Atch 26- Nuclear Gauge Form 1.xlsx
XLSX spreadsheet 14 KB Posted
- Attached to
- Nellis/Creech AFB Multiple Award Construction Contract (MACC) Solicitation Federal contract opportunity
- Solicitation number
- FA486119RA001
About this file
This document is a request form for authorization to bring radioactive materials onto Nellis Air Force Base, Creech Air Force Base, or the Nevada Test and Training Range. The form collects information on the licensee, radiation safety officer, authorized users, authorized devices, and license details. Applicants must submit the completed form along with copies of their USAF contract, current NRC or state license, written RSO authorization, applicable NRC forms, user training certificates, and a current leak test certificate at least 30 days prior to using a nuclear density gauge on base. Approval will be granted for three months and can be extended with documentation that all information provided remains valid. False statements on the form will result in application denial or rescinding of existing authorization and notification to the responsible regulatory agency.
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Text version
Sheet1
| REQUEST FOR AUTHORIZATION TO BRING RADIOACTIVE 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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