Attachment II - Form RHA-PNC "Radioactive Waste Shipment Prior Notification and Manifest Form"

Form RHA-PHC

(5/80) SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL

Radioactive Waste Shipment Prior Notification and Manifest Form

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See Reverse Side for Instructions

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1. Name and Address of Shipper: :

2. Person Responsible for Radioactive

: Waste Shipment:

: (a) Name

: (b) Title

: (c) Telephone No. ( )

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3. Radioactive Waste Transport :

4. Shipment Identification No.:

Permit No. :

:

:

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5. Location from which waste :

6. Name and Address of Consignee will be shipped: :

:

:

:

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7. Scheduled Date of Departure :

8. Estimated Date of Arrival of of Shipment: : Shipment:

:

:

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9. Carrier: :

10. Type of Transport :

11. Trailer No. and Owner

: Vehicle: : (if available)

: :

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12. Routes shipment will follow in State of South Carolina (Be Specific):

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Manifest Summary

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13. Type Container :

14. Container Spec. :

15. Total No. of

or Cask: : : Containers

: :

: :

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16. Waste Description: Physical and Chemical :

17. Prominent

Form : Radionuclides:

:

:

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18. Total Curies: :

19. Transport Group: :

20. Total Cubic Feet:

: :

: :

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21. Waste Classification:

[ ] Radioactive [ ] Bulk LSA Normal Special Fissile

LSA Form Form

[ ] Radioactive [ ] Limited [ ] Type A [ ] Type A [ ] Class I

LSA quantities quantity quantity

greater and radio- [ ] Type B [ ] Type B [ ] Class II

than active quantity quantity

Type A devices [ ] Large [ ] Large [ ] Class III

quantities quantity quantity

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CERTIFICATION

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I hereby certify on behalf of the above-named shipper to the South Carolina

Department of Health and Environmental Control that the information provided

herein is complete and correct to the best of my knowledge; and that the

shipper has complied with all the provisions as required by Act No. 429 of

1980, the South Carolina Radioactive Waste Transportation and Disposal Act.

Date _________________________________

______________________________________ _______________________________________

Typed Name and Title of Agent of Signature

Shipper

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CONSIGNEE ACKNOWLEDGEMENT

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This acknowledges to the South Carolina Department of Health and

Environmental Control that the above-described radioactive waste

shipment was received.

__________________________________ ____________________________________

Date of Delivery Signature of Consignee or authorized

Agent

____________________________________

Typed or Printed Name and Title

DHEC 802 ( 5/80 )

(Copies of this form may be reproduced locally as needed)