e-form

RPC - SHIPMENT OF SEALED SOURCES BETWEEN THE MEMBER STATES OF THE EUROPEAN COMMUNITY

Form to be used persuant Council Regulation No. 1493/93

NOTICE
- The consignee of sealed sources must complete boxes 1 to 5 and send this form to the Radiation Protection Commission.
- The Radiation Protection Commission must fill in box 6 and return this form to the consignee.
- The consignee must then send this form to the holder in the forwarding country prior to the shipment of the sealed sources.
- All sections of this form must be completed and boxes ticked were appropriate

1 THIS DECLARATION CONCERNS

ONE SHIPMENT

Expected date of shipment (if available):

SEVERAL SHIPMENTS

2 DESTINATION OF THE SOURCE(S)

Name of consignee :

Person to contact :

Address :

Tel :

Email :

3 HOLDER OF THE SOURCE(S) IN THE FORWARDING COUNTRY

Name of holder:

Person to contact :

Address :

Tel :

Email :

4 DESCRIPTION OF THE SOURCE(S) INVOLVED IN THE SHIPMENT(S)

(a) Radionuclide(s)

(b) Maximum activity of individual source (MBq)

(a) Radionuclide(s)

(c) Number of sources

(d) If this (these) sealed source(s) is (are) mounted in (a) machinery/device/equipment, short description of the machinery/device/equipment

(e) Indicate (if available)

- national or international technical standard with which the sealed source(s) comply(ies) and certificate number

- date of expiry of certification :

- name of the manufacturer and catalogue reference:

5 DECLARATION OF THE AUTHORISED OR RESPONSIBLE PERSON

- I the consignee, hereby certify that the information provided in this form is correct.
- I the consignee, hereby certify that I am authorised or otherwise permitted to receive the source(s) described in this form.
- Authorisation or other permission number (if applicable) and validity date thereof :

Authorisation No.:

Expiry date

- I the consignee, hereby certify that I comply with all the relevant national requirements, such as those relating to the safe storage, use or disposal of the source(s) described in this form.
- I the consignee, hereby certify that arrangements are in place to ship back the source/s at the end of its/their useful life.

This form must be printed when filled, signed and submitted to the Commission via email ( info.rpc@gov.mt ) or by other means to address below.

Name and Surname

Signature

6 CONFIRMATION BY THE RADIATION PROTECTION COMMISSION THAT IT HAS TAKEN NOTE OF THIS DECLARATION

Address

Sorbonne Centre, Unit F22, Mosta Technopark, Mosts, MST3000, Malta

Tel:

+356 27998676

This declaration is valid until

Authorising Officer

Signature of Authorising Officer

Stamp

Date