Government of India Atomic Energy Regulatory Board Radiological Safety Division Niyamak Bhavan, Anushaktinagar Mumbai– 400 094. AERB/RSD/TP-DISP-Q-1/REV.5 Information on transport of radioactive material for disposal (Note: This form should be duly filled in duplicate and forwarded to Head, RSD, AERB, Niyamak Bhavan, Anushaktinagar, Mumbai – 400 094. Packages should be dispatched only after obtaining specific authorisation from this Division for transport of radioactive material. Kindly note that incomplete form may cause delay in further action.) 1. Name and address of the Institution

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2. Is the Institution permitted by BARC for handling radioactive material? Give reference, if any.

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3. Date of procurement of radioactive material and activity of the material on that date

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4. Name and address of the supplier of the radioactive material

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5. Reasons for disposal of the material

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6. Name and address of the Agency where the waste material is to be disposed off (BARC/BRIT/Original supplier abroad)

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7. Description of the radioactive material

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Name(s) No. of sources Activity of each source as on date Physical form(s) Chemical form(s) Principal radionuclide(s) contained in the material Nature of application Volume of radioactive material(s) in cm3 (Please attach additional sheet, if necessary) 8.a Details of source housing/container showing the position of the source with diagram/sketch and procedure for retrieval of the source. (Please attach additional sheet, if necessary)

: : : ------ Ci/mCi as on -------- (date) : Solid/liquid/gas/powder/contaminated object : : :Teletherapy/Brachytherapy/Industrial radiography/nucleonic gauges : :

8.b Details of the package in which radioactive material is : proposed to be transported. (Please attach blue print or sketch showing all the dimensions including shielding detail)

9. Total number of packages and the number of source(s) : in each package 10. Gross weight of each package

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11. Maximum radiation level at external surface of the package

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---------- mrem/h

12. Maximum radiation at 1 m from external surface of the : package

---------- mrem/h

13. Proposed mode of transport

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Road/Rail/Air/Sea

14. If it is type B package, Package identification No. Serial No.

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15. Details of facilities for handling the package

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16. Whether material is proposed to be transported in the original package supplied by the supplier If yes, whether the packaging is in good condition

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Yes/No

17. How the package is proposed to be immobilised in the : vehicle during transport (Applicable for packages of gross weight exceeding 30 kg) 18. Whether empty container, after removal of source is : required (Applicable only for sources disposed off at BARC/BRIT) 19. Any other information

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Certified that the external surface of the package is free from non-fixed (transferable) contamination.

Signature of Radiation Safety Officer/Site-in-charge Name Designation Address Place: Date: