Waste Form: ❑Carboy <br /> ED 30 gat ❑1000 gal WTO <br /> 1155 gal ❑5000 'gal ❑.Secured Pickup. <br /> Comments: ❑Solid ❑Drum ❑1xlxl.5 ft <br /> ❑85 gal ❑ <br /> Did this Waste Minimization effort begin in current calendar year? 1:1 Yes ❑No quid Tank-Fixed ❑2x4x7 it HWM Feld Pum p�Qut <br /> 8.Profile No: 9.Directorate: Sludge ❑Tank-Portable ❑4x4x7 ft F: <br /> ❑Slud ❑HWM Generated-Waste , <br /> H P � ~ ❑Gas Other: Other: /bgal <br /> cu ft ❑'Sewer DATE <br /> 14.ITEM 15.AQUEOUS ONLY 16.ANALYSIS 17.SOURCE 18.CHEMICAL/PHYSICAL DESCRIPTION 19.QUANTITY <br /> NO. . SAMPLE NO. CODE per Item <br /> H Normality amount units <br /> Qel Prom nad,-- <br /> I r® <br /> A Ann <br /> --- <br /> For RMMA Waste Normality Required if pHs 2 or pH i 12.5 USE CONTINUATION FORM FOR ADDITIONAL 17-EMS <br /> 20.Was the waste kept isolated from -any operation that could have 22.Describe other controls used to prevent radioactive contamination: <br /> produced radioactive contamination 23.1 certify,to the best of my knowledge,that the information provided on this requisition is correct.I understand that I may be liable to State and Federal prosecution by intentionally <br /> (using a glove box,vent hood,etc.)? providing false information. <br /> Yes❑ No❑ <br /> (If no.full rad analysis required) Generator Name(Print-Last,First): L-Code: Ext.: Inspected by HWM(Pr t Name=Last,First): Ext.: <br /> 21 Was the waste exposed to particle er / L5 A: , 8?-7 T,5-2140 j <br /> be,m,s capable of inducing radioactivity Signature Employee No. Date: Ignatu ♦ Employee No.: Date: <br /> by rt,aivalion? Yes(] No[.J <br /> L (If yes,full rad analysis required) 3 Z1 91/ Z l 7p <br /> ITEM RCH RCH P Origin Form EPA NO. DTSC NO. MSDS NO. Hazardous Properties Handling Code: By: <br /> Prefix Code Code <br /> T C I R <br /> Date: Loc: <br /> 2 f ❑ ❑ -- <br /> ❑ ❑ 0 ❑ Chemical Compatibility Code: <br /> U L <br /> DOPart'ent Generating W <br /> El E—] IDa e: <br /> ❑ El <br /> Re n Approval:( nature <br /> r, ❑ ❑ Employee No.: Date: _ <br /> LL 53.1-4$,r{rv.3413) ?6tt0-0302 �— -- <br /> White—HWM Copy <br />