AERB/RSD/NG/SOURCE-MOVE

Government of India
Atomic Energy Reg!atory Board
Radio!ogica! Safety Divi"ion
Niyama# B$avan
An"$a#tinagar% Mm&ai- '((()'
Application for permission to move nucleonic gauges/XRF Analysers/X-ray Units
This form duly filled in should be submitted IN DUPLICATE to Head, Radiologial !afety Di"ision,
Atomi Energy Regulatory #oard, Niyama$ #ha"an, Anusha$tinagar, %umbai&'((()' *rior to
underta$ing any mo"ement of the soure from the *remises +here the soure is authorised to be
handled by AER#,
*+Name and de"ignation of t$e con"entee , t$e -er"on in .$o"e
name at$ori/ation .a" i""ed &y AERB to $and!e 0 Mr. Deepak Dongre
radioactive materia!1 at t$e -re"ent "ite Dy. General Manager
2e!e-$one 3$one No 0 +!-"#-$#!!"$% &'(t-!"!)
4a5 No 0 +!-"#-*!"%+,
6+ Addre"" of t$e !ocation .$ere t$e device i" -re"ent!y 0 -.ermo 'lectron /n0ia 1vt 2t0
at$ori/ed to &e $and!ed &-'/12)
$!%3 $
t.
floor3
4ity point3
!,3 D.ole 1atil Roa03
1U5'-$!! ##!.

7+ Addre"" of t$e "ite .$ere t$e device i" -ro-o"ed to &e "ed 0 Reliance /n0ustries 2imite0
6illage 7Mora3 18.9.at.a3
:urat-;a<ira Roa03 :URA--,$%!#.
'+ Name and de"ignation of t$e -er"on re"-on"i&!e for t$e "afety
and t$e "ecrity of t$e device at t$e -ro-o"ed "ite 0 Mr. 9.anu D.iman
Dy. General Manager
2e!e-$one No 0 +!-"*!-,#,%,+
4a5 No 0 +!-"*!-,#,%,
8+ 3artic!ar" re!ating to t$e device 0 1orta=le Alloy Analy<er 0evice =eing
Returne0 =ack after 0ecaye0 40-!#
source replacement an0 cali=ration of
t.e instrument.
Ma#e Mode! UDN Sorce Activity ,on
date of
3rocrement1
Reference of at$ori"ation
again"t .$ic$ "orce .a"
-rocred and date of
at$ori/ation
USN Nm&er
of t$e "orce
Meta!!rgi"t )699 *+ Cd-*()
6+ 4e-88
8 mCi
'8 mCi
R3SD/ADV-NG-:R-
*)7/6((*'/); dated May6*%
*));+
;+ Ma#e% Mode! and Sr+ No+ of t$e radiation "rvey meter
to &e "ed at t$e -ro-o"ed "ite 0Not A--!ica&!e
9+ a1 Name of t$e Radio!ogica! Safety Officer at t$e -ro-o"ed "ite 0 Mr+ Uday "$an#ar "ing$
&1 Detai!" of reference of AERB a--rova! of RSO 0
<+ 3ro-o"ed date of "orce movement from t$e -re"ent "ite 0 *8
t$
Novem&er% (7
)+ E5-ected date of retrn of t$e device to t$e origina! "ite 0 7*
"t
Decem&er% (7
/ .ere=y certify t.at t.e information furnis.e0 a=ove is correct to t.e =est of my kno>le0ge. / am
a>are of t.e ra0iological safety precautions to =e o=serve0 0uring t.e .an0ling of t.e 0evice an0
s.all ensure t.at all t.e precautions stipulate0 overleaf >oul0 =e o=serve0.
*(+ I $ere&y nderta#e t$at t$e fo!!o.ing condition" .o!d &e d!y com-!ied .it$ &y me for en"ring "afe
tran"-ort of t$e a&ove nc!eonic device 0
a1 2$e device d!y incor-orating t$e radioactive "orce .o!d &e tran"-orted in t$e origina!
container in .$ic$ it .a" received &y " from t$e "--!ier of t$e device+
&1 2$e device .o!d &e tran"-orted a" an item of cargo and dec!ared a" "c$ in t$e a--!ica&!e
tran"-ort docment"+ It .o!d not &e tran"-orted in t$e -a""enger ca&in of any conveyance , e+g+
&"/train/aircraft1+ I nder"tand t$at it co!d% $o.ever% &e tran"-orted &y road in an e5c!"ive ve$ic!e+
c1 2$e device .o!d di"-!ay t$e radioactivity !a&e! and a!"o !a&e!" indicating t$e category of t$e -ac#age+
It .o!d &e en"red &y " t$at t$e -artic!ar" regarding t$e content" of t$e -ac#age di"-!ayed in t$e
!a&e!" are correct+ Name" and addre""e" of t$e con"ignor and t$e con"ignee .o!d &e -ro-er!y di"-!ayed
on t$e e5terior of t$e -ac#age+
d1 2$e carrier .o!d &e in"trcted &y " t$at "$o!d any mi"$a- invo!ving t$e -ac#age occr dring
t$e tran"-ortation%
i1 Effort" "$o!d &e ta#en to re"ce t$e in=red%
ii1 4ig$t fire% if any% and t$at
iii1 A me""age regarding t$e condition of t$e -ac#age and intimating t$e name of t$e con"ignor and
t$e !oca! contact -artic!ar" "$o!d &e "ent to t$e De-artment of Atomic Energy Emergency
Commnication Room ,DAE-ECR1% Mm&ai ,2e!e-$one0 (66-66(67)9< and (66-66<7(''* and
4a5 0 (66-66<7(''*1 and t$at t$e -ac#age "$o!d &e garded nti! frt$er advice i" received from
t$e DAE-ECR in t$i" regard+
e1 2$e device .o!d &e $and!ed on!y &y a -er"on fami!iar .it$ t$e o-eration of t$e device+
f1 2$e o-eration of t$e device .o!d &e "-ervi"ed &y a Radio!ogica! Safety Officer% a--roved &y t$e
com-etent at$ority+
g1 2$e Radio!ogica! Safety Divi"ion% AERB .o!d &e informed &y t$e nder"igned% -on t$e retrn of t$e
device to t$e origina! "ite+
,Mr+ Uday "$an#ar "ing$1
Signatre and Name Signatre of t$e con"entee Signatre of t$e em-!oyer
of t$e RSO of t$e In"tittion Name 0 S$ B D D$iman Name 0 S$+ M M Sing$
De"ignation 0 Dy+ Genera! Manager De"ignation 0 3re"ident
3!ace 0 Srat
Date 0 *7/**/(7
:eal of t.e /nstitution
4or Officia! U"e on!y
Ref 0 RSD/NG/ /6((6/ Date 0
2$e movement of device,"1 a" de"cri&ed a&ove i" -ermitted "&=ect to t$e condition t$at t$e
nderta#ing frni"$ed in Item *( a&ove "$a!! &e d!y com-!ied .it$+
:ignature an0 5ame of
A'R9 Representative
A00ress of t.e 4onsentee?
Re!iance Ind"trie" >imited
Vi!!age ?Mora% 3O+B$at$a%
Srat-@a/ira Road%
SURA2-7)'8*(