INDUSTRIAL HYGIENE AIR SAMPLE SURVEY FORM Sample Date: 11.26.2013

Laboratory:Navy and Marine Corps Public Health Center
CIHL Detachment Norfolk
1285 West D Street
Norfolk VA 23511-2387 / IH Group: Commanding Officer
Attn: Industrial Hygiene
Naval Health Clinic
3259 Catlin Avenue
Quantico, VA 22134-6050
IH POC: Charles Barnett IH eMail:
Laboratory Report #: / IH Comm/DSN Phone: 703.784.1674 IH Fax:
IH UIC:N00231 Activity:G-4 LogisticsUIC:N45967
Bldg./Hull #:27263Shop Location:Quantico WestShop Code/Name:Bulk Fuel Farm
Employee Name:______SEG: ______Gender: M/F
Last First MI
SSN/FN#/Badge #: ______Job Title:______Mil/Civ/FN: M/C/FN
TAD: Y/N Parent Activity: ______Parent UIC: ______SF600 Sent to: ______
Shift: / 1. Day / Frequency
of
Operation / 1. Daily / 2. 2-3/wk / 3. Weekly / 4. 2-3/mo / Duration
of
Operation / 1. 0-15 min / 2. 15-30 min / 3. 30-60 min / 4. 1-2 hr
2. Eve. / 3. Night / 5. Monthly / 6. 2-3/yr / 7. Yearly / 8. Special / 5. 2-4 hr / 6. 4-6 hr / 7. 6-8 hr / 8. > 8 hr
1 / 2 / 3 / 4

Personal or Area

/ Area / Personal
Worksite / General Office / Field
Distance from Source (feet) / 10’ / -

Boundary

/ In Out No

OPCODE

Operation

/ 1430-1517 / 1437-1517

Task

/ Clerical / Unload and Test
Exposure Origin / Ambient / Operator
Related Shop SOP

Materials/Products Used

/ Gasoline / Gasoline
Ventilation Description (if present) / Windows / Outside

Ventilation Used

/ Yes
Ventilation Meets Specs / Unknown

Respirator Description (if used)

/ None used

Respirator #

/ TC-
Respirator Meets Specs / Yes No Unknown
PPE Description (if used) / Gloves

PPE Adequate

/ Yes No Unknown / Unknown
Sample Duration (min.) / 100 / 40
Flow Rate (lpm) / 0.0940 / 0.0937
Volume (liters) / 9.40 / 3.75

Sample #

/ BZ1311-09 / BZ1311-12
Laboratory #
Stressor / CAS# / Concentration/Unit / Concentration/Unit / Concentration/Unit / Concentration/Unit / 8 hr TWA
Gasoline / 8006-61-9
Pre Cal Date: ______PostCal Date: ______Field Calibrated By: ______
1 / 2 / 3 / 4
Field #

Pump Type

Pump Mfg. / SKC / SKC

Pump Model

/ 222-3 / 222-3

Pump Serial #/Name

/ 6.261.32 / 01.122.13
Calibrator Mfg. / BIOS / BIOS

Calibrator Model

/ Defender 510 / Defender 510

Calibrator Serial #/Name

/ 122915 / 122915
Pre Cal Flow Rate (lpm) / 0.0945 / 0.0943
Post Cal Flow Rate (lpm) / 0.0940 / 0.0937
Lower Flow Rate (lpm) / 0.0940 / 0.0937

Media

/ Anasorb CSC / Anasorb CSC

Media Lot/Tube #

/ 2000 / 2000
Media Expiration Date

Time Off

/ 1517 / 1517
Time On / 1430 / 1437
Pump Check(s)
Calculations:
Exposure during the unsampled period is: __ Same as sample period __ Zero __ Other ______
Shift Length: ______Actual Length of Sampled Work: ______Time Course of Events/Comments:
______
Sampler: ______Date Completed: ______/ Sent to Lab By: ______Date Sent: ______
Data Entered By: ______Date Entered: ______/ Received By: ______Date Received: ______
Reviewing IH: ______Date Reviewed: ______
PRIVACY ACT STATEMENT: Authority: 5 U.S.C. 301, Departmental Regulations; 10 U.S.C. 1095, Collection from Third Party Payers Act; 10 U.S.C. 5131 (as amended); 10 U.S.C. 5132; 44 U.S.C. 3101; 10 CFR part 20, Standards for Protection Against Radiation; 29 CFR, Labor Standards; and, E.O. 9397 (SSN). Purpose: This system is used by officials, employees and contractors of the Department of the Navy in the performance of their official duties relating to the health and medical treatment of Navy and Marine Corps members and civilian employees. Use: Information is close-hold and shared with only those with a need-to-know. Supervisory personnel will have access to information concerning their employees. Administrative/web personnel will have access for purposes of maintaining the data base. Disclosure of information is treated as “For Official Use Only – Privacy Sensitive”. Disclosure: Disclosure of the requested information is voluntary; however, if not provided, acceptance of the submitted record may be denied.

NMCPHC 5100/13(REV 11/2009) For Official Use Only – Privacy Sensitive: Any misuse or unauthorized disclosure may result in both civil and criminal penalties.