Form Rpd-37 - Norm Waste Manifest - Louisiana Department Of Environmental Quality
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1
2Louisiana Department of Environmental Quality
Emergency and Radiological Services Division
P.O. Box 4312
Baton Rouge, LA 70821-4312
Phone: (225) 219-3041 Fax: (225) 219-3154
PLEASE PRINT OR TYPE
1. Page 1 of ____
2. Generator’s NORM Facility ID #
NORM WASTE MANIFEST
1
2
3. Generator’s or Shipper’s
Name and Mailing Address
5. Generator’s General License #
(Check as apply) ٱGenerator ٱShipper
4. Phone (
)
6. Transporter #1 Company Name
8. Transporter #1’s ICC/USDOT/MC #
7. Phone (
)
9. Transporter #2 Company Name
11. Transporter #2’s ICC/USDOT/MC #
10. Phone (
)
12. Designated Commercial Facility Name
14. Facility’s Specific License #
(Check as apply) ٱDisposal ٱStorage ٱDecontamination
13. Phone (
)
If the designated facility is not a commercial facility, complete items 15 & 16 (Check as apply) ٱDisposal ٱStorage ٱDecontamination
15. Facility name (if applicable) and location:
16. Phone (
)
17. Description of NORM waste (e.g., scale, soil,
18.
19.
20.
21.
22.
23.
sludge) or contaminated equipment (e.g., heater
MicroR/
Activity
Number of
Container
Total
Unit
treater, tubulars). Enter US DOT description if
hr
Concentration
Containers
Type
Quantity
Wt/Vol
required.
Reading
pCi/gm
a.
b.
c.
24. Special Handling Instructions and Additional Information
25. Generator’s certification: I hereby declare that the contents of this consignment are fully and accurately described above by proper
shipping name and are classified, packed, marked, and labeled, and are in all respects in proper condition for transport according to
applicable international and national government regulations.
Generator’s Printed Name
Signature
Date
Shipper’s Printed Name
Signature
Date
26. Transporter 1 Acknowledgement of Receipt of NORM
Printed Name
Signature
Date
27. Transporter 2 Acknowledgement of Receipt of NORM
Printed Name
Signature
Date
28. Designated Facility Owner or Operator: Certification of Receipt of NORM
Printed Name
Signature
Date
IF SPILLED IN LOUISIANA CALL THE DEQ HOTLINE at (225) 765-0160.
1
Shipper denotes a decontamination or treatment facility.
RPD-37 (Rev 1/06)
2
Or Shipper’s Specific License #
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