Form Rhf - 1pg - Application For Radioactive Material License

Form Rhf - 1pg - Application For Radioactive Material License - Portable Gauge Page 8

SHIPPING PAPER

SHIPPER OF DEVICE:

____________________________________________________________

ADDRESS:

_____________________________________________________________________

PHONE NO: _________________________________________

Shipper’s Emergency Phone Number: ___________________________________

Shipper’s Emergency Contact Person: ___________________________________

State of Washington, Department of Health 24 Hour Emergency Phone Number:

206 NUCLEAR (206 682-5327)

Proper Shipping Name: - Radioactive Material, Type A Package, Special Form, Non Fissile

Fissile Excepted, RQ

Hazard Class: 7

Identification Number: UN3332, RQ

ISOTOPE(S): _______________________________ / ___________________________

ACTIVITY(S): __________________________MBq. / __________________________MBq.

(__________________________) mCi / (___________________________)mCi

DOT Label: _____ Yellow II, or

______ Yellow III (Placards Required)

Transport Index (TI): ____________________

DEVICE MANUFACTURER: ____________________________________________________

DEVICE MODEL: ______________________________________________________________

This is to certify that the above-named materials are properly classified, described, packaged, marked and

labeled, and are in proper condition for transportation according to the applicable regulations of the U.S.

Department of Transportation.

Signed: _________________________________ Title: _______________________________

This document and an Emergency Procedure must be carried in the transport vehicle (within

arm’s reach of driver) while device is being transported on any public roadway by any person.

The shipper’s emergency phone number must be monitored at all times that the device is in

transportation, including storage incidental to transportation.

322-028 JAR 4/17/12 Page 8 of 8

Form Rhf - 1pg - Application For Radioactive Material License - Portable Gauge Page 8