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H135905 <br /> ACCEPTABLE FuR 69A <br /> LAWRENCE LIVERM Y is NATIONAL LABORATORY <br /> I <br /> HAZARDOUS WASTE DISPOSAL REQUISITION HWM Use Only Page t ot_ <br /> 1.Building No: 2. Roo No: 3. RMMA: 10.Hazardous Outer Contalner/Retenuon TenkiD Oyerpaek? scheduled Wast*Run oats: Void Requisition: <br /> ❑ Yes No Properties: QY•a ❑No IJ C] <br /> Toxic <br /> 4.WAA No: 5.Workplace nd D te' 6.Accoun No: , I 12.Outer Container 13.Outer Container Size: ❑HWM Waste Run initlais/D <br /> b ❑Corrosive <br /> Type: ❑ 1 gal ❑330 gal RTO <br /> 7.Waste Minimization Efforts Practiced During Generation of this Waste? io '44 ❑Box ❑ 5 gal ❑660 gai ❑Off-Safe to LLNL <br /> ❑ Reactive ❑Can ❑ 7 gal El <br /> gal 0 m <br /> Comercial Shipment <br /> Oyes, Activity Codes(enter up to four): W W W W ❑30 gal EJ 1000 gal WTO <br /> ----- <br /> 11.Waste Form: El Carboy F-155 gal ED 5000 gal ❑Secured Pickup <br /> olid El Drum 1385 gal ❑1xlx1.5 ft <br /> Did this Waste Minimization effort begin in current calendar year? El Yes El NLiquid Tank-Fixed ❑2x4x7 It ❑HWM Field Pump Out <br /> 8.Profile No: 9.Directorate: ❑Sludge <br /> ❑Tank-Portable F-1 4x4x7 ft HWM Generated Waste� <br /> H P n ❑Gas Other: Other: ���yy.� 9a1 <br /> �/ ❑cu It ❑Sewer DATE:_J_J RSDR#4 <br /> 14.ITEM 15.AQUEOUS ONLY 16.ANALYSIS 17.SOURCE 18.CHEMICAL/PHYSICAL DESCRIPTION 19.QUAN I-ITY <br /> NO. H Normality SAMPLE NO. CODE per.tern <br /> Amount Units <br /> -7 <br /> For RMMA Waste ormality Required if pHs 2 or pH i 12.5 + 11'USE CONTINUATION FORM FOR ADDITIONAL ITEAIS <br /> 20.Was the waste kept isolated from <br /> 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.: t aSt First): Ext <br /> 21.Was the waste exposed to particle ' " <br /> t .y.-. <br /> beams capable of inducing radioactivity Signature: Employee No.: Date: Signature: Employee No.: a Date tis <br /> by activation? Yes❑ No❑ <br /> (If yes,full rad analysis required) ghift <br /> t <br /> Origin Form EPA No. DTSC NO. <br /> ITEM ROH RCH P g MSDS NO He rdous Properties Handling Coda; By: <br /> Prefix Code Code <br /> T C I R <br /> ss, <br /> Date: Loc: <br /> Chemical Compatibility Code: <br /> ❑� a <br /> e rtment a eraUng Waste <br /> HW s Uori,P. <br /> ' ro (S ature) <br /> ❑ ❑ ❑: ❑ tar s:k x, <br /> t s 6 .�4--r ❑". fi❑ E pltoy Y 40.�' T- V., <br /> r r, <br /> LL 5344-B(Rev.3/93) 7600-70302 <br /> White--HWM Copy <br /> t <br />