UCD COMMITTEE ON IONIZING RADIATION

Environmental Health and Safety Department,
Office of the Assitant Vice Chancellor for Regulatory Copmpliance
Box F-484

Radioactive Materials Authorization Update

Principal Investigator:    Authorization Number* (5-digit)     Isotope:

* If the changes apply to more than one authorization, please separate the authorization numbers with a comma. To check on your authorization/application number(s) please go to: http://www.uchsc.edu/safety/RadiationSafety/RadioactiveAuthorizations.htm.

This form is used to request changes in any of the following:

  1. location of use
  2. users
  3. possession limit
  4. annual limit
  5. compound (same experimental protocol)
  6. waste generated

For all other changes, please complete the Application for Radioactive Materials Authorization (Non-Human Use). For inquiries please contact the Radiation Safety Office at 4-0345 or email us at RadAppNH@UCHSC.edu.

Please check mark all the changes that apply:

1.     Location of Use

Add the following location(s) (Building/Room #)**. Use the abbreviation given below for the building name.

a.    b.     c.  

Delete the following location(s) (Building/Room #)**:

a.    b.     c.  

**Buildings Abbreviation:

2.     Users

Add the following users:

a.    b.     c.    

Delete the following users:

a.     b.     c.      

3.     Possession Limit Increase

Radionuclide         New Possession Limit mCi

4.     Annual Limit Increase

Radionuclide         New Annual Limit mCi

5.     Compound(s): (Same experimental protocol)

Add the following compound(s):

a.    b.     c.

Type of use summary (restated from original application)

6.     Waste items generated

Waste Type Volume Generated per Month % of Total Radioactivity Requires Disinfecting (10% bleach)
Dry Solids cubic feet Yes   No
Aqueous liters Yes   No
Non-Hazardous Scintillation Vials, cocktail brand name: # of trays Yes   No
Hazardous Scintillation Vials, cocktail brand name: # of trays Yes   No
Biological (non-carcass) Solid cubic feet

Liquid  liters

Scint. Vials  trays

Yes   No
Biological (carcass) Solid cubic feet Yes   No
Organic (mixed waste) List of chemical name and percentage: Solid cubic feet

Liquid liters

Yes   No
Other: Yes   No

Comments:

By submitting this form, I, , agree that all radioactive materials procured as a result of this application will be used only as specified above, and in accord with the guidelines of the EH&S Radiation Safety Manual, as well as all other applicable UCD policies and procedures, the UCD radioactive materials license, and state and federal regulations.