RADIATION CON TROL LE GISLATION

Government of COUN TRY

LICE N CE
POSSE SSION AN D USE OF RADIOACTIVE SOURCE S

LICE N SE E N AME OF RE SPON SIBLE LE GAL PE RSON

Main City Hospital Dr F Ronald, Director of Nuclear Medicine

Department of Nuclear Medicine
RADIATION PROTE CTION OFFICE R
Box 5678 Post Office
CAPITAL CITY 01234 Mr P J Desford

LOCATION OF PRE MISE S PURPOSE OF LICE N CE

Main City Hospital 1st floor Diagnostic Nuclear Medicine

Department of Nuclear Medicine
Main Street MINING TOWN 01234 QUALIFIE D E XPE RT
Mr I A D Vise BSc

RADIOACTIVE SOURCE S APPROVE D FOR POSSE SSION AN D USE

Mfr. Model Serial No. Nuclide Activity Activity Date Use Location

Mo 99 200 GBq Max activity Generator B.034

Tc 99m 80 GBq Max activity Diagnosis Department
Tl 201 2 GBq Max activity Diagnosis Department
GE X456 Co 60 2 MBq Jun 2003 Calibration Laboratory
GE Y564 Cs 137 10 MBq Jun 2003 Calibration Laboratory

AUTHORIZE D USE RS
See attached list. The licensee is directed to ensure that any personnel who subsequently may be engaged to
operate, install, maintain or otherwise deal with the radiation sources on the premises have approved training in
accordance with the criteria stated in the licensee’s Radiation Protection Programme.

LICE N CE CON DITION S

The licensee is directed to —
• comply with regulations 12 – 25 inclusive and with any attached conditions;
• comply with the attached Radiation Protection Programme (RPP)
• provide prior written notification to the regulatory body of any intention to — sell, relocate, install, or
dispose of radiation sources (by any means); of plans to modify the structure of the premises in any way that
may significantly impact on radiation safety; nominate a replacement Qualified Expert or Radiation
Protection Officer (RPO);
• ensure that the installation, service or maintenance of radiation sources on the premises is performed only by
personnel authorized by the regulatory body.

The Licence is approved ________________________________ ______________________

Not valid unless signed by an authorized officer Date

This Authorization must be displayed in a prominent public location within the premises.

Regulatory Body Telephone (880) 222 3333

Box RA5678 Post Office Fax (880) 222 3334
CAPITAL CITY 01235 E-mail rra@isp.gov.country

LICE N CE N UMBE R 133/ 2002 E XPIRY DATE 5 February 2005