Consignors Declaration This is to certify that the package containing radioactive material as identified by the following details is safe

for transport by rail, road, sea or air. Package forwarded by (Consignor) Package addressed to (Consignee) Proper Shipping name UN Class of dangerous goods United Nations No Subsidiary risk Name of Radioactive material Quantity/Activity material :

: : : : : 7 UN No. Nil
192

Ir / 60Co/ Gbq ( Ci)

of Radioactive :

Package details Dimensions of the package Weight of the package Type of package* Radiation level on the surface of the package in mSv/h Transport index of the package Category of the package
*

: : :

: : I-WHITE/ II-YELLOW/ III-YELOOW

In case of Type B(U)/(M) package, Competent Authority identification number should also be given. I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name and are classified, packed, marked and labelled, and are in all respects in proper condition for transport according to the AERB Safety Code, AERB/SC/TR-1, currently in force. Signature: Date: Name and address Seal