Part II Results of Surveillance Test:

SB 740-95-20

(2) Column b. Month and year of manufacture

Form 984), Part II Results of Surveillance Test:

a. Block 7.

Cite the serial number (where

of light source(s). This may be obtained from the item's

applicable) of each sample item subjected to inspection

radioactive material label.

(3) Column c. Date of conduct of inspection

and/or test.

b. Block 8. Not applicable.

and/or test per TRC-LSR.

c. Block 9. The following shall be cited:

(4) Column d. Notation of "x" in event light

(1) Column a.

Type of light source(s) or

source is physically damaged.

(5) Column e. Notation of "x" in event item

isotope, i.e., tritium (H3), etc. This may be obtained from

radioactive material label is missing.

the item's radioactive material label.

C-3