Radiation Contamination Survey Service Recharge Agreement

Recharge Agreement

Principal Investigator____________________________ RUA#______________

Department____________________________ Campus___________________

Lab Supervisor___________ Mailing Address___________ Phone#__________

Billing Contact____________ Mailing Address___________ Phone#__________

Survey Locations

Bldg.& Rm#_________ # of Wipes____ Bldg.& Rm#__________ # of Wipes____

Bldg.& Rm#_________ # of Wipes____ Bldg.& Rm#__________ # of Wipes____

Bldg.& Rm#_________ # of Wipes____ Bldg.& Rm#__________ # of Wipes____

Bldg.& Rm#_________ # of Wipes____ Bldg.& Rm#__________ # of Wipes____

Total # of Wipes_______

Survey Frequency: Weekly___ Monthly___

Budget Authorization

Account Title:____________________________________________________

Account Number: 2 _ _ _ _ _ _ _ - _ _ _ _ _ - _ _

Account Approval:________________________________________________

Signature & Date

OEH&S Representative:___________________________________________

Signature & Date

OEH&S Use Only

Total Wipes per Month:________ X $________/ wipe = $__________ per month

Total Visits per Month:_________ X $________/ visit = $__________ per month

OEH&S Radiation Contamination Survey Service Recharge Agreement

The OEH&S Radiation Contamination Survey Service Recharge Agreement must be completed to initiate radiation monitoring. Your OEH&S eh&s specialist can assist you with survey location selection, map preparation, etc. Your advisor will also determine your survey frequency.

Instructions for completing the OEH&S Radiation Contamination Survey Service Recharge Agreement.

  1. Provide investigator’s identification.
  2. List locations to be surveyed.
  3. Indicate survey frequency.
  4. Provide account information.
  5. Sign and date form.
  6. Attach facility map with wipe testing locations indicated.
  7. Forward to OEH&S.