Atch 23-APPENDIX 21 Nuclear Gauge Request Form 2.pdf

REQUEST FOR AUTHORIZATION TO BRING RADIOACTIVE MATERIALS (RAM) ONTO NELLIS AFB,

CREECH AFB, OR THE NEVADA TEST AND TRAINING RANGE (NTTR)

1. NAME OF LICENSEE (person or firm proposing to conduct the activities described below)

2. TYPE OF REQUEST

INITIAL UPDATE

3. ADDRESS OF LICENSEE (mailing address or other location where licensee may be located)

4. LICENSEE CONTACT AND TITLE

5. PHONE NUMBER

6. WORK CELL NUMBER

7. FAX NUMBER

8. LICENSEE RADIATION SAFETY OFFICER NAME

9. RSO PHONE NUMBER

10. LICENSEE EMAIL ADDRESS

11. ACTIVITES TO BE CONDUCTED ON THE INSTALLATION

Well Logging Leak Testing and/or Calibrations

Portable Gauges Other (specify):

Radiography

12. INSTALLATION WHERE ACTIVITIES WILL BE CONDUCTED

Nellis AFB

Creech AFB

NTTR

13. PRIMARY CONTRACTOR INFORMATION (Name, Address, City, State, Zip Code)

14. ACTUAL PHYSICAL ADDRESS OF WORK LOCATION (Provide GPS coordinates if known)

15. PRIMARY CONTRACTOR PHONE NUMBER 16. WORK LOCATION PHONE NUMBER

Office

Work Cell

Office

Work Cell

17. DATES FOR REQUEST AUTHORIZATION 18. NUMBER OF DAYS

19. ADD

20. DELETE

21. CONTRACT PROJECT NUMBER

FROM:

TO:

WEEKENDS

YES NO

LIST ADDITIONAL WORK SITES ON A SEPARATE SHEET(S) TO INCLUDE ALL INFORMATION CONTAINED IN ITEMS 12-21 ABOVE

22. PROVIDE A DESCRIPTION OF THE TYPE AND SCOPE OF THE ACTIVITIES TO BE PERFORMED

23. MANUFACTURER:

24. MODEL NO:

25. SERIAL NO:

26. RAM License Number:

27. STATE: 28. EXPIRATION DATE:

29. AUTHORIZED USERS: (Last Name, First Name)

This request for authorization must be submitted to the Installation RSO at least 30 calendar days before bringing RAM onto the installation IAW AFI 40-201. Submission of this request for authorization with less than 30 days notice requires a signed letter by the requesting military organization addressing why the requirements of AFI 40-201 could not be met. The letter must also contain a signed acknowledgement from the requesting organization’s group commander.

In addition to this document the following information must be submitted as a part of the request for authorization:

- A copy of the USAF contract clause describing work to be performed at the installation and the inclusive dates of the work.

- A copy of a current NRC or Agreement State license

- Written authorization for the Installation RSO to conduct periodic assessments 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.

- Applicants holding a RAM license not issued by an Agreement State must also submit an approved NRC Form 241.

- Applicants applying to bring RAM onto NTTR must also submit an approved NRC Form 241.

- A copy of training certificates for all authorized users listed on this document. Training should be commensurate with the hazard/material being used.

- A copy of a current leak test certificate which meets the requirements of the RAM license.

Failure to submit a complete package containing the aforementioned documents will result in automatic denial of the request.

NOTE: If locations, dates, and times cannot be provided as a result of them being undetermined, written or email notification will be provided to the Installation RSO not later than 24 hours prior to bringing RAM onto the installation. The notification must contain the location, date, and time window of the activity is to be performed. Failure to comply with this requirement may result in rescinding of the authorization and notification to the NRC and/or State.

WARNING: False statements on this request for authorization to bring radioactive material onto Nellis AFB, Creech AFB, or the NTTR will result in immediate denial of this application or rescinding of your authorization if already issued. Additionally, notification will be made immediately to the Nuclear Regulatory Commission and/or the Agreement State jurisdictionally responsible for your license. Notification to the

NRC or State may result in civil and/or criminal penalties.