|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Service Requested |
|
|
|
| |
|
|
| *
Denotes A Required Field |
| |
|
STATEMENT OF TRANSFER OF RADIOACTIVE MATERIALS
- I accept responsibility for the physical security, safe handling, and transportation of the radioactive material(s) listed below.
- I have been formally trained in Radiation Safety to understand the special requirements for the use, safe handling, and transportation of nuclear moisture, density, and asphalt content gauges.
- I will comply with and insure that all persons, including observers, comply with applicable safety rules and regulations.
- I understand that source transfers can only be executed to entities explicitly licensed to possess the radioactivematerial(s) listed below.
- The source(s) involved in this transfer may be accurately described as follows:
|
|
|
|
|
|
|
|
|
| Radioactive Material |
Radioactive Quantity |
|
mCi |
|
mCi |
| Type Instrument |
|
|
|
| |
| Formal Reference |
Radoactive Material Special Form, N.O.S., 7 |
| Identification |
UN 3332 USA DOT 7A |
| Form |
Special Form Sealed Source |
| Category |
Yellow II Label |
| Transport Index |
No more than 0.7 |
| Transform Type |
"A" |
| |
|
| GAUGE DELIVERY: |
|
|
|
|
|
Date In |
| Atlantic Supply |
|
| |
|
| GAUGE PICK UP: |
|
|
|
|
|
|
Date Out |
| Atlantic Supply |
|
| |
|
|
| By submitting the information above, both certified individuals authorizing this transfer assure that the aforementioned material(s) areproperly classified, described, packaged, marked, labeled, and are in proper condition for transportation according to the applicable regulations of the Health Dept. |
|
| **
Please bring over or fax us a copy of your Radioactive
License to (334) 280-2712
** |
| **
Please comply with Federal DOT requirements ** |
|
|
|
