Atch_41_APPENDIX_20_Nuclear_Gauge_Forms_1_ _2.pdf

Submit to: issam.sebaihi@us.af.mil Phone number: 702-653-3316 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 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)

Radiation Safety Officer(RSO)

RSO on site Name and Cell Phone number:

Alternate RSO Name / Cell #:

REQUEST FOR AUTHORIZATION TO BRING RADIAACTIVE

MATERIALS (RAM) ONTO NELLIS AFB, CREECH AFB, OR THE

NEVADA TEST AND TRAINING RANGE (NTTR)

1239914680C Typewritten Text ATTACHMENT 41 - Nuclear Gauge Form 1

Safety Monitor Name / Cell #:

Onsite Project Mgr Name / Cell#:

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:

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:

License Company's RAM License #:

Expiration Date:

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

Name: Signature: Date:

4- Written authorization for the installation RSO to conduct periodic assessments.

Please submit the following 1-6 in one single pdf file in order in pdf file format:

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.

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.

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.

1- The request for authorization to bring radioactive materials (this Form)

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.

- 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 one day prior to bringing RAM onto the installation. The notification must contain the location, date, and time 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.

1239914680C Typewritten Text ATTACHMENT 41 - Nuclear Gauge Form 2

Sheet1