Radioactive Material Declaration Form - Radioactive Waste Manual Page 2
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1
2Radioactive Material Declaration Form
Exhibit to the Radioactive Waste Manual (RWM)
For RP use only
For RP use only
Container #: ______________________________
Declaration Number: _________________________________
Location: ________________________________
Old Declaration Number: ______________________ [ ] N/A
C. Freestanding and/or absorbed liquid present:
[
] Yes
[
] No
(If yes, complete the following :)
Type of liquid present:
Estimated volume of liquid present
:
(N/A for Ion Exchange Resin)
[
] Water only
[
] Freestanding: ___________ (ml, cup, liter, gal) circle one
[
] Oil (includes oil and water mixtures)
[
] Absorbed: _____________ (ml, cup, liter, gal) circle one
[
] Other (describe):
Sorbent Type:
[
] N/A
Sorbent Amount:
[
] N/A
[
] CHEMSORB
_________________________ (ml, cup, liter, gal) circle one
[
] Other: ___________________
D. Hazardous Waste Classification
(If the hazardous waste classification is unknown, submit form to the RP RWM Group at MS 84
for evaluation – note waste may require sampling and analysis)
[
] Hazardous Waste
(If this block is marked, list the underlying hazards below. Attach all applicable documentation describing the
hazardous waste: e.g., process knowledge statement, MSDS, manufacturer's specifications, sample analysis, Hazardous Waste
Determination Form, etc.).
List Underlying Hazards:
[
] Non-Hazardous Waste
E. Generator’s Certification
[By signing the form, the generator certifies (based on process knowledge or certified records) that all
information is complete and accurate to the best of his/her knowledge. The generator also certifies (based on process knowledge or
certified records) that (1) the hazardous classification of the item is accurate to the best of his/her knowledge and (2) that the waste
meets the acceptance criteria of Chapter 5 of the SLAC Radioactive Waste Manual. By signing the form, the generator also authorizes
the disposal of the waste item.]
Generator Name/Signature:
Dept/Group:
Date:
Ext:
F. Radiological Data
Radiation exposure rate: Contact: _____________mR/h
Cal. Due
30 cm: _____________mR/h
Date
Instrument Type
Serial #
Radioactive contamination:
[
] N/A (Activated only)
2
Internal: _______________dpm/100cm
[
] Unknown
2
(External contamination must be < 1000 dpm/100 cm
)
Remarks/Comments: _________________________________________________________________________________
_____________________________________________________________________________________________________________________________
RP Health Physics Technician Name/Signature:
Date:
Ext:
G. Receiver Name/Signature:
Dept/Group:
Date:
Ext:
12/5/2013 (form date)
SLAC-I-760-2A08Z-001 (RWM number)
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