Date: _____________ |
Ledger Number: ____________________ |
Preferred Supplier: __________________ |
Department: _______________________ |
Catalog Number: ___________________ |
Authorized User: __________________ |
Quantity in mCi: ____________________ |
Person Making Request: ____________ |
Element & Isotope: __________________ |
Phone Number: ____________________ |
Chemical Form: ____________________ |
Amount in Possession: ______________ |
Assay Date: _______________________ |
Account Number: ___________________ |
Other Specifications: _______________
|
Cost: _____________________________ |
_________________________________
|
Signed: ___________________________ |
***********************************************************************************
- Condition of Package
Okay ___ Punctured ___ Crushed ___ Wet ___ Other _____________________
- ________ GM survey for removable contamination < background ( ____ cpm),
meter # ___________________
- Transport Index (as read on package label) ____________ mR/Hr
Measured Transport Index ____________ mR/Hr @ 1 meter
Measured Radiation Units _____________ (surface mR/Hr)
- Does Packing Slip/Vial Content/Package Label Agree?
- Radionuclide: Yes ___ No ___
- Amount: Yes ____ No ___
- Chemical Form: Yes ___ No ___
- Swipe Results (DOT labeled packages)
LSC #104607
1st region (0-12 KeV) _______________________________ dpm/cm2 2nd region (12-156 KeV) _____________________________ dpm/cm2 3rd region (156-1700 KeV) ___________________________ dpm/cm2
Gamma G5000
Swipe Results: ______ dpm/ cm2 NOTE: The regulatory limit is 22 dpm/cm2
Wipe Results (initials _____________ ) *********************************************************************************************************************
|
Date Order Placed: _____________________ |
Date Received: _____________________ |
By: __________________________________ |
Via: ______________________________ |
Vendor: ______________________________ |
|
PO Number: ___________________________ |
|
Invoice Number: ________________________ |
|
Date Delivered: _________________________ |
|