Rc002 1 Form – Fill Out and Use This PDF

RC002-1

DEPARTMENT OF HEALTH

The Director, Radiation Control, Private Bag X62, BELLVILLE, 7535. !(021) 9486162; Fax no. (021) 9461589

APPLICATION IN TERMS OF ARTICLE 4 OF THE HAZARDOUS

SUBSTANCES ACT, 1973 (ACT 15 OF 1973)

Section A: CHANGE OF RESPONSIBLE PERSON

Section B: DISPOSAL OF A LICENSED ELECTRONIC PRODUCT AND/OR NEW/MODIFIED PREMISES

For office use only

File no:

Licence no:

Code:

1.PARTICULARS OF APPLICANT

Name and postal address of licence holder:

Postcode:

!	Fax no.:		E-mail:
Name and postal address of contact person (IF DIFFERENT FROM ABOVE):
				Postcode:
!		Fax no.:

1. DECLARATION (by/on behalf of the applicant):

I, (PLEASE PRINT):	hereby declare that the information
supplied is to the best of my knowledge true and correct.

Designation:

Section A: CHANGE OF RESPONSIBLE PERSON

2. DETAILS OF NEW RESPONSIBLE PERSON

Surname:

Title:

Initials:

ID no:

Address:

Experience regarding radiation protection:

Designation:Qualification:

2

Section B:	DISPOSAL OF A LICENCED ELECTRONIC PRODUCT AND/OR NEW/MODIFIED PREMISES
3. TYPE OF APPLICATION (Indicate with a X in the applicable block)
Unit dismantled		Unit sold/ transferred	Unit stolen	Unit Stored	Generator disposed	New/modified premises

4.1DETAILS OF GENERATOR

Name of manufacturer:			Licence no:
Brandname:		Model:
Generator serial no:		Unit serial no:
4.2	DETAILS OF PERSON/COMPANY TO WHOM ELECTRONIC PRODUCT HAS BEEN SOLD/TRANSFERRED
Name and postal address:
Name of contact person:
!		Fax no:

4.3PARTICULARS OF NEW/MODIFIED PREMISES

Address: - General (i.e. block, floor, room, vehicle reg. no.)

Section:

Street:

Building:

4.4DIAGRAM OF NEW/MODIFIED PREMISES

Please attach a diagram or plan indicating the appropriate enclosure or room with special reference to:

(a)The normal location of the x-ray tube and extend of x-ray tube movement; general direction(s) of the useful beam; locations of any windows and doors; the location of the operator's booth; and the location of the x-ray control panel.

(b)The structural composition and thickness or lead equivalent of all walls, doors, partitions, floor, and ceiling of the room(s) concerned.

(c)The dimensions of the room(s) concerned.

(D)The type of occupancy of all adjacent areas inclusive of space above and below the room(s) concerned. If there is an exterior wall, show distance to the closest area(s) where it is likely that individuals may be present.

To what extent does the new/modified premises entail an increased radiation danger:

______________________________________________________________________________________________________

For office use only

Type of modification/disposal	Generic code
Unit sold to another user	DP001
Unit transferred to new premises of the same licence holder	DP002
Unit sold to a distributor	DP003
Unit dismantled	DP004
Licence holder disappeared	DP005
Unit disappeared	DP006
Unit stolen	DP007
Unit in storage	DP008
New generator installed	DP009