Annual Compliance Reporting Form Page 2
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4940E
PROTECTED WHEN COMPLETED
ANNUAL COMPLIANCE REPORTING FORM
Licensed Activity: liquid scintillation counters (940)
1. CNSC Licence Number: ____________________________
2. This Annual Compliance Report is for the 12 month period ending: __________ (yyyy/mm/dd)
3. Licensee Information
Licensee Name: _________________________________________________________
Head Office Address: ____________________________________________________
City: _____________________Province/State:
_________________
Country: __________________Postal/Zip Code:
________________
4. Radiation Safety Officer/Licence Contact Person
Name:
________________________________________________________
Mailing Address: ________________________________________________
(if different from above) City: ______________ Province/State:
_______________
Country: __________________Postal/Zip Code:
______________
Telephone:
__________________ Facsimile:
_____________
E-mail address: ____________________________________________
5. Alternate Contact Person (if applicable)
Name:
_________________________________________________________
Telephone:
__________________ Facsimile: _______________
E-mail address: ____________________________________________
6. Financial Contact Person (if applicable)
Name:_____________________________________________________
Position Title:_______________________________________________
Mailing Address:____________________________________________
(if different from above) City: ______________ Province/State:
________________
Country: __________________Postal/Zip Code:
_______________
Telephone:
__________________ Facsimile:
______________
E-mail address: _____________________________________________
If the space allotted in this form is insufficient, please attach additional pages in the format shown.
7. Provide a list of all locations (with complete addresses) where the licensed activity has been
conducted for more than 90 consecutive days during the reporting period. If the licensed activity
has been conducted in more than one location, use the same format and list all locations that
remain in use or storage.
Address____________________________________________________
City:
______________________________ Province: _______
Postal Code: ______________________
7.1
Indicate those locations that have become inactive and have been decommissioned.
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