PWS_Attachment_8_U D.pdf

NATIONAL INSTITUTES OF HEALTH

RADIOACTIVE MATERIAL UTILIZATION AND DISPOSAL RECORD

TOBACCO

0.001

A/S

97001179

C 14

01/01/1969

CAT. NO.

NIH 88 - 1 No. ITEM #

SUPPLIER

NUCLIDE ACTIVITY

2817 Putnam,Israel

USER ID FULL NAME USER ID FULL NAME USER ID FULL NAME

STORAGE LOCATION :________________________________

PERSON(S) DESIGNATED TO USE THIS MATERIAL

USER ID FULL NAME USER ID FULL NAME

ARRIVAL DATE

(NEW DESIGNATED USERS MAY USE THIS ORDER PROVIDED THE AUTHORIZED USER HAS INDICATED APPROVAL BY SIGNATURE ANY WHERE ON THIS FORM.)

ENTER BELOW WHEN ANY MATERIAL IS USED OR DISPOSED IN RADIOACTIVE WASTE CONTAINERS. YOU ARE REMINDED THAT THE NIH RADIATION SAFETY RULES DO NOT PERMIT ANY RADIOACTIVE RELEASES TO THE SEWER .

( TO BE COMPLETED BY USERS ) RECORD OF TRANSFER, USE, AND DISPOSAL OF THIS SHIPMENT

Name Of User User Id Date Of Use

Activity Used (uCi)

I HEREBY CERTIFY THAT THIS MATERIAL IS COMPLETELY USED AND /OR DISPOSED

(SIGNATURE OF AUTHORIZED USER OR DESIGNEE)

(DATE)

RSB, RMCS COMMENTS FROM PACKAGE INSPECTION :

RETURN OR FAX (480-9708) A LEGIBLE COPY OF THIS REPORT TO RADIATION SAFETY, BUILDING 21, AS SOON AS POSSIBLE AFTER THIS MATERIAL IS COMPLETELY USED OR DISPOSED, SO THAT THIS ITEM CAN BE DEDUCTED FROM YOUR POSSESSION INVENTORY. FILE THE ORIGINAL COPY IN YOUR LABORATORY RADIATION SAFETY RECORDS NOTEBOOK AND HAVE IT AVAILABLE FOR INSPECTION IN THE LABORATORY FOR 3 YEARS AFTER THE MATERIAL IS COMPLETELY USED OR DISPOSED.

Date Activity (uCi)

Disposal Act.(uCi)

Date Physical Form, e.g.

(Liq.,Solid,Carcass)

Name & User Id of Person Receiving Material mCi

DISPOSAL TRANSFERS

USER ID FULL NAME

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,Is ra el (2

7)

It em

P ho ne

F O

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ASSAY DATE :______________________

AUTHORIZED USER # :

USED FOR TRAINING OF BREMSTRAULIN - (GLASS VIAL)

002817

COMPOUND NAME : TOBACCO LEAF RESIN 07/07/2014DELIVERY DATE : OLD STORAGEPO # :

FOR QUESTIONS ABOUT THIS SHIPMENT CALL RADIATION SAFETY 301-496-3277