AERB/RSD/NGU-1

Government of India Atomic Energy Regulatory Board

Radiological Safety Division

APPLICATION FOR AUTHORISATION / NO OBJECTION CERTIFICATE TO PROCURE & USE NUCLEONIC GAUGE(S) / ANALYZER(S) / RADIOACTIVE SOURCES

_________________________________________________________________________ (Kindly note : a) This application would be considered by the competent authority for issuance of

authorisation (Licence) for handling radioactive materials, under the Radiation Protection Rules, 1971 (RPR).

For the text of RPR, refer to our website: www.aerb.gov.in b) Attach extra sheets wherever required. c) This form is intended to enable AERB to assess the suitability of the institution to

handle Nucleonic Gauges/ Analyzers, hereinafter referred to as Nucleonic Devices d) The duly completed form should be sent to Director, Radiological Safety Division

(RSD), AERB, Niyamak Bhavan, Anushaktinagar, Mumbai-400094 with necessary documents.

e) Incomplete applications and those without all relevant documents are liable to be rejected.)

__________________________________________________________________________________________

1. (a) Name and designation of the Applicant : [Applicant is the person in whose name the authorisation (Licence) to handle the source may be issued under RPR, and would have the responsibilties of “licensee” prescribed in RPR.] (b) Name and address of the Institution :

Telephone : Fax : Email : 2. Department and location where the nucleonic device(s) containing ionizing radiation sources will be used : 3. Name & Designation of the Head of the Institution [The head of the institution is the person who would have the responsibilities of “employer” prescribed in RPR.] : 4. (a) Whether this application is for a fresh source or for the : Fresh Source / Replacement Source replacement of a source

(b) If it is for a replacement source whether permission for : Yes / No / Not Applicable disposal has been obtained from AERB

5. Name and designation of the individual who is : entrusted with day to day administration of radiation : protection in the department and responsible in case : Telephone No. - Office : of emergency. : Residence :

6. Details of training and experience , if any, of your staff members in handling Radiation Sources:

(Attach Additional Sheets if necessary)

Name

A. B. C. D. E.

Designation

A. B. C. D.

E.

Academic

Qualifications

A. B. C. D. E.

Training in safety, if any,

A. B. C. D. E.

Year of passing

A. B. C. D.

E.

Experience (Nucleonic

Device/Radiation sources used)

A. B. C. D. E.

If there is no individual in your institution with the prescribed qualification, please furnish the following undertaking. Please delete the following undertaking, if not applicable

I hereby undertake to get one of our personnel trained in radiological Safety within one year from the date of issuance of the Authorization / NOC for the procurement of the radiation source.

Signature of Applicant

7. Particulars of Nucleonic Devices for which this application is made

Description &. Model No. of the Nucleonic Device to be procured

A.

B.

C.

Name of the source

A.

B.

C.

Activity Bq / Ci

A.

B.

C.

Number of Nucleonic Devices / Sources

A.

B.

C.

Address of the supplier of the source

A.

B.

C.

Purpose / Application of the Nucleonic Device

A.

B.

C.

Whether the device has been Type Approved by AERB (If ‘Yes’, Ref. And date of AERB Certificate)

A.

B.

C.

Details regarding the Type Approval Certificate issued by the Atomic energy Regulatory Board (AERB), Mumbai may be obtained from the Manufacturer of the device or the vendor. If Type Approval certificate in respect of the device has not been obtained from AERB, Mumbai, the necessary authorisation for procuring the above device cannot be issued. For obtaining the necessary Type Approval, please write to Head, Radiological Safety Division, AERB, Niyamak Bhavan, Anushaktinagar, Mumbai 400 094.

8. Particulars of Nucleonic Devices already in the possession of the institutions __________________________________________________________________________________ Sr. Description Name Activity Number of Address of Purpose/ Installation Ref No. and No. and Model. of of the devices supplier Application location date of No. of source source authorisation Source Bq (Ci) issued by Housing / AERB Nucleonic Device __________________________________________________________________________________

__________________________________________________________________________________

9. Particulars relating to the facility where the source is proposed to be handled:

(a) Layout of the installation (Enclose a site plan, drawn to scale, (size: 275 mm x 200 mm) clearly indicating the occupancies in the immediate vicinity).

(b) Details of facilities for storage of Nucleonic Devices before installation. (c) The height at which the gauge shall be installed, in the case of fixed Nucleonic Devices. (d) Details regarding the storage room and the mode of transport from the storage room

to the site(s) of use, in the case of portable Nucleonic Devices. (e) Copy of the document of registration of the user institution with central /state

Government.

10. (If this application is for procuring a betascope or an XRF Analyzer, please skip this item and proceed to item No. 11.) Whether a radiation survey meter is available in working condition: YES / NO a) If `YES' (Please furnish the following particulars relating to the radiation survey meter) Make :

Model : Sr.No. :

b) If `NO', please furnish an undertaking as given below. (Please delete the following undertaking, if a monitoring instrument is available.)

I hereby undertake to procure a suitable radiation survey meter within one year of the date of issuance of the authorization/ NOC for the procurement of the source for which this application is being made.

Signature of Applicant

11. Whether a copy of the undertaking furnished by the original supplier of the source to take back the disused / decayed source is attached: Yes / No [In the absence of such undertaking, authorisation can not be issued.] 12. We do hereby certify that all the statements made above are correct to the best of my knowledge and belief. 13. We hereby agree to abide by the following conditions of authorization for use of the Nucleonic Devices.

a) The radiation sources will not be used for purposes other than those specified in item 7

of this form. b) The radiation sources will not be moved from the authorised place specified in item 2

of this from. c) Co-operation will be extended by us to any authorised representative of AERB, who

may be deputed to inspect the Nucleonic Device installations in our institution. d) Persons engaged in radiation work, if recommended by AERB, will be provided with

appropriate personal monitoring badges.

e) The radiation sources will not be sold, rented, replaced, transferred or disposed off

without obtaining prior permission from AERB. f) Any change in the information supplied in this form will be immediately intimated to

Head, RSD, AERB. g) The Nucleonic Device installations shall be stored, installed and safeguarded so as to prevent unauthorised operation, removal and theft.

h) Installation / maintenance of the Nucleonic Devices containing radiation source would be done by qualified / trained persons.

i) The details regarding Nucleonic Devices shall be furnished in the Proformas A and B respectively, to Head, RSD, AERB, after receiving and installing the nucleonic

devices, respectively and a status report of all Nucleonic Devices will be submitted to Head, RSD in first week of January and July every year, in the prescribed Proforma-C.

j) Radioactive sources would a never be taken out of the Nucleonic Device. k) The Nucleonic Devices shall be checked for leakage radiation at 5 cm from any accessible point from the source housing once a month and proper reports will be maintained.

l) The Nucleonic Devices shall be switched 'OFF' prior to undertaking any maintenance repair work in and around the vicinity of the installations and a Log-book in respect of use / ON-OFF would be maintained

m) All recommendations made by AERB from time to time, in the interest of radiological safety shall be duly implemented.

n) Decayed / unwanted radiation sources shall be returned to the original supplier and would be replaced / disposed off in accordance with stipulated procedures. Head, RSD, AERB would be contacted for advice regarding replacement / safe disposal. The expenditure for source replacement / decommissioning and will be borne by our institution.

o) Any incident such as fire, accident, theft, damage etc., involving ionising radiation source and / or Nucleonic Devices shall be reported to Head, RSD, AERB, immediately.

p) An emergency response manual prescribing specific action plans to identified persons for specific emergency scenarios will be prepared and all the concerned persons will be made familiar with their responsibilities.

14. Additional information, if any: Signature & Name of applicant: [ Person in whose name the authorisation (licence) is required to be issued] Signature, name and designation Place: of the Head of the institution. Date: [Employer]*

SEAL OF THE HEAD OF THE INSTITUTION * Ref: RPR,1971 ( www.aerb.gov.in)

CHECKLIST TO BE MARKED PRIOR TO SUBMISSION OF PROFORMA

AERB/RSD/NGU-1/2003 TO HEAD, RSD, AERB.

(It should be ensured by the applicant that the to each of the check points listed below should be properly marked prior to forwarding the proforma to Head, RSD, AERB, Niyamak Bhavan, Anushaktinagar, Mumbai 400 094.)

Sr. No.

Check Point Response

1. Complete address , telephone & fax No.s included in Item 1 of the proforma

YES / NO

2. Item 6 of the proforma has been filled in and, if applicable, an undertaking has been furnished about getting an appropriate person trained in radiological safety

YES / NO

3. Item 10 (a) of the proforma has been filled in. YES / NO

4. Item 10 (b) of the proforma has been filled in and an undertaking has been furnished about procuring an appropriate radiation survey meter

YES / NO

5 The proforma has been signed by the applicant in the last page YES / NO 6. The proforma has been signed by the applicant and the Head of the

institution in the last page YES / NO

7. The Registration document of the institution (Item 9) is attached Yes / No 8 Copy of undertaking from Original Supplier for acceptance of decayed /

disused attached (Item 11) Yes / No

Signature, name and designation of the Head of the institution .

SEAL OF THE HEAD OF THE INSTITUTION