SUPPLEMENTAL RADIOACTIVE WASTE PROFILE FORM
Generator   Contact Name
Address Phone
  Fax
City E-mail
USEPA ID No. State Zip

DRUM
NO.		 WASTE
TYPE		 CONT
SIZE
(gal)		 WASTE
STREAM
NAME		 NU CLIDE TOTAL
ACTIVITY
mCi		 CONCENTRATION
(As applicable)
uCi/gram  uCi/milliliter

THE ABOVE LISTED WASTE MATERIAL(S) ARE LIQUID SCINTILLATION OR ANIMAL TISSUE, OR WERE GENERATED FROM IN-VITRO OR IN-VIVO LABORATORY TESTING OR RESEARCH ACTIVITIES.


WASTE TYPES:
02. SCINTILLATION VIALS 07. DRY NON-COMPACTED
02P. SCINTILLATION PLATES/PAPERS 07C. DRY COMPACTED
02B. BULK SCINTILLATION LIQUID 07N. DRY NON-COMPACTABLE
03. BACTEC VIALS 08. ANIMAL CARCASS
04. BULK ORGANIC LIQUID 09. SEALED SOURCES
05. BULK AQUEOUS LIQUID 10. LABPACKED CONTAINERS
06. URANIUM/THORIUM COMPOUNDS 99. OTHER (attach description)

AUTHORIZED SIGNATURE
TITLE Date

   

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