Form Qwp-Cdrrhr-4-01-Annex 2.3 - Application Form For A License To Operate A Non-Medical X-Ray Facility Page 3

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IV X-ray machine Specifications
Maximum
Maximum
Manufacturer
Serial No.
Type*
Application/Use**
Location
mA
kVp
use separate sheet if necessary
* For Type, indicate whether
**for Use
- Cabinet Type
- Industrial Radiographic
- Scanning Electron Microscopy
- Closed Installation
- Industrial Fluoroscopic
- Fat Analyzer
- Open Installation
- Thickness Gauge
- Photo-ionizer
-
Handheld
- Diffractometry
- Analytical
-
LINAC
- Spectrometry
- Veterinary
V Name and qualifications of other personnel working in the x-ray facility
Training in
Name
Designation
Signature
Radiation Protection
*use separate sheet if necessary
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