4._N3B-Form-2120_Beryllium_Release_Fillable_Form__DRAFT.pdf

N3B-Form-2120

Beryllium Release Forms Released From

TA: Bldg.: Room or Area:

Name: Z No.: Org.: Phone:

Released To TA: Bldg.: Room or Area:

Name: Z No.: Org.: Name:

Organization and Address if not N3B: (use comma to separate lines if needed)

Release Details Item Description (NO CLASSIFIED INFORMATION)

Surface contamination level determined by (check all that apply):

Sampling (CTS Survey ID#: or attach results) Approved Cleaning Method (identify method)

Maintained Control of Item Knowledge of Process/History (attach or provide justification in comments) Recipient commitment to implement controls confirmed by:

Written Commitment (attached) Approved Subcontractor/Supplier Releaser can attest recipient has knowledge of beryllium hazards and will implement controls (N3B only).

If batch release, number of packages:

Type of Release

Free Release of Non-Beryllium Item, NO LABEL REQUIRED. Surface contamination ≤ 0.2 µg/100 cm2 and no potential for internal or hidden contamination; determination has been made that item is not contaminated.

Beryllium Article Release, LABEL AS DIRECTED BY QIHSP. If conditions below are not met, release as a Beryllium Item or Beryllium-Contaminated Item.

Article has been cleaned to reduce surface contamination as low as feasible ( N/A, justify in comments).

Unlikely to release airborne beryllium or spread beryllium contamination > 0.2 µg/100 cm2 under anticipated conditions of use/transport.

Confirmed no potential for loose internal or hidden contamination at time of release.

Beryllium labeling/identification None Required (justify in notes) Beryllium Danger Label Other Label/Documentation: _______________________

Beryllium Item Release, BERYLLIUM DANGER LABEL REQUIRED. Release to other beryllium areas or approved recipients only.

Beryllium item has been cleaned to reduce surface contamination as low as feasible OR Powder or liquid forms of beryllium have been double packaged.

All outer package surface beryllium contamination ≤ 0.2 µg/100 cm2.

Confirmed by Sampling (attach results) Confirmed by New, Clean Materials General Release of Beryllium-Contaminated Item, BERYLLIUM DANGER LABEL REQUIRED. Surface contamination ≤ 0.2 µg/100 cm2. Potential internal or hidden contamination.

Responsible Associated Director approval for release to the general public:

Name: Z #: Signature/Date:

Restricted Release of Beryllium-Contaminated Item, BERYLLIUM RESTRICTED RELEASE LABEL REQUIRED.

Surface beryllium contamination ≤ 3.0 µg/100 cm2. Item packaged.

Surface beryllium contamination may be > 3.0 µg/100 cm2. Item double-packaged.

All outer package surface beryllium contamination ≤ 0.2 µg/100 cm2.

Confirmed by Sampling (attach results) Confirmed by New, Clean Materials

Release Approved By (see reverse for comments/notes) Name: Z No.: Org: Phone:

Signature: Title: Date:

DRAFT

RFP-0000297

Instructions for Completing the Beryllium Release Form

The release process in this section applies to items or materials removed from beryllium-contaminated designated beryllium areas or that are used for beryllium operations, and that are being released to the general public, an N3B non-beryllium area, or another DOE facility for non-beryllium use. The release process also applies to beryllium items or beryllium-contaminated items being sent off-site. Refer to P101-21 for definitions and details on release requirements. P101-21 further allows for transfers between N3B facilities under specified conditions.

1. Fill in the information for each section below:

Released From: Location the item is being released from—Contact information for the person/group releasing the item.

Released To: Location the item is being released to—Contact information for the person/group receiving the item. If not N3B, include a mailing address for the contact.

Item Description: Enter a brief description of the item. Include enough detail to clearly identify the item. Description should note any unusual conditions or hazards associated with the item. DO NOT enter classified information (e.g., part numbers). Avoid including UCNI;

mark the checkbox if UCNI is entered. If release is from a controlled area or you are uncertain, a review by a Derivative Classifier (DC) may be needed.

2. Check to indicate how the beryllium contamination level on the accessible surfaces of the item was determined (check all that apply).

a. Sampling is the preferred method. Enter the CTS Survey ID # or attach a summary copy of the sampling results.

b. A cleaning method that has been validated as specified in P101-21 may be used in place of sampling for small items that are processed in a routine manner.

c. Items that have been under constant control of a worker and have no potential for contamination do not require sampling.

d. Knowledge of a process, the history of an item, and the control of the item can be used to support the determination that an item is either contaminated or clean. Describe in comments below or attach a written justification by a Qualified Industrial Hygiene and Safety Professional (QIHSP) or an RM-designated responsible person.

3. Check to indicate how the recipient’s commitment to implement controls to prevent exposure was confirmed.

a. Written commitment is preferred and is required for release outside of N3B (email acceptable).

b. Subcontractor/Supplier control requirements are incorporated into N3B issued contracts (see P101-21).

c. Within N3B, the releaser can attest that recipient has knowledge of beryllium hazards and will implement appropriate controls.

4. If this is a release of a batch of items, indicate the total number of packages.

5. Check and complete one of the boxes on the far left, depending on the type of release. Complete other boxes as applicable.

Free Release of Non-Beryllium Items:

Determination was made that the item is not contaminated. Item may be released from the beryllium area without labels or restrictions.

Beryllium Article Release:

Beryllium Articles (see P101-21 definition) that have been determined to not meet the definition of a beryllium-contaminated item may be released as a beryllium article if based on anticipated conditions of use/transport the article is not expected to release airborne beryllium, spread beryllium contamination, and does not potentially contain loose internal or hidden contamination at the time of release. Otherwise articles/items should be released as Beryllium Items (i.e., it is anticipated the item may not meet definition of article) or Beryllium-Contaminated Items.

Note: Beryllium Articles that have not been used in beryllium-contaminated areas or used in beryllium operations are not subject to release requirements unless otherwise specified by a QIHSP.

Beryllium Item Release:

Beryllium Items (including beryllium materials, see P101-21 definition) may be released from beryllium areas when packaged according to P101-21 and with a Danger Beryllium Label attached. Check box that indicates how the outer package surface was determined to be ≤ 0.2 µg/100 cm2.

General Release of Beryllium-Contaminated Items:

Item has potential internal contamination. Item may be released from the beryllium area with a Danger Beryllium Label attached and recipient commitment to implement controls to prevent exposure. Surface contamination may not exceed 0.2 µg/100 cm2. This release mode is not appropriate for beryllium articles if compliance with this release limit cannot be confirmed. Directorate level approval is required before items with internal contamination can be released to the general public. Release to an approved subcontractor/supplier is not considered a release to the general public.

Restricted Release of Beryllium-Contaminated Items:

Item has potential internal and/or surface contamination. Item may be released from the beryllium area to another beryllium area with a Beryllium Restricted Release Label attached. Item must be packaged according to P101-21. If item has beryllium contamination > 3.0µg/100 cm2, it must be double packaged and the appropriate box on the Beryllium Restricted Release Label checked. Check box on form to indicate how the outer package surface was determined to be ≤0.2 µg/100 cm2.

6. Release is approved by a QIHSP or a RM-designated responsible person working under the guidance of a QIHSP. The release form travels with the item to the intended recipient (not required for free release). Forward a copy of the completed Beryllium Release Form to the Beryllium Program Lead.

Comments/Notes:

DRAFT

RFP-0000297

https://int.lanl.gov/policy/documents/P101-21.pdf