GIY PHP CHP NH PHNG X

RADIOGRAPHY PERMIT
Project (d n): ..

Contractor (Nh Thu):

Sub-contractor (nh thu ph): .

Description and location of work to be carried out (khu vc cng tc phng x):
..
attached sketch showing area likely to be affected by radiation. (nh km bn v nhng cng vic gn khu vc
chp nh phng x)
Details of radiation source: (chi tit v ngun phng x):

Serial No.: Nature: Activity:

S sri Bn cht ngun Hot ng
Date (s) and time (s) of work to be carried out (Thi gian tin hnh cng vic)

From: Date _Time To: Date _Time

T: ngy _Gi n: ngy _Gi

Name of person making notification (Ngi thng bo): Radiation Protection Supervisor (Ngi Gim st):
. .
Job title (cng vic):. Date (ngy):.
Date (ngy):.. Contact Number (in thoi lin lc):.
Signature (Ch k): Signature (Ch k):

Drawing attached (nh km bn v): Yes / No

Risk assessments/Method statements attached (nh km nh gi ri ro/bin php thi cng): Yes / No
Other supporting document (Ti liu khc): Yes / No
Comments (Nhn xt): .........................
.
Approved by Consultant Requested by Contractor
(Ph duyt ca T vn) ( ngh t Nh thu)

Name (Tn): Name (Tn):

Position (Chc v): Position (Chc v):

Send to (Ni gi): ................................................................................................

.
.

Revision 00 HSE-15
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