REQUEST_TO_USE_RADIOACTIVE_DEVICE.docx
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- Attached to
- Construct 799 ABS Comm Storage Facility
- Solicitation number
- FA4861-13-R-A012
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Request Use Radioactive Device
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CONTRACT NUMBER: PROJECT NUMBER:
PROJECT TITLE:
The contractor anticipates using equipment containing the following radioactive material:
| |_| | Radioactive material requiring specific licensing under the regulation issued pursuant to the Atomic Energy Act of 1954, as amended, as set forth in Title 10 of the Code of Federal Regulations, in effect on the date of this contract. |
| |_| | Other radioactive material not requiring specific licensing in which the specific activity is greater than 0.002 microcuries per gram or the activity per item equals or exceeds 0.01 microcuries. |
The following pertains to the part(s) of the item(s) which contain radioactive materials:
DESCRIPTION OF MATERIALS:
NAME & ACTIVITY OF THE ISOTOPE:
MANUFACTURER OF THE MATERIALS:
NAME OF LOCAL REPRESENTATIVE:
LOCAL ADDRESS OF LOCAL REPRESENTATIVE:
TELEPHONE # OF LOCAL REPRESENTATIVE:
NAME OF RSO NAMED ON LICENSE:
LOCAL ADDRESS OF RSO NAMED ON LICENSE:
TELEPHONE # OF RSO NAMED ON LICENSE:
STATEMENT OF STORAGE AND SECURITY CONDITIONS IF THE MATERIAL WILL BE STORED ON BASE:
THE FOLLOWING DOCUMENTS ARE ATTACHED AS APPROPRIATE:
| |_| | A copy of the appropriate NRC or Agreement State license to operate/own the radioactive device. |
| |_| | A copy of the operator’s qualifications and/or radiation safety training. |
| |_| | A copy of the safety and health plan. |
| |_| | Copies of the last two (2) leak tests, if appropriate. |
| |_| | Any other information known to the contractor which will put users of the items on notice as to the hazards involved (OMB No. 9000-01070). |
By submission of this notice, the contractor acknowledges that the Base RSO can make periodic checks to ensure that contractor personnel follow radiation safety practices to prevent exposure to AF personnel and avoid contamination of government property.
| SIGNED BY: | DATE: | |
| Signature | Date |
End of Clause
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