Radioactive Material Declaration Form - Radioactive Waste Manual
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1
2Radioactive Material Declaration Form
Exhibit to the Radioactive Waste Manual (RWM)
RADIOACTIVE MATERIAL DECLARATION FORM
For RP use only
For RP use only
Container #: ______________________________
Declaration Number: _________________________________
Location: ________________________________
Old Declaration Number: ______________________ [ ] N/A
Complete this form in full. RP cannot accept the waste/material if this form is not filled out completely and properly. Call x2823 if you have questions.
A. Item Description:
[
] Special Project
[
] Accelerator Equipment Upgrades/Replacement
Generation
Process:
[
] Facility Upgrades/Changes
[
] Emergency or One-Time Cleanup Operations
[
] Remediation/Excavation
[
] Decommissioning & Decontamination
[
] Other (please describe): ___________________________________________________________
Generation location/system:
Account #:
Destination:
[
] RAMSY
[
] Other: __________
B. Waste Properties, Characteristics, Constituents
3
Waste Volume:
(ft
, liters) circle one
Attach documentation: SDS, manufacturer specifications, analytical results, process knowledge collection documents which
further describe the item’s materials of construction and/or function.
Physical
pH:
[
] Solid
[ ] < 2
State:
[ ] > 2 but < 12.5
[
] Solid w/freestanding or absorbed liquid
[ ] N/A
[ ] > 12.5
[
] Liquid (If liquid, indicate if the liquid is:
o
Flashpoint:
[
] Single Layer
[
] < 140
F
o
o
[
] Multi-layer
[
] > 140
F but < 200
F
o
[
] Gas
[
] N/A
[
] > 200
F
Characteristics: Asbestos
Metal Content:
Content:
[
] Corrosive
[
] Friable
[
] Aluminum
[
] Chromium
[
] Nickel
[
] Other (List)
[
] Ignitable
[
] Non-Friable
[
] Antimony
[
] Cobalt
[
] Selenium
[
] Reactive
[
] None
[
] Arsenic
[
] Copper
[
] Silver
[
] Radioactive
[
] Barium
[
] Iron
[
] Stainless Steel
PCB Content:
[
] Toxic
[
] Beryllium
[
] Lead
[
] Thallium
[
] > 5 ppm
[
] Brass/Bronze
[
] Mercury
[
] Vanadium
[
] < 5 ppm
[
] Cadmium
[
] Molybdenum
[
] Zinc
[
] None
[
] None
[
] Friable, powder, or finely divided metals and metal compounds (list) :
Composition
[
] Batteries
[
] Cloth
[
] Paint
[
] Rubber
[
] Wood
[
] Cardboard
[
] Concrete
[
] Paper
[
] Soil
[
] Other (describe):
[
] Circuit board
[
] Glass
[
] Plastic
[
] Solder
Constituent:
Volume % (range):
Constituent:
Volume % (range):
12/5/2013 (form date)
SLAC-I-760-2A08Z-001 (RWM number)
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