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Orlando - Service Request Form  
 
 
 
 
 
 
 
 
Service Requested  
     
 
 * Denotes A Required Field
 
STATEMENT OF TRANSFER OF RADIOACTIVE MATERIALS
  1. I accept responsibility for the physical security, safe handling, and transportation of the radioactive material(s) listed below.
  2. 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.
  3. I will comply with and insure that all persons, including observers, comply with applicable safety rules and regulations.
  4. I understand that source transfers can only be executed to entities explicitly licensed to possess the radioactivematerial(s) listed below.
  5. 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 or fax us a copy of your Radioactive License to (407) 246-6518 **
** Please comply with Federal DOT requirements **

 
 
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