+----------------------------------------+-----------------------------+
| Constituent Assessment (Part A)        |                             |
+----------------------------------------+-----------------------------+
| **Site Information**                   |                             |
|                                        |                             |
| 1\. SWMU/AOC Number:                   |                             |
| [     ]{.underline} 2. Date/Time:      |                             |
| [          ]{.underline}               |                             |
|                                        |                             |
| 3\. RRES-RS Point of Contact:          |                             |
| [     ]{.underline} 4. FMU/Point of    |                             |
| Contact: [     ]{.underline} /         |                             |
| [     ]{.underline}                    |                             |
+----------------------------------------+-----------------------------+
| 5\. Description of the historical      |                             |
| operations of this SWMU/AOC:           |                             |
+----------------------------------------+-----------------------------+
| 6\. Description of the current         |                             |
| operations of this SWMU/AOC (if any):  |                             |
|                                        |                             |
+----------------------------------------+-----------------------------+
| **SWMU/AOC Status**                    |                             |
|                                        |                             |
| 7\. Action/Status to Date (check all   |                             |
| that apply) Date Completed             |                             |
|                                        |                             |
| >  None or Anticipated                |                             |
| >                                      |                             |
| > Field Investigation  Phase I       |                             |
| > Phase II [     ]{.underline}         |                             |
| >                                      |                             |
| > Interim Measures  IM  BMPs         |                             |
| > [     ]{.underline}                  |                             |
| >                                      |                             |
| > Accelerated Cleanup VCA  VCM       |                             |
| > [     ]{.underline}                  |                             |
| >                                      |                             |
| > Other  Monitoring  CMs             |                             |
| > [     ]{.underline}                  |                             |
| >                                      |                             |
| > Report Status  RFI Report  SAP     |                             |
| > [     ]{.underline}                  |                             |
| >                                      |                             |
| >  NFA/DOU --- If checked, supply     |                             |
| > criteria number(s):                  |                             |
| > [     ]{.underline}                  |                             |
|                                        |                             |
| [Comments]{.underline}:                |                             |
+----------------------------------------+-----------------------------+
| **Sample Information**                 |                             |
|                                        |                             |
| Y N                                    |                             |
|                                        |                             |
|   8. Have surface/sediment (depth    |                             |
| less than 12 in.) samples been         |                             |
| collected that reflect current site    |                             |
| conditions?                            |                             |
|                                        |                             |
| > If yes: 1) Attach data.              |                             |
| >                                      |                             |
| > 2\) Include analyte name, value,     |                             |
| > units, location ID, sample ID, SAL,  |                             |
| > depth, and media (soil, tuff, etc.). |                             |
| >                                      |                             |
| > 3\) Please attach existing map that  |                             |
| > shows where samples were taken, if   |                             |
| > available.                           |                             |
|                                        |                             |
|   9. Have surface water samples been |                             |
| collected that reflect site            |                             |
| conditions?                            |                             |
|                                        |                             |
| > If yes: 1) Attach data.              |                             |
| >                                      |                             |
| > 2\) Include analyte name, value,     |                             |
| > units, location ID,                  |                             |
| > filtered/nonfiltered, and flow data  |                             |
| > (if available).                      |                             |
| >                                      |                             |
| > 3\) Please attach existing map that  |                             |
| > shows where samples were taken, if   |                             |
| > available.                           |                             |
|                                        |                             |
|   10. Is data pending? If yes: 1)    |                             |
| List anticipated date data:            |                             |
| [     ]{.underline}\                   |                             |
| 2) Provide as an attachment a list of  |                             |
| COPCs identified in RFI Work Plan.     |                             |
+----------------------------------------+-----------------------------+
| 11\. RRES-WQH Representative:          |                             |
| [     ]{.underline}                    |                             |
|                                        |                             |
| (Print name and title, then sign)      |                             |
+----------------------------------------+-----------------------------+
| **SOP-02.01, R1**                      | **Los Alamos National       |
|                                        | Laboratory**                |
|                                        |                             |
|                                        | **RRES-Remediation          |
|                                        | Services**                  |
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