ࡱ> wzv_ vbjbjڿڿ  q-b-be 2228jL2*8*:*:*:*:*:*:*$e,/^*5"55^*Bs*58*58*r((T()sv< ^|($**0*(/B/()/()0"8T^*^*WB*5555/B : APPLICATION FOR AN INTERNAL RADIOISOTOPE PERMIT The applicant/permit holder is responsible for completing this application. Review will be performed by the Radiation Safety Committee. If approved, a radioisotope permit will be issued that is valid for a maximum of 2 years. The permit holder is also responsible for notifying the Radiation Safety Officer (RSO) of any changes to information provided at the time of the application. For further assistance completing this form please contact the RSO at 26472. NEW PERMIT RENEWALCONTACT INFORMATIONApplicant Name and Position: Applicant Phone Number: Applicant Email: Department/Program: Laboratory (Room number): Application Date: Proposed Start Date for Current Application: Proposed End Date for Current Application:  OPEN SOURCE MATERIALS: List requested radioisotope possession limit (indicate the maximum activity expected to be on hand at any one time). IsotopeActivityDescription (include state and chemical)(Bq)(uCi) SEALED SOURCES: A sealed source consists of radioactive material inside a metal or plastic capsule that is designed to be a permanent enclosure, including sources inside of equipment. *Note: for renewal, submit a list of all current sealed sources IsotopeActivityDescription(Bq)(uCi) STATEMENT OF INTENDED USES(S). Specify exact use/procedure involved regarding each isotope, including safety steps. Please submit information on technical equipment that will be used in conjunction with the radioisotopes (use a supplemental sheet). LOCATION(S) OF USE. Specify laboratory and storage locations. Indicate security measures taken to prevent unauthorized access to this area. DESCRIPTION OF THE EXPECTED FORM, CONTENT, AND VOLUMES OF RADIOACTIVE WASTES PER MONTH. List all materials and chemicals that will be in the waste. Use a supplemental sheet if necessary. Indicate a disposal plan for the radioactive waste. TOTAL AMOUNT OF ACTIVITY YOU WILL USE OR REQUIRE OVER THE NEXT TWO YEARS FOR EACH RADIOISOTOPE INCLUDING WASTE HELD FOR DECAY. LIST OF SUPPLEMENTAL SHEETS SUBMITTED WITH THIS DOCUMENT: Document Descriptions I verify that the above information is accurate and valid: Signature of Applicant/Permit Holder Date Signature of Department Head indicating permission Date      UNIVERSITY OF NORTHERN BRITISH COLUMBIA Committee on Radionuclides and Radiation Hazards IRP Application April 2020 2  Committee on Radionuclides and Radiation Hazards IRP Application April 2020 1 /015_           . 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