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    AppForm - Gauge 007

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    Alvin Garcia Palanca
    This document is an application for a license to use sealed radioactive sources contained in industrial devices in the Philippines. [1] It requests information such as the applicant's name and contact details, radioactive materials and devices to be used, locations of use, facilities and equipment, radiation safety program, security measures, and waste management. [2] The applicant must certify that the application is prepared according to PNRI regulatory requirements and that the information provided is true and accurate.

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    AppForm - Gauge 007

    Uploaded by

    Alvin Garcia Palanca
    8 views3 pages
    This document is an application for a license to use sealed radioactive sources contained in industrial devices in the Philippines. [1] It requests information such as the applicant's name and contact details, radioactive materials and devices to be used, locations of use, facilities and equipment, radiation safety program, security measures, and waste management. [2] The applicant must certify that the application is prepared according to PNRI regulatory requirements and that the information provided is true and accurate.

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    AppForm.gauge 007

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    This document is an application for a license to use sealed radioactive sources contained in industrial devices in the Philippines. [1] It requests information such as the applicant's name and contact details, radioactive materials and devices to be used, locations of use, facilities and equipment, radiation safety program, security measures, and waste management. [2] The applicant must certify that the application is prepared according to PNRI regulatory requirements and that the information provided is true and accurate.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    8 views3 pages

    AppForm - Gauge 007

    Uploaded by

    Alvin Garcia Palanca
    This document is an application for a license to use sealed radioactive sources contained in industrial devices in the Philippines. [1] It requests information such as the applicant's name and contact details, radioactive materials and devices to be used, locations of use, facilities and equipment, radiation safety program, security measures, and waste management. [2] The applicant must certify that the application is prepared according to PNRI regulatory requirements and that the information provided is true and accurate.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
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    of 3

    NRLSD/LRE-007 Rev2. Feb.

    2007 Page 1 of 3

    PHILIPPINE NUCLEAR RESEARCH INSTITUTE Department of Science and Technology Commonwealth Ave., Diliman, Quezon City APPLICATION OR LICENSE OR USE O SEALED SOURCE CONTAINED IN INDUSTRIAL DE!ICE
    INSTRUCTIONS : To (om)lete this a))li(ation, re*er to %art 17 o* the Code o* %N-I -e3ulations and the (orres)ondin3 -e3ulatory 8uide *or the %re)aration o* A))li(ation *or the 9se o* ,ealed ,our(es Contained in Industrial Devi(es. ,u+mit an ori3inal and two (o)ies o* the (om)leted a))li(ation, with the s)e(i*ied li(ense *ee, and all re1uired atta(hments, to the Nu(lear -e3ulations, :i(ensin3 and sa*e3uards Division o* the %hili))ine Nu(lear -esear(h Institute. %rovide additional sheets i* ne(essary. THIS IS AN APPLICATION OR: '(he(; a))ro)riate +o .. A. New :i(ense 0. Amendment to :i(ense No. <<<<<<<<<<<<<<<<<<<<<<<<< C. -enewal o* :i(ense No. <<<<<<<<<<<<<<<<<<<<<<<<<

    1.

    NA"E AND "AILIN# ADDRESS O APPLICANT Institution/Firm: Address: Tel. No.: Fa No.: !"#ail Address:

    $.

    PERSON$S% TO &E CONTACTED A&OUT THIS APPLICATION Name: %osition/Title: Address: Tel. No.: Fa No.: !"#ail Address:

    &.

    RADIOACTI!E "ATERIAL$S% &.1 Sealed So'rce$(% Contained in Ind'(trial De)ice( 'For ea(h ty)e o* sour(e, su+mit certificate of design approval *or ,)e(ial Form -adioa(tive #aterial, i* a))li(a+le, and *or ea(h sour(e, su+mit initial leak test certificate.. -adioa(tive #aterial '!lement / #ass No.. #odel No. ,erial No. #anu*a(turer #a . A(tivity )er ,our(e 012 'mCi.
    'Indi(ate reference date *or ea(h sour(e.

    ,ealed ,our(e -e3istry No.

    2 1 milli(urie4&5 167 +e(1uerels or &5 #01

    NRLSD/LRE-007 Rev2. Feb. 2007 Page 2 of 3

    &.$ Devi(e

    Ind'(trial #a'ging De)ice ',u+mit (o)y o* radiation )ro*ile/isodose (urve, i* a))li(a+le.. #odel No. ,erial No. #anu*a(turer/ Distri+utor 8au3in3 Devi(e -e3istry No. 9se o* the Devi(e

    =.

    LOCATION$S% *HERE RADIOACTI!E "ATERIAL *ILL &E USED+ ',)e(i*y the lo(ation where the devi(e will +e installed or stored. I* the devi(e is )orta+le, indi(ate the lo(ations where su(h devi(e will +e used..

    >.

    INSTALLATION,CO""ISSIONIN# O

    ACILITIES AND E-UIP"ENT'*or Installed 8au3es ?nly.

    >.1 %ro)osed date >.$ %ersonnel res)onsi+le in installation/(ommissionin3 and )roo*s o* 1uali*i(ations 7. INDI!IDUALS RESPONSI&LE OR RADIATION SA ET. PRO#RA" AND THEIR TRAININ# AND E/PERIENCE 'For -@,?, a((om)lish the Attachment *or the trainin3 and e )erien(e, su+mit o**i(ial a))ointment and duties and responsibilities. A))ointment o* A-@,? is o)tional. -e1uirements o* -@,? and A-@,? are the same. For authorized 3au3e o)erator other than -@,? or A-@,?, the *ollowin3 should +e )rovided: a (erti*i(ation that the )ro)osed o)erator has (om)leted the manu*a(turerAs trainin3 )ro3ram and trainin3 and instru(tions on radiation sa*ety )rin(i)les and )ra(ti(es (ondu(ted +y the -@,?, the trainin3 )ro3ram/sylla+us..

    5.

    ACILITIES AND E-UIP"ENT 'For )orta+le and non")orta+le 3au3in3 devi(e..

    B.

    RADIATION SA ET. PRO#RA" 'Che(; a))ro)riate s)a(e and atta(h in*ormation (alled *or.. Item No. B.1 B.$ B.& B.= B.> B.7 B.5 B.B B.C B.16 B.11 Title Des(ri)tion Atta(hed

    Des(ri)tion o* the ?r3anization Trainin3 %ro3ram %ersonnel #onitorin3 %ro3ram -adiation Dete(tion Instrument's. and -adiation #onitorin3 %ro3ram :ea; Testin3 #aintenan(e Trans)ortation o* Devi(es to Field :o(ations 'a))li(a+le only to )orta+le 3au3es. ?)eratin3 and !mer3en(y %ro(edures Annual Audit o* -adiation ,a*ety %ro3ram Inventories -e(ord ;ee)in3 -e1uirements

    C.

    SECURIT. "EASURES *or radioa(tive materials a3ainst the*t or malevolent use.

    NRLSD/LRE-007 Rev2. Feb. 2007 Page 3 of 3

    16. 11.

    *ASTE "ANA#E"ENT ',u+mit an agreement that the de)leted/s)ent sour(e will +e a((e)ted +y the )rin(i)al su))lier.. ILIN# EE: <<<<<<<<<<<<<<<<<<< O+R+ No.: Date: O+R+ No+0 Date0 <<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<< 11111111111111111111111 11111111111111111111111

    LICENSE EE0 1111111111111111111 1$.

    CERTIFICATION: THE APPLICANT UNDERSTANDS THAT ALL STATE"ENTS AND REPRESENTATIONS "ADE IN THIS APPLICATION ARE &INDIN# UPON THE APPLICANT+ THE APPLICANT AND AN. O ICIAL E/ECUTIN# THIS CERTI ICATION ON &EHAL O THE APPLICANT NA"ED IN ITE" 23 CERTI . THAT THIS APPLICATION IS PREPARED IN CON OR"IT. *ITH THE APPLICA&LE RE-UIRE"ENTS IN THE CODE O PNRI RE#ULATIONS AND THAT ALL IN OR"ATION CONTAINED HEREIN IS TRUE AND CORRECT TO THE &EST O ITS,HIS 4NO*LED#E AND &ELIE .

    ,i3nature ?ver %rinted Name %osition / Title Date

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