ML20034E459
Text
tfltti5'fso'N SONGS RADIOLOGICAL SURVEY tftti5"fso'N A,1 NJ1.1,,.1,~n/l-°<.HifJ,V.1U;,~"'"
,lo l/)U/JNIN/UJ,AJl(*UI.C..<'r,,.,1 DATE S f_.!i._j...J..!i TIME e>i:3c,.,,f Page_l_of__!_!i-SURVEY REASON Post-Decon D Pre-Job SURVEY NO.
D Routine. __
D Shipment/Receipt MONO.
D Job Coverage D Source/Leak Test REP NO.
D Pwr Entry __ %
[R] Other EQUIP. ID.
Mesa Hand Tools. Lot numbers #1 through #137. SPA-8 background <2000 cpm, 2-1 background 40-60 cpm. Visual check for magenta paint, tri-foils, etc. performed on all tooling except for new items. 10%
indirect survey of tooling was performed by direct frisk. All tooling including cabinets and storage boxes were checked with SPA-8. No counts above background were detected, No magenta painted items were found.
SMEARS MASSLINNS NO.
[3-y a
NO.
[3-y a
1 16 2
17 3
18 4
19 5
20 6
21 7
22 8
23 24 25 SURVEY CLASS D Trend Pt.
D Component D Boundary
[XI General Area D Individual SURVEY DESCRIPTION: Direct/Indirect release surve Mesa Tools/Equipment REMARKS:
Material release survey in accordance with N N #202803980 Instruments used Serial No. I '1;1'7 1.!i~{C't1~ -----
TECHNICIAN SURVEY TYPE R.Haskins/D.Ginn D Shutdown (S/D)
DATES I '1 /J.j_
TIME P8'1t> *- )IJ,t>t> Page_d__of___li_
SURVEY REASON Post-Decon D Pre-Job SURVEY NO.
D Routine __
Shipment/Receipt MONO.
[] Job Coverage D Source/Leak Test REP NO.
D Pwr Entry __ %
~ Other EQUIP. ID.
Mesa Tools, Drills and Harnesses. Lot numbers #148 through #286. SPA-8 background <2000 cpm, 2-1 background 40-60 cpm. Visual check for magenta paint, tri-foils, etc. performed on all tooling except for new items. 10% indirect survey of tooling was performed by direct frisk. All tooling including cabinets and storage boxes were checked with SPA-8. No counts above background were detected, No magenta painted items were found.
SMEARS MASSLINNS NO.
[3-y a
NO.
[3-y a
1 16 A
2 17 3
18 C
4 19 D
5 20 E
6 21 F
22 8
23 9
24 10 25 11 12 13 14 15 SURVEY CLASS '0 Trend Pt.
0 Component D Boundary
[XI General Area D Individual SURVEY DESCRIPTION: Direct/Indirect release surve Mesa Tools/Equipment REMARKS:
Material release survey in accordance with NN #202803980 APPROVED BY Print Form Number 1_S_ig,,,_n--+~-~-'-----.-----:----. scE HP (2/3) 1259-1000 Approval REV. 3 09/07
rt:li~TWs'o"N SONGS RADIOLOGICAL SURVEY t:)m5Tso'N DATE K' /!f_j_j_j_
TIME O$Ho** 1/Jtli) Page__l_of__li_
UNIT SURVEY REASON Post-Decon O Pre-Job SURVEY NO.
AREA N D Routine___
D ShipmenVReceipt MO NO.
SMEARS MASSLINNS
._E_LE_V ____ -*
D Job Coverage D Source/Leak Test REP NO.
NO.
13-y a
NO.
13-y a
NO.
i.,:R:..:;O:..;O::.:.M:.:..1--_).!....iD...i....P;....;w:.:.;,r..::E.:..:..:nt~ry;;;;;==;.;.;%;..._~* ~0;;.::th:.:.::e::..r======a......J..::E:..::Q:..::U.:.;.IP..:.... l:.::D.:........J.. ___
N......:...J.:....:A ___
-J.. __
,.--i 1 16 A
l---f-1.---1---1--++---+---1--1-+---l---1 2
17 B
Mesa Cabinets, Tool, Flammable. Lot numbers #287 through #309. SPA-8 background <2000 cpm, 2-1 3
18 C
19 D
20 E
1--l---\\---l----1---1--\\---1-- background 40-60 cpm. Visual check for magenta paint, tri-foils, etc. performed on all tooling except for 4
1--1----1---J.---1---1-----\\---1----+
new items. 10% indirect survey of tooling was performed by direct frisk. All tooling including cabinets and 5
- ---'---'--l----1---1----'
21 F
storage boxes were checked with SPA-8. No counts above background were detected, No magenta 6
1--l---<
22 painted items were found.
7 1--1------\\-1---+----1---\\
N 8
23 9
24 10 25 11 12 13 14 15 SURVEY CLASS O Trend Pt.
0 Component D Boundary
[XI General Area D Individual SURVEY DESCRIPTION: Direct/Indirect release surve Mesa Tools/Equipment REMARKS:
Material release survey in accordance with NN #202803980 Model
.5*
Serial No. 1 r,r11 :2SB'r7'il TECHNICIAN SURVEY TYPE Print R.Haskins/0.Ginn D Shutdown (S/D)
Sign R.. ~
Reference Number S0123-Vll-20.9 Print Form Number
,_S__,ig"-n-1-__,,__ _ _,__,__ __ _, scE HP (2/3) 1259-1000 Approval o ime:/ 5'..7c REV. 3 09/07
~iti5'fs'o'N SONGS RADIOLOGICAL SURVEY
~ED'fso'N DATE_§j_:J_j..!_!j_
TIMEOS3c> *-/~M Page~of.J.i_
--~*11~~'.:~(l\\"*ltN~/'J>:O/
~--::_:.:llort~)!/.lll<:'.,'.'./'{/'.'.;::LJ0.\\,<'::":.11(1*::_:."~:::~:...* --1-_:__:____:__:___--==:;:::..:==:-===-J_-__:=::::::::=====-_L-~::::;::::==---====-l UNIT SURVEY REASON
_AREA -NA D Routine __
ELEV D Job Coverage ROOM D Pwr Entry __ %
D Post-Decon D Pre-Job D Shipment/Receipt D Source/Leak Test l1J Other SURVEY NO.
MONO.
REP NO.
EQUIP. ID.
Mesa Tools, Rope, Power Cords. Lot numbers #310 through #364. SPA-8 background <2000 cpm, 2-1 background 40-60 cpm. Visual check for magenta paint, tri-foils, etc. performed on all tooling except for new items. 10% indirect survey of tooling was performed by direct frisk. All tooling including cabinets and storage boxes were checked with SPA-8. No counts above background were detected, No magenta painted items were found.
SMEARS MASSLINNS NO.
13-y a
NO.
13-y a
NO.
1 16 A
2 17 B
3 18 C
4 19 D
5 20 E
6 21 F
7 22 8
23 24 25 SURVEY CLASS D Trend Pt.
D Component D Boundary lli] General Area D Individual SURVEY DESCRIPTION: Direct/Indirect release survey Mesa Tools/Equipment REMARKS:
Material release survey in accordance with NN #202803980 Instruments used Form Number i--=-r--4--~-?------1 SCE HP (2/3) 1259-1000 REV. 3 09/07
~tr5"fso*N SONGS RADIOLOGICAL SURVEY lf:lrto'fscrN la tiJ/~1>/t IN /tS'l-11/tJ,qt C0,'N"1
-1* /VJJ.11t< l~lt~~-11/(JN,V. C"'*l'MI D Post-o"econ D Pre-Job UNIT SURVEY REASON SURVEY NO.
AREA D Routine D Shipment/Receipt MONO.
ELEV D Job Coverage D Source/Leak Test REP NO.
ROOM D Pwr Entry __ %
' Other EQUIP. ID.
Mesa Rigging. Lot numbers #467 through #472. SPA-8 background <2000 cpm, 2-1 background 40-60 cpm. Visual check for magenta paint, tri-foils, etc. performed on all tooling except for new items. 10%
indirect survey of tooling was performed by direct frisk. All tooling including cabinets and storage boxes were checked with SPA-8. No counts above background were detected, No magenta painted items were found.
SMEARS MASSLINNS 0
13-y Gross NO.
13-y a
NO.
a NO.
Part.
dpm D'iliJ.
1 16 A
2 17 B
3 18 C
4 19 D
5 20 E
6 21 F
7 22 8
23 9
24 25 D Trend Pt.
D Component Boundary
[X] General Area D Individual SURVEY DESCRIPTION: Direct/Indirect release survey Mesa Tools/Equipment REMARKS:
Material release survey in accordance with NN #202803980 Instruments used Model S ',4-'i/
1.. - I Serial No. I~ *11 'J-5,J't '7'6 TECHNICIAN SURVEY TYPE Print R.Haskins/D.Ginn D Shutdown (SID)
Sign (d,. ~fe-:_ i). Co I rt1v-l Reference Number APPROVED BY S0123-Vll-20.9 Form Number
t]rBYs'oN SONGS RADIOLOGICAL SURVEY rf)E't5'fsc>'N An WJ>t>N 1'1!/"',\\11{1~.\\tt,wr*"T
,W WIM)I< 1¥11/l~,1//0J<lf.("~i,r""}
DATE b I Cf IJ!i TIME OS3o ~ lki>t, Page~of-1.!i_
SURVEY REASON O Routine __
0 Job Coverage ROOM O Pwr Entry __ %
D Post-Decon D Shipment/Receipt D Source/Leak Test
~ Other Pre-Job SURVEY NO.
MONO.
REP NO.
EQUIP. ID.
Mesa Welders. Lot numbers #480 through #509. SPA-8 background <2000 cpm, 2-1 background 40-60 cpm. Visual check for magenta paint, tri-foils, etc. performed on all tooling except for new items. 10%
indirect survey of tooling was performed by direct frisk. All tooling including cabinets and storage boxes were checked with SPA-8. No counts above background were detected, No magenta painted items were found.
SMEARS MASSLINNS NO.
13-y a
NO.
13-y a
NO.
1 16 A
2 17 B
3 18 C
4 19 D
5 20 E
6 21 F
7 22 8
23 9
24 10 25 11 12 13 14 15 SURVEY CLASS D Trend Pt.
D Component D Boundary
[Z] General Area O Individual SURVEY DESCRIPTION: Direct/Indirect release surve Mesa Tools/E uipment REMARKS:
Material release survey in accordance with N N #202803980 1 _____
.:.=_.=..=-:::__:.:__:"--"--'"-"-------" SURVEYTYPE Print R.Haskins/D.Ginn D Shutdown (S/D)
Sign Reference Number APPROVED BY S0123-Vll-20.9 Print Jeff Carey Form Number 1_S----'ig"'---n_, _ _,___-----.H-c-_------,--=---~L scE HP (2/3) 1259-1000 Approval o REV. 3 09/07
l---l,~-I~,'.,1;:::I?:::'.'::~'.... __
S_O_N_G_S_=R_A_D
___ I_O_L_O-=G_I_C...,-.,A_L-.--S_U_R_V--,E_--;Y-:-;--.;;;~~"}~~!?.:~i:!o::;::~:~"-:::-: ---1--D_AT_E-=.6:::;:-::..::/ :'::ff=-=/='
I,..=-' J__TI_M_:E =Ofl==3=o=-=' l.,=--t>t>.J__Pa~g--=e ;:::7=-of='=='-1=-l SURVEY REASON Post-Decon O Pre-Job UNIT SURVEY NO.
D Routine___
D Shipment/Receipt MONO.
D Job Coverage D Source/Leak Test REP NO.
ROOM D Pwr Entry __ %
Other EQUIP. ID.
Mesa Gas Bottle Holders. Lot numbers #510 through #511. SPA-8 background <2000 cpm, 2-1 background 40-60 cpm. Visual check for magenta paint, tri-foils, etc. performed on all tooling except for new items. 10% indirect survey of tooling was performed by direct frisk. All tooling including cabinets and storage boxes were checked with SPA-8. No counts above background were detected, No magenta painted items were found.
SMEARS MASSLINNS ot NO.
13-y a
NO.
13-y a
NO. Gross Part.
dpm (Yili).
1 16 A
2 17 B
3 18 C
4 19 D
5 20 E
6 21 F
7 22 8
23 9
24 10 25 11 12 13 14 15 SURVEY CLASS D Trend Pt.
D Component D Boundary
[XI General Area D Individual SURVEY DESCRIPTION: Direct/Indirect release surve~
Mesa Tools/E uipment BEMARKS:
Material release survey in accordance with N N #202803980 Instruments used Model
.Gi' -'l 2 - I Serial No. I g*17 2.S~(('j'1((
TECHNICIAN SURVEY TYPE Print R.Haskins/D.Ginn D Shutdown (S/D)
Sign Reference Number APPROVED BY S0123-Vll-20.9 Print Form Number
1--~-+g~::~;:=~?=::.:~_S_O_N_G_S~R=-A_D __ I_O_L_O-=Gc:--I C_A----------;L,....S_U_R_V....,...E_Y~...'.:.:.'~'.'.'.'."..'.""}'.";;~?,,~!:!o~::~:......: ---1--D_AT_E..::::jj::;=.-:..=/ 'f==-=I ft:::::::_J__T_IM_E-=c>=~=3=D=*-='/;_J__P~ag::....:e::;=c/,=-of-=I L==-l/
D Post-Decon D Pre-Job SURVEY REASON D Routine __
D Job Coverage ROOM D Pwr Entry __ %
D Shipment/Receipt Source/Leak Test
-Other SURVEY NO.
MONO.
REP NO.
EQUIP. ID.
NIA Mesa Tool Boxes, Cabinets. Lot numbers #584 through #621. SPA-8 background <2000 cpm, 2-1 background 40-60 cpm. Visual check for magenta paint, tri-foils, etc. performed on all tooling except for new items. 10% indirect survey of tooling was performed by direct frisk. All tooling including cabinets and storage boxes were checked with SPA-8. No counts above background were detected, No magenta painted items were found.
SMEARS MASSLINNS 13-y a
NO.
13-y a
NO.
16 A
17 B
18 C
19 D
20 E
21 F
22 23 9
24 10 25 11 12 13 14 15 SURVEY CLASS D Trend Pt.
D Component D Boundary
[XI General Area D Individual SURVEY DESCRIPTION: Direct/Indirect release survey Mesa Tools/E uipment REMARKS:
Material release survey in accordance with N N #202803980 Instruments used Model G' If-- C/
- 2. - l Serial No. I 17 2.';~f/9 '1 TECHNICIAN SURVEY TYPE Print R.Haskins/D.Ginn D Shutdown (S/D)
Sign R., ~
ID, (.;i i,-.1 Reference Number APPROVED BY S0123-Vll-20.9 Print Form Number
,_S_ig~n ____ ~~----......, scE HP (2/3) 1259-1000 Approval REV. 3 09/07
~g:!?.:!:~~~
SONGS RADIO LOG I CAL,_S_U_R_V_E,_Y~,...:;~~:,:,,::'.'.'.".,~?:;::.::.~:~~:~:::::...~ _
1_D_A_T......:::E =.5;:::..:" !='i=l=J!i::::.J..._T_IM_E=f>=6=1o=-=l"=6t>......L.....P......:ag~e:::;=='1=-o-=f =' '1==-1
-**.. *--*-* *-*--,-S-U-RV_E_Y-REASON D Post-Decon D Pre-Job SURVEY NO.
1-----1-~-~-----<
D Routine___
D Shipment/Receipt MO NO.
1-'-==--'-'-=---1----...L"""---l"'-',-----I CJ Job Coverage D Source/Leak Test
>-R_E_P_N_O_. -+------,,~'-'---A-----<
0 Pwr Entry __ %
~-other EQUIP. ID.
Mesa Cabinets, Sheet Metal. Lot numbers #690 through #699. SPA-8 background <2000 cpm, 2-1 background 40-60 cpm. Visual check for magenta paint, tri-foils, etc. performed on all tooling except for new items. 10% indirect survey of tooling was performed by direct frisk. All tooling including cabinets and storage boxes were checked with SPA-8. No counts above background were detected, No magenta painted items were found.
13-y 9
10 11 12 13 14 15 SMEARS MASSLINNS
--G--Hot' 13-y a
NO.
dross Part.
1~--+----l---H......J2'!1....(Yill)_
a NO.
16 A
17 18 19 20 21 22 23 24 25 SURVEY CLASS D Trend Pt.
0 Component D Boundary
[Xi General Area D Individual SURVEY DESCRIPTION: Direct/Indirect release survey Mesa Tools/E uipment REMARKS:
Material release survey in accordance with N N #202803980 Instruments used Model Sf it~ 'd 1- \\
Serial No. I ~1 *7 '1.ii'i"f '7f ----*
TECHNICIAN SURVEY TYPE
,--~----------
Print R.Haskins/D.Ginn D Shutdown (S/D)
Sign J2 * ~t...:_ j), (;; bN.J Reference Number APPROVED BY 80123-Vll-20.9 Print Form Number
DATE _1;- Jj__J.11._
TIMEt>~3t> *- lb~t>
Page_lQ_of_l_L SURVEY REASON D Routine __
D Job Coverage D Pwr Entry __ %
D Post-Decon D Pre-Job D Shipment/Receipt D Source/Leak Test Other SURVEY NO.
14 D0 Oct.-oo--z.__
MONO.
/VIA-REP NO.
NA EQUIP. ID.
Mesa Bottle Racks, Water Tanks, Dumpers. Lot numbers #700 through #709. SPA-8 background <2000 cpm, 2-1 background 40-60 cpm. Visual check for magenta paint, tri-foils, etc. performed on all tooling except for new items. 10% indirect survey of tooling was performed by direct frisk. All tooling including cabinets and storage boxes were checked with SPA-8. No counts above background were detected, No magenta painted items were found.
SMEARS MASSLINNS NO.
13-y a
NO.
13-y a
NO.
1 16 A
2 17 B
3 18 C
4 19 D
5 20 E
6 21 F
7 22 8
23 9
24 10 25 11 12 13 14 15 SURVEY CLASS D Trend Pt.
D Component D Boundary
[XI General Area D Individual SURVEY DESCRIPTION: Direct/Indirect release surve Mesa Tools/Equipment REMARKS:
Material release survey in accordance with NN #202803980 Instruments used Model
~* 'vf-'?
1-1 APPROVED BY Form Number i-~--t--..f---::;;---/'rt----;;-7::::;ci SCE HP (2/3) 1259-1000 REV. 3 09/07
~
...-::.,_I~_*::}_:~-.~~_:: _S_O_N_G_S_R_A_D_I_O_L_O_G_I_C_A_L_S_U_R_V_E~Y __ ~_
.. m,,,_,I_~:i:s_:~-'~ --<-D_A_TE 5-I 3_; J.!:J__
TIME P~)P.. /IJ>t>P Page_ll_of _J.i_
UNIT SURVEY REASON D Routine __
D Job Coverage ROOM D Pwr Entry __ %
D Post-Decon D Pre-Job D Shipment/Receipt D Source/Leak Test l:l'.1-0ther SURVEY NO.
MONO.
REP NO.
EQUIP. ID.
Mesa Ladders, Plywood. Lot numbers #710 through #736. SPA-8 background <2000 cpm, 2-1 background 40-60 cpm. Visual check for magenta paint, tri-foils, etc. performed on all tooling except for new items. 10% indirect survey of tooling was performed by direct frisk. All tooling including cabinets and storage boxes were checked with SPA-8. No counts above background were detected, No magenta painted items were found.
SMEARS MASSLINNS NO.
13-y a
NO.
13-y a
NO.
1 16 A
2 17 B
3 18 C
4 19 D
5 20 E
6 21 F
7 22 8
23 9
24 10 25 11 12 13 14 15 SURVEY CLASS D Trend Pt.
D Component D Boundary IB] General Area D Individual SURVEY DESCRIPTION: Direct/Indirect release surve Mesa Tools/Equipment REMARKS:
Material release survey in accordance with NN #202803980 Instruments used TECHNICIAN APPROVED BY Print Form Number 1_S_ig~n--t-r--=----.-T,1---;;=---i scE HP(2/3) 1259-1000 REV. 3 09/07
~J.~!~."!:~::~~
SONGS RAD I O::......::L__:__0-=-=:.G_I_:::C_A __ L-.-=.-S-=U-=R--V---.-EY---,-c_:'.'..'.:".~~""'~'.'..'.'.:'.'.'!~,1'.:'.:.'.':::~~::'.'.'."::~'...___1
_=.o.:....:.A T.:...=E:=.h::;:::-*::..:=1
~:::':::,
=-=/ J!i=I
- ..L..:...:.Tl.:....:.M=.:E J>='=3P=-/=/.P=t,;,t>::._J_p:__::a~ge~/ 1=.:...::of=f=!.i=-1 D Post-Decon D Pre-Job SURVEY REASON D Routine __
D Job Coverage ROOM D Pwr Entry __ %
D Shipment/Receipt D Source/Leak Test Other SURVEY NO.
MONO.
REP NO.
EQUIP. ID.
Mesa A-Frames. Lot #737 through #744. SPA-8 background <2000 cpm, 2-1 background 40-60 cpm.
Visual check for magenta paint, tri-foils, etc. performed on all tooling except for new items. 10% indirect survey of tooling was performed by direct frisk. All tooling including cabinets and storage boxes were checked with SPA-8. No counts above background were detected, No magenta painted items were found.
SMEARS MASSLINNS 13-y a
NO.
p-y a
SURVEY CLASS D Trend Pt.
D Component D Boundary
[XI General Area D Individual SURVEY DESCRIPTION: Direct/Indirect release survey Mesa Tools/E uipment REMARKS:
Material release survey in accordance with NN #202803980 Jeff Carey Form Number l---"'-------+-J.-~~~--~--1 SCE HP (2/3) 1259-1000 REV. 3 09/07
SONGS RADIOLOGICAL SURVEY f:) Ei5rS07~
,I~ 1/J/IU,~ /~/ti~.\\1/0,~*lLl'.>:."r.t-'>Y DATE.5-l!L).J.!j_
TIME i,g_3c ** 1/..ot>t; Page_Ll_of-1.i_
UNIT AREA ELEV ROOM SURVEY REASON D Routine __
D Job Coverage D Pwr Entry __ %
Post-Decon D Pre-Job SURVEY NO.
D Shipment/Receipt MONO.
D Source/Leak Test REP NO.
Other EQUIP. ID.
Mesa Cargo Container Equipment. Lot #745 through #799. SPA-8 background <2000 cpm, 2-1 background 40-60 cpm. Visual check for magenta paint, tri-foils, etc. performed on all tooling except for new items. 10% indirect survey of tooling was performed by direct frisk. All tooling including cabinets and storage boxes were checked with SPA-8. No counts above background were detected, No magenta painted items were found.
SMEARS MASSLINNS NO.
p-y a
NO.
p-y a
1 16 2
17 3
18 4
19 5
20 6
21 7
22 8
23 9
24 10 25 11 12 13 14 15 SURVEY CLASS D Trend Pt.
D Component D Boundary
[XI General Area D Individual SURVEY DESCRIPTION: Direct/Indirect release survey Mesa Tools/Equipment REMARKS:
Material release survey in accordance with NN #202803980 Instruments used Model v+-i 1-1 Serial No.
TECHNICIAN SURVEY TYPE Print R.Haskins/D.Ginn D Shutdown (S/D)
Sign
- ~/b, t 1 iJ Reference Number S0123-Vll-20.9 Print Form Number 1_S_ig~n-1---f-'--7""9-~----.-..... l scE HP (2/3) 1259.1000 REV. 3 09/07
SONGS RADIOLOGICAL SURVEY
~iti5YSCrN A~ rmw.~ tv/ t~N.,rm.~,tc,:,_.,w.-,
UNIT SURVEY REASON D Post-Decon D Pre-Job SURVEY NO.
D Shipment/Receipt D Source/Leak Test AREi\\ [',J A.. D Routine __
ELEV D Job Coverage MONO.
REP NO.
- ROOM --
D Pwr Entry __ %
Other EQUIP. ID.
Mesa Computer/Telephone Equipment. Lot #800 through #835. SPA-8 background <2000 cpm, 2-1 background 40-60 cpm. Visual check for magenta paint, tri-foils, etc. performed on all tooling except for new items. 10% indirect survey of tooling was performed by direct frisk. All tooling including cabinets and storage boxes were checked with SPA-8. No counts above background were detected, No magenta painted items were found.
SMEARS MASSLINNS Gross Hot NO.
13-y a
NO.
13-y a
NO. _cJJJ_n:i_
Part.
(Yi.NJ 1
16 A
2 17 B
3 18 C
4 19 D
5 20 E
6 21 F
7 22 8
23 9
24 10 25 11 12 13 14 15 SURVEY CLASS D Trend Pt.
D Component D Boundary
[XI General Area D Individual SURVEY DESCRIPTION: Direct/Indirect release survey Mesa Tools/Equipment REMARKS:
Material release survey in accordance with NN #202803980 Instruments used Model Serial No. IS '7 7 2!i"'i/"ll'i!.
TECHNICIAN SURVEY TYPE Print R.Haskins/D.Ginn D Shutdown (SID)
Sign R. ~Ji,,.;.,
C::>11,vvl Reference Number APPROVED BY S0123-VI 1-20.9 Form Number Print
---1--+r~:=.,.....='-----j 1_S_i=gn--+--c,,__-=--cr-----c---1 scE HP (2/3) 1259.1000 Approval REV. 3 09101