Sample Verification Form

JSC Toxicology Group Toxicologist for STS-112/ Medical Operations Branch ISS-9A: NASA Johnson Space Center, SF23 Hector D. Garcia, Ph.D. Houston, TX 77058 Office: 281-244-5113 FAX: 281-483-3058 Pager: 281-707-4306 Alternate FAX: 281-483-0402 (Notify toxicologist when using alternate fax)

TO: Bill Kalinowski Voice (cell): 303-817-3658 STS-112 PGBA KSC Fax: 321-853-7701 DATE: September 26, 2002 SUBJECT: Verification Step 2 (V-2) Form for As Loaded Sample Materials Listed in the Hazardous Material Summary Table (HMST) for the Plant Generic Bioprocessing Apparatus (PGBA) Experiments

PSRP Policy: The JSC Payload Safety Review Panel allows experiment containers to be loaded only with materials in amounts and concentrations less than or equal to those listed in the final HMST for that container or with materials in the same HMST approved for other containers of the same experiment. The levels of containment of the materials must be consistent with the Hazard Level assigned.

Instructions: For Late Loading: At the time of sample loading, the person supervising or responsible for sample loading shall mark any corrections (including changes in sample labels or locations) legibly on the CGBA/PGBA HMST dated 9/23/2002 2:24:09 PM, pages 7-19 ONLY, initial within the body (not the margins) of the HMST by each material that is loaded, draw a line through materials that are not loaded, and complete and sign the verification form below. The signed form and the marked-up HMST must be faxed to Dr. Garcia immediately after loading and the originals mailed to Dr. Garcia after launch.

V-2 for STS-112/ISS-9A PGBA TEST MATERIAL/CHEMICAL DATA VERIFICATION STEP-2 (As Loaded List)

Check one box below and fill in the blanks.  The materials loaded are exactly as listed in the final HMST for STS-112/ISS-9A CGBA/PGBA dated 9/23/2002 2:24:09 PM, pages 7-19 ONLY.  The materials loaded are consistent with the PSRP policy stated above; deletions/corrections are marked on the final HMST for STS-112/ISS-9A CGBA/PGBA dated 9/23/2002 2:24:09 PM, pages 7-19 ONLY

Signature: Date:

Print Name:

Organization:

Role associated with the Payload Experiment:

Telephone: Fax: