Atch 22-APPENDIX 20 Nuclear Gauge Request Form 1.xlsx
XLSX spreadsheet 30 KB Posted
- Attached to
- Nellis AFB Paving IDIQ
- Solicitation number
- FA486125R0006
About this file
This document is an Authorization Form for Bringing Radioactive Materials (RAM) onto Nellis Air Force Base, Creech AFB, or the Nevada Test & Training Range (NTTR). The comprehensive form requires detailed documentation for contractors planning to use nuclear gauges, including submission of a complete package with specific requirements such as a request letter, contract copy, current NRC or state license, training certificates for authorized users, and leak test certificates. Contractors must complete all yellow-marked sections and submit the documentation at least 30 days prior to using nuclear density gauges, with the understanding that authorization may take up to 30 days to process and is valid for 3-6 months.
The form mandates strict safety protocols, including on-site logging of nuclear gauge usage, identification of Radiation Safety Officers, authorized users, and specific device details. Contractors must provide precise location maps, contact information, and agree to potential periodic assessments by the Installation Radiation Safety Officer to ensure compliance with radiation safety practices. The authorization letter does not guarantee base entry, and failure to submit a complete package will result in automatic denial of the request.
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Text version
Authorization Form
| Requesting Authorization to Bring Radioactive Materials (RAM) onto Nellis AFB, Creech AFB, or The Nevada Test & Training Range (NTTR) | |
| Submit to: usaf.nellis.99-mdg.list.99-omrs-sgpb-all-personnel@mail.mil Phone: 702-653-3316 | |
| 1 | What base you will be working on? Nellis/Creech/NTTR/? |
| Name of the Licensee (person or firm proposing to conduct the activities described below): | |
| The final approval letter will be sent to: Attention to (Name & Cell #): | |
| The Email address the approval letter will be sent to: | |
| Full Physical Address/Phone # of Licensee: | |
| Email address of the licensee: |
Author: Author:
| 2 | Contract | Ensure you submit a copy of the contract. |
| Contract Project #: | ||
| Project Name: | ||
| Projected Starting Date: | ||
| Projected Ending Date: | ||
| Type of scope of activities to be performed: | ||
| Project Location: |
Author: Provide: the closest major cross street & Bld#(if any).
Map Link:
Author: Place a MAP Link (google/other) indicate where exactly the equipment will be used (with an arrow). Or place a map on the bottom of this sheet showing the exact location where the equipment will be used, major cross street needs to be shown. If there are more than one location, please ensure you paste more than one map under each others.
Author: Author:
| 3 | Radiation Safety Officer(RSO) | |||
| RSO on site Name and Cell #: | ||||
| Alternate RSO Name /email/Cell #: | ||||
| Safety Monitor Name/email/Cell #: | ||||
| Onsite Project Mgr Name/email/Cell #: | ||||
| 4 | Is a copy of the following A or B attached with your request? | Please make sure you submit this required document. | ||
| A) State of Nevada Dept Of Health Human Sevices health deivision, Bureau of Health care quality and compliance (Nevada License and Authorized Rad Material). | (YES) _______ (NO)____________ | |||
| B) NRC Approval (required only for NTTR/TTR operation) not required for Creech or Nellis. | (YES) _______ (NO)____________ | |||
| 5 | Authorized Users | |||
| Author: Please make sure you submit all their certificates in the same order as in this sheet | Please make sure you submit all their certificates in the pdf file in the same order as in this sheet | |||
| a- Authorized User Name: | ||||
| User's Certification date: | ||||
| b-Authorized User Name: | ||||
| User's Certification date: | ||||
| c-Authorized User Name: | ||||
| User's Certification date: | ||||
| d-Authorized User Name: | ||||
| User's Certification date: | ||||
| e-Authorized User Name: | ||||
| User's Certification date: | ||||
| f-Authorized User Name: | ||||
| User's Certification date: | ||||
| g-Authorized User Name: | ||||
| User's Certification date: | ||||
| h-Authorized User Name: | ||||
| User's Certification date: | ||||
| 6 | Authorization devices | Please make sure you submit all the leak certificates in the pdf file in the same order as in this sheet. Certificates in this sheet should match the one in pdf. | ||
| a-Authorized Device Model #: | ||||
| Authorized Device Manufacturer: | ||||
| Authorized Device Serial #: | ||||
| Swipe Test Date: | ||||
| RAD Sources: | ||||
| Activities: | ||||
| b-Authorized Device Model #: | ||||
| Authorized Device Manufacturer: | ||||
| Authorized Device Serial #: | ||||
| Swipe Test Date: | ||||
| RAD Sources: | ||||
| Activities: | ||||
| c-Authorized Device Model #: | ||||
| Authorized Device Manufacturer: | ||||
| Authorized Device Serial #: | ||||
| Swipe Test Date: | ||||
| RAD Sources: | ||||
| Activities: | ||||
| d-Authorized Device Model #: | ||||
| Authorized Device Manufacturer: | ||||
| Authorized Device Serial #: | ||||
| Swipe Test Date: | ||||
| RAD Sources: | ||||
| Activities: | ||||
| e-Authorized Device Model #: | ||||
| Authorized Device Manufacturer: | ||||
| Authorized Device Serial #: | ||||
| Swipe Test Date: | ||||
| RAD Sources: | ||||
| Activities: | ||||
| f-Authorized Device Model #: | ||||
| Authorized Device Manufacturer: | ||||
| Authorized Device Serial #: | ||||
| Swipe Test Date: | ||||
| RAD Sources: | ||||
| Activities: | ||||
| 7 | License | |||
| Company's RAM License #: | ||||
| Name of the license under: | ||||
| Expiration Date: | ||||
| Please ensure you send the following documents in one pdf file in the same order 1-6 as follows: | ||||
| 1- A request letter from the company (what/where/when/who?) | ||||
| 2- Copy of this spread sheet. | ||||
| 3- Copy of the contract | ||||
| 4*- Copy of the current NRC or Agreement State License. (Working in NTTR ranges requires an approval from the Nuclear Regulatory Commission (NRC)- A signed form 241 is required. OR a copy of the license from an approved state only if your work area is only within Nellis/Creech) | ||||
| 5- Copy of training Certificates for all authorized users listed on this document. Training should be commensurate with the hazard material being used. |
| 6- Copy of a current leak test certificate that meets the requirements of the RAM license. |
| 7- Another copy of this sheet in Excel Format (* need to be sent separately*). |
| 8- The contractor MUST use the "LOG sheet" (see next tab in this Excel Sheet). All yellow marking needs to be completed before emailing the log sheet. Please make sure you follow the proper procedure within the authorization letter that you will be receiving within 30 days or less from the date that this sheet is received. This 30 days may exceed if the required information is not completed. |
| 9- Once you receive your authorization letter, make sure you carry it at all time while you are on base. |
| 10 - Keep in mind your Authorization may take 30 days to be approved by Bioenvironmental Engineering |
| 11- The authorization letter does not mean you have a clearence to enter USAF base |
| 12- The above items along with this excel sheet must be submitted 30 days prior using nuclear density gauge on base. |
| 12- Ensure all the yellow boxes are filled out accordingly. All information will be re-verified. |
| 13- You will receive the approval for 3 or 6 months or up to the swipe sample date whichever is less, the approval can be extended. |
| Failure to submit a complete package containing the aforementioned documents will result in automatic denial of the request. |
| By signing this agreement you acknowledge the Installation RSO may conduct a periodic assessment of your work to ensure contractor personnel are complying with radiation safety practices to prevent exposures to USAF personnel and the general public, as well as, avoiding contamination of government property. |
| Name, Signature &Date: |
| Place your map here below (resize it to fit this frame) |
Log
| 1- This log is required to be kept onsite at all-time PROJECT/Contract #:_______________________________________ | |
| 2- Fill out #1-5 (and email this sheet no less than 24 hours before entering the installation). Make sure you place the Project # in the subject line windows. #1-4 can be empty if unknown, but then it will be filled out accordingly. | Email: usaf.nellis.99-mdg.mbx.99-amds-bio-eng@mail.mil |
| 3- Fill out # 6-9 before leaving the installation. No need to email it when completed. However, this sheet can be requested at any time by the Installation Radiation Safety Officer (IRSO). | During Duty Hours: 702-653-3316 |
After Duty Hours: 702-289-3486
| 4- Name your file in the following format before emailing it to IRSO: Date-ProjName-ProjNumber with attention in the subject line: IRSO Project/contract# | |||||||||
| Nellis AFB/Creech AFB/NTTR (Circle one) RAM UTILIZATION LOG | |||||||||
| RAM Use Location: | Company: | Project: | |||||||
| Event | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 |
| Operator (Full Name) | Model | Serial Number | Calibration Date | Projected Date &Time Entering Base | Actual Date & Time Entering Base | Actual Date & Time Exiting Base | Time Source Removed from Shielding | Time Source Returned to Shielding | |
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File details come from the government source that posted it. Updated .