Attachment_6_Request_to_Use_Radioactive_Material.pdf

(Your Company Letterhead) Date

Company Name Address

Mr. Wayne Blanco-Cerda Joint Base Ft. Sam Houston RSO 502d ABW/SEG 2250 Engineer St. Bldg 4196 Ft. Sam Houston, TX 78234-5036

Greeting

We are writing this correspondence as a request to use radioactive material, specifically

Troxler and Humboldt Series #### moisture density gauges on Fort Sam Houston

(Camp Bullis and Canyon Lake are covered by JBFSH/RSO, but must be identified if by location if work is to be performed there) for the (Project Name, Contract Number). We have attached a copy of the Air Force/Army Contract describing work to be performed with the official start date and scheduled completion date of the project. We estimate using gauges on the project from (date) to (date).

The following is submitted for your review and approval: (Please edit and format accordingly)

1. Our gauges have been leak tested in accordance with NRC Regulations, and were found to be acceptable. Copies of current leak tests are attached.

2. Attached you will find a copy or our Nuclear Regulatory Commission (NRC)

Form 374, Radioactive Material License.

3. Or NRC Form 241, Report of Proposed Activities in Non-Agreement States with the NRC.

4. And a copy of the Texas Radioactive Material License (TRC Form 12-1). This form must accompany the NRC Form 241.

5. The authorized gauge users list, and certificates of training.

6. Radiation Safety Program to include standard operating procedures (SOP), training program and designation of Radiation Protection/Safety Officer.

7. Your request for written confirmation that the JBFSH/RSO can conduct periodic assessments and has authority to suspend contractor operations believed to be unsafe is also included.

FA301618B0004

Attachment #6

“___(Your Company Name) ___ recognizes that the Joint Base Ft. Sam Houston

Radiation Safety Officer (RSO) is authorized to periodically conduct assessments to ensure compliance with radiation safety practices to prevent exposures to Air Force personnel and to prevent contamination of Government property. Additionally, ___(Your

Company Name) ___ recognizes the authority of the JBFSH/RSO to suspend contractor operations believed to be unsafe.”

If you need additional information please call (Your company RSO @ xxx-xxx-xxxx).

Salutation