Atch_37_Nuclear_Gauge_Form_1.xlsx
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- Solicitation number
- FA4861-16-R-A100
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Atch 37_Nuclear Gauge Form 1
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Sheet1
| REQUEST FOR AUTHORIZATION TO BRING RADIAACTIVE MATERIALS (RAM) ONTO NELLIS AFB, CREECH AFB, OR THE NEVADA TEST AND TRAINING RANGE (NTTR) | ||
| Submit to: | issam.sebaihi@us.af.mil | Phone number: 702-653-3316 |
| 1 | State what base is your project? Nellis/Creech/NTTR? | |
| Name of the Licensee (person or firm proposing to conduct the activities described below): | ||
| The approval letter will be sent to: Attention to (Name & Cell # of POC): | ||
| Email address the approval letter will be sent to: | ||
| Project #: | ||
| Activity to be conducted on the installation: (Well logging, Radiography, Leak testing and Calibration, other specify): | ||
| Contract | ||
| 2 | Project #: | |
| Contract # (if it is different from Project # if any): | ||
| Project Name: | ||
| Project Location where the equipment will be used (address and building #): | ||
| Link of onsite MAP (google/other) with arrow showing the location where the use of equipment (or attached a picture) | ||
| 3 | Radiation Safety Officer(RSO) | |
| RSO on site Name and Cell Phone number: | ||
| Alternate RSO Name / Cell #: | ||
| Safety Monitor Name / Cell #: | ||
| Onsite Project Mgr Name / Cell#: | ||
| 4 | Authorized Users | |
| 1- Authorized User Name: | ||
| User's Certification date: | ||
| 2-Authorized User Name: | ||
| User's Certification date: | ||
| 3-Authorized User Name: | ||
| User's Certification date: | ||
| 4-Authorized User Name: | ||
| User's Certification date: | ||
| 5-Authorized User Name: | ||
| User's Certification date: | ||
| 6-Authorized User Name: | ||
| User's Certification date: | ||
| 5 | Authorization devices | Only one gauge is authorized to be used at one time. |
| 1-Authorized Device Model #: | ||
| Authorized Device Manufacturer: | ||
| Authorized Device Serial #: | ||
| Swipe Test Date: | ||
| 2-Authorized Device Model #: | ||
| Authorized Device Manufacturer: | ||
| Authorized Device Serial #: | ||
| Swipe Test Date: | ||
| 3-Authorized Device Model #: | ||
| Authorized Device Manufacturer: | ||
| Authorized Device Serial #: | ||
| Swipe Test Date: | ||
| 4-Authorized Device Model #: | ||
| Authorized Device Manufacturer: | ||
| Authorized Device Serial #: | ||
| Swipe Test Date: | ||
| 5-Authorized Device Model #: | ||
| Authorized Device Manufacturer: | ||
| Authorized Device Serial #: | ||
| Swipe Test Date: | ||
| 6-Authorized Device Model #: | ||
| Authorized Device Manufacturer: | ||
| Authorized Device Serial #: | ||
| Swipe Test Date: | ||
| 6 | License | |
| Company's RAM License #: | ||
| Expiration Date: | ||
| Please submit the following 1-6 in one single pdf file in order in pdf file format: | ||
| 1- The request for authorization to bring radioactive materials (this Form) | ||
| 2- A copy of the USAF contract clause describing work to be performed and date of the work. | ||
| 3- A copy of the current NRC or Agreement State License. | ||
| 4- Written authorization for the installation RSO to conduct periodic assessments. | ||
| 5- Applicants holding a license not issued by an Agreement State must submit an NRC form 241. | ||
| 6- Applicants applying to bring RAM onto NTTR must also submit an approved NRC form 241. | ||
| 7- A copy of training Certificates for all authorized users listed on this document. Training should | ||
| be commensurate with the hazard material being used. | ||
| 8- A copy of a current leak test certificate which meets the requirements of the RAM license. | ||
| 1- The above items must be submitted 30 days prior using nuclear density gauge on base. | ||
| 2- You will receive the approval for 3 months, the approval can be extended. | ||
| 3- Proof of documentation of all the information provided below. | ||
| 4- Please make sure you fill in all the yellow boxes accordingly | ||
| Warning: False statements on this request for authorization to bring radio active material onto Nellis, Creech, or NTTR will result in immediate denial of this application or rescinding of your authorization if already issued. Additional, norification will be made imeediately to the Nuclear Regulatory Commisssion and / or the Agreement State Jurisdictionally resposible for your license. Notification to the NRC or State may result in civil and/or criminal penalties. | ||
| Name: Signature: Date: |
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