Hawaii Army National Guard Army Radiation Permit.docx

Hawaii Army National Guard Army Radiation PermitRSO Use Only

ARP No.:___________

Instructions:

This form is to be completed by the requesting organization and approved by the State Radiation Safety Officer (SRSO), State Safety Officer (SSO) and Garrison Commander (GC) prior to any work performed with radioactive materials. The requesting organization should submit the completed form to the SRSO.

PRIMARY AUTHORIZED USER:

TITLE/POSITION:

DEPARTMENT:

TELEPHONE:

E-MAIL:

DATE PREPARED:

List all the isotopes and physical forms for which the permit is being sought (use supplemental sheets if necessary). If your permit is for a sealed source, please contact the vendor to obtain a copy of the Sealed Source and Device Registry certificate and attach it to this ARP. If it is a machine-produced ionizing radiation source please indicate so.

Isotope*

This application is (please check all that apply):

|_|An initial application for this/these isotope(s) |_|A request for a change of approved location for an existing ARP |_|A request for an increase of an isotope approved in an existing ARP |_|A request to add an operator to an existing ARP |_|A request to change the contact information for the primary user in an existing ARP |_|A request to use radioactive material away from original approved site |_|Other:

Please answer the following questions (use another sheet of paper if additional space is required).

1. Briefly explain the intended use of the radioactive materials/equipment.

2. What dates will the radiation source(s) be on the installation?

3. Provide a summary of operating personnel’s professional qualifications.

4. Provide a copy of the applicant’s radiation safety Standing Operating Procedures (SOPs).

5. Provide procedures for notifying the Garrison of reportable incidents/accidents.

6. Depending on the radiation material/source, please provide a valid NRC License, DOE radiological work permit, Agreement State License, or State Authorization.

7. List the building(s) and room(s) where the radiation source(s) will be stored and/or used. Attach a scale floor plan showing these locations and the adjacent non-radiation use areas.

8. Is (are) this(these) location(s) currently an approved radioactive materials use/storage area ?

|_|Yes |_|No If yes, explain.

9. Provide storage provisions when the radiation source is not in use.

10. List the ARP No. for any other approved Army Radiation Permit you have been issued.

11. Describe the experiment/procedure in general terms. Indicate typical activities of radioactive materials to be used, and duration/frequency of use. Describe physical/chemical manipulations or activations intended, if applicable. If any activation products will result from the use of the indicated radioactive material, provide detailed information.

12. Will this material/source be used by persons other than you? |_|Yes |_|No If yes, provide information to identify these persons, their qualifications, and indicate how you intend to ensure that they receive adequate supervision.

13. Are you familiar with the provisions and regulations of the following:

14. If there is (or shall be) possession of survey and monitoring equipment, complete the Survey and Monitoring Equipment Form in Item 20. Itemize specific items owned and/or those which you plan to obtain if this application is approved.

15. Outline the specific plans for the transportation, order, receipt, use, and storage of radioactive material(s). Specify the records that will be kept.

16. Outline the specific plans for storage and disposal of radioactive waste (if any). Specify the records that will be kept.

17. Describe arrangements that have been made with the Radiation Safety Officer with respect to personnel monitoring requirements.

|_| There is (or shall be) personnel monitoring. A Dosimetry Form is completed in Item 21. Include any additional information that is important regarding personnel monitoring.

|_| Personnel monitoring is not needed (state why).

18. Outline the plans for the orientation of assistants, staff, students, or visitors with respect to radiological safety in general.

19. Describe any storage facility(ies) for the radioactive material(s) and outline plans to secure isotope(s) and contaminated waste from use or possession by unauthorized personnel, or to prevent accidental loss.

20. What facilities and protective equipment are available? (Hoods, absorbent paper, labels, tags, shielding, etc.)

21. Describe the precautions that will be taken to test for leakage and/or contamination upon receipt of these materials.

22. What measures will be taken to prevent, detect, and handle a “spill” or “leak”?

23. (For existing users only) Provide any information on training or experience not listed on your AU application that is relevant to this ARP.

24. Please provide any other information that might be helpful to the Radiation Safety Officer and the Radiation Safety Committee.

25.

Radioactive Materials Information Form

Types (α, β, γ, x, n) Isotope On

WKU

License?

*Copy of

SSDR

Attached?

*Note: If your application is for a sealed source, obtain a copy of the Sealed Source and Device Registry certificate from the vendor for the item you are purchasing and attach it to this application.

26. Survey and Monitoring Form

Radiation Survey Meter(s)

|_| Check here if survey meter is not required

27. Dosimetry Form

Personal Dosimetry

Frequency

|_| Check here if personal dosimetry is not required

Visitor/Observer Dosimetry

|_| Check here if visitor/observer dosimetry is not required

Army Radiation Permit Application

I certify that the work performed with the materials requested in this application will be done in accordance with the rules and regulations contained in Army Regulation 385-10 (The Army Safety and Occupational Health Program), 10 CFR 20.1003 Standards for Protection Against Radiation.

Applicant’s Signature:

Date:

Approved by:

Date:

(HING SRSO)

Approved by:

Date:

(93rd CST Commander)

Approved by:

Date:

Date:

(HING J3 DOMS)