ENTER LAB DIAGRAM HERE IDENTIFY RELEVANT FEATURES AND LOCATIONS OF SURVEY POINTS REQUIRED FREQUENCY – Room Number(s): Building: Weekly Monthly Key RADIONUCLIDES In Use Eff. Eff. Β- γ Wipe Test Assay System (Beta) Manufacturer: Model #: Serial #: Serial #: Wipe Test Assay System (Gamma) Manufacturer: Model #: Date: / / / / / / / / / / Survey Wipe Test Wipe Test Meter Wipe Test Meter Wipe Test Meter Wipe Test Meter (dpm/100 (cpm, cps, (dpm/100 cm2) (cpm, cps, (dpm/100 (cpm, cps, (dpm/100 (cpm, cps, (dpm/100 cm2) (cpm, cps, Location cm2) or mR/hr) or mR/hr) cm2) or mR/hr) cm2) or mR/hr) or mR/hr) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. Survey Meter: (manufacturer) (manufacturer) (manufacturer) (manufacturer) (manufacturer) (model) (serial #) (model) (serial #) (serial #) (model) (serial #) (model) (serial #) Survey Performed By: (signature) (signature) (signature) (signature) (signature)
ENTER LAB DIAGRAM HERE – IDENTIFY RELEVANT FEATURES AND LOCATIONS OF SURVEY POINTS Room Number(s): Building: REQUIRED FREQUENCY Weekly Monthly Key RADIONUCLIDES In Use Eff. Β- Eff. γ Wipe Test Assay System (Beta) Manufacturer: Model #: Serial #: Wipe Test Assay System (Gamma) Manufacturer: Model #: Serial #: Date: / / / / / / / / / / Survey Location Wipe Test (dpm/100 cm2) (cpm, cps, or mR/hr) Wipe Test (dpm/100 cm2) Meter (cpm, cps, or mR/hr) Wipe Test (dpm/100 cm2) Meter (cpm, cps, or mR/hr) Wipe Test (dpm/100 cm2) Meter (cpm, cps, or mR/hr) Wipe Test (dpm/100 cm2) Meter (cpm, cps, or mR/hr) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. Survey Meter: (manufacturer) (manufacturer) (manufacturer) (manufacturer) (manufacturer) (model) (serial #) (model) (serial #) (serial #) (model) (serial #) (model) (serial #) Survey Performed By: (signature) (signature) (signature) (signature) (signature)
rsc-application-for-approved-location-change.docx