Western Australian Current Regulations Western Australian Current Regulations[Regulations 3, 10 and 59]
Forms
Form RS 1
Application for licence in respect of radioactive substances
First Application
Fee: $ .................
TO: The RADIOLOGICAL COUNCIL,
Box C134, G.P.O.
PERTH, W.A. 6001.
1. Name of Applicant.
2. Address:
3. Occupation:
4. Telephone No.:
5. Particulars of radioactive substances to be
used, manufactured, stored, transported, sold, possessed or otherwise dealt
with by APPLICANT (maximum quantities to be used, manufactured, stored,
transported, sold, possessed or otherwise dealt with at any one time):
|
Sealed/unsealed |
Isotope |
Quantity and form |
| | | |
6. Purpose for which radioactive substances are to
be used, manufactured, stored, transported, sold, possessed or otherwise dealt
with by APPLICANT:
7. Qualifications and experience of APPLICANT to
use, manufacture, store, transport, sell, possess or otherwise deal with
radioactive substances referred to in 5:
8. Location(s) at which it is intended to use,
manufacture, store, transport, sell, possess or otherwise deal with
radioactive substances referred to in 5:
.................................................
Signature of applicant
DATE .................................................
Form RS 2
Application for renewal of licence in respect of radioactive substances
Renewal Application
Fee: $ ......................
TO: The RADIOLOGICAL COUNCIL,
Box C134, G.P.O.
PERTH, W.A. 6001.
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1. Name of Applicant: | |
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2. Address: | |
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3. Licence No.: |
Expires: |
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4. Occupation: |
5. Telephone No.: |
6. Give details of any changes in the particulars
of radioactive substances to be used, manufactured, stored, transported, sold,
possessed or otherwise dealt with by APPLICANT (maximum quantities to be used,
manufactured, stored, transported, sold, possessed or otherwise dealt with at
any one time) which changes have not previously been notified to and approved
by the Council:
|
Sealed/unsealed |
Isotope |
Quantity and form |
|
|
7. Give details of any changes in the location(s)
of use, manufacture, storage, transport, sale or possession of or other
dealing with radioactive substances and in the purpose for which radioactive
substances are used, manufactured, stored, transported, sold, possessed or
otherwise dealt with, which changes have not previously been notified to and
approved by the Council:
...........................................................
Signature of
applicant
DATE ...........................................................
Form RS 3
Licence in respect of radioactive substances
A licence is hereby granted under the provisions of the Radiation Safety
Act 1975 to the person named below to use, manufacture, store, transport,
sell, possess or otherwise deal with radioactive substances of the type and
for the purpose designated below. The licence is subject to all applicable
regulations under that Act and to any conditions, restrictions or limitations
specified below or in any attachments hereto.
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1. Name of licensee: | |||
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2. Address: | |||
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3. Licence No.: |
Licence expires: |
Fee: $ | |
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4. Occupation: | |
5. Telephone No.: | |
6. Particulars of radioactive substances to be
used, manufactured, stored, transported, sold, possessed or otherwise dealt
with by HOLDER (maximum quantities to be used, manufactured, stored,
transported, sold, possessed or otherwise dealt with at any one time):
|
Sealed/unsealed |
Isotope |
Quantity and form |
|
| ||
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7. Conditions, restrictions or limitations: | ||
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8. Purpose of licence: | ||
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9. Location(s) of use, manufacture, storage,
transport, sale, possession or other dealing with radioactive substances
referred to in 6: | ||
.........................................
.......................................................................
Date
Chairman, Radiological Council
(This licence is not valid until it is signed by
the Chairman, Radiological Council.)
Form RS 4
Application for licence in respect of irradiating apparatus or electronic
products
First Application
Fee: $ ...............
TO: The RADIOLOGICAL COUNCIL,
Box C134, G.P.O.
PERTH, W.A. 6001.
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1. Name of Applicant: | |
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2. Address: | |
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3. Occupation: |
4. Telephone No.: |
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5. Type of irradiating apparatus or electronic
product to be operated, used, manufactured, stored, transported, sold,
possessed, installed, serviced, maintained, repaired, tested or otherwise
dealt with by APPLICANT: | |
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6. Purpose for which irradiating apparatus or
electronic products to be operated, used, manufactured, stored, transported,
sold, possessed, installed, serviced, maintained, repaired, tested or
otherwise dealt with by APPLICANT: | |
|
7. Qualifications and experience of APPLICANT to
operate, use, manufacture, store, transport, sell, possess, install, service,
maintain, repair, test or otherwise deal with irradiating apparatus or
electronic products of type referred to in 5: | |
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8. Location(s) at which it is intended to operate,
use, manufacture, store, transport, sell, possess, install, service, maintain,
repair, test or otherwise deal with irradiating apparatus or electronic
products referred to in 5: | |
...........................................................
Signature of
applicant
DATE ...........................................................
Form RS 5
Application for renewal of licence in respect of irradiating apparatus or
electronic products
Renewal Application
Fee: $ ......................
TO: The RADIOLOGICAL COUNCIL,
Box C134, G.P.O.
PERTH, W.A. 6001.
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1. Name of Applicant: | |
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2. Address: | |
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3. Licence No.: |
Expires: |
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4. Occupation: |
5. Telephone No.: |
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6. Give details of any changes in type of
irradiating apparatus or electronic products to be operated, used,
manufactured, stored, transported, sold, possessed, installed, serviced,
maintained, repaired, tested or otherwise dealt with, which changes have not
previously been notified to and approved by the Council: | |
|
7. Give details of any changes in location(s) of
operation, use, manufacture, storage, transport, sale, possession,
installation, service, maintenance, repair, testing or other dealing with
irradiating apparatus or electronic products and in the purpose for which
irradiating apparatus or electronic products are to be operated, used,
manufactured, stored, transported, sold, possessed, installed, serviced,
maintained, repaired or otherwise dealt with, which changes have not
previously been notified to and approved by the Council: | |
...........................................................
Signature of
applicant
DATE ...........................................................
Form RS 6
Licence in respect of irradiating apparatus or electronic products
A licence is hereby granted under the Radiation Safety Act 1975 to the
person named below to operate, use, manufacture, store, transport, sell,
possess, install, service, maintain, repair, test or otherwise deal with
irradiating apparatus and electronic products of the types and for the purpose
designated below. The licence is subject to all applicable regulations under
that Act and to any conditions, restrictions or limitations specified below or
in any attachments hereto.
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1. Name of licensee: | |||
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2. Address: | |||
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3. Licence No.: |
Licence expires: |
Fee: $ | |
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4. Occupation: | |
5. Telephone No.: | |
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6. Types of irradiating apparatus or electronic
products: | |||
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7. Conditions, restrictions or limitations: | |||
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8. Purpose of licence: | |||
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9. Location(s) of operation, use, manufacture,
storage, transport, sale, possession, installation, service, maintenance,
repair, testing or other dealing with irradiating apparatus or electronic
products referred to in 6: | |||
...................................................
........................................................
Date Chairman, Radiological Council
(This licence is not valid until it is signed by
the Chairman, Radiological Council.)
Form RS 7
Application for registration of premises in which radioactive substances (in
gaseous self luminous devices) are to be used or stored
First Application
Fee: $ ...............
TO: The RADIOLOGICAL COUNCIL,
Box C134, G.P.O.
PERTH, W.A. 6001.
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1. Name of Applicant: | ||||
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2. Address: | ||||
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3. Occupation: |
4. Telephone No.: | |||
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5. Particulars of GASEOUS SELF LUMINOUS DEVICES: |
||||
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Number |
Make and type |
Purpose or wording |
Location* | |
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| ||||
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6. Particulars and location of premises subject of
application: | ||||
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7. Name and position of person responsible for
gaseous self luminous devices at premises referred to in 6: | ||||
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8. Name of architect, builder, electrician,
contractor, etc. responsible for installation of gaseous self luminous
devices: | ||||
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I/We hereby apply for registration under section 28 of the
Radiation Safety Act 1975 in respect of the premises referred to in 6 for
the use or storage of radioactive substances (in gaseous self luminous
devices) therein. DATE ........................................
Signature of .............................................. | ||||
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* A plan or sketch must be provided which enables
the gaseous self luminous devices in the building to be located. It should
show the address or locality of the building, the location of the building
with respect to other buildings in a complex, the orientation of the building
with respect to access ways, and the location of those devices in the building
(show whether ground, first, second or other floor). | ||||
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NOTE: An application for registration must be made
by the owner of the premises. As defined in the Radiation Safety Act 1975
, owner includes hirer, lessee, borrower, bailee or mortgagee in possession
and any attorney, agent, manager, foreman, supervisor or other person in
charge or having control or management and any person acting or representing
himself to be acting for an owner. The attention of applicants is drawn to the
responsibilities of the person in whose name the premises are registered as
set out in the Radiation Safety Act 1975 and the Radiation Safety
(General) Regulations 1983 . | ||||
On completion, this form and accompanying plans or
sketches should be sent to:
Radiological Council,
Box C134, G.P.O.,
PERTH, W.A. 6001.
Form RS 8
Application for renewal of registration of premises in which radioactive
substances (in gaseous self luminous devices) are used or stored
Renewal Application
Fee: $ .....................
TO: The RADIOLOGICAL COUNCIL,
Box C134, G.P.O.
PERTH, W.A. 6001.
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1. Name of Applicant: | ||||
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2. Address: | ||||
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3. Registered No.: |
Registration expires: | |||
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4. Occupation: |
5. Telephone No.: | |||
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6. Particulars of GASEOUS SELF LUMINOUS DEVICES: |
||||
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Number |
Make and type |
Purpose or wording |
Location* | |
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| ||||
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7. Give details of any changes in particulars of
premises subject of application: | ||||
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8. Name and position of person responsible for
gaseous self luminous devices at premises referred to in 7: | ||||
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I/We hereby apply for renewal of the registration held under the
Radiation Safety Act 1975 in respect of the premises described above for
the use or storage of radioactive substances (in gaseous self luminous
devices) therein. DATE ................................... Signature
of ................................................... | ||||
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* If space is insufficient for any item, attach
supplementary notes signed by the applicant. | ||||
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NOTE: An application for renewal of registration
must be made by the person in whose name the premises concerned are
registered. The attention of applicants is drawn to the responsibilities of
the person in whose name the premises are registered as set out in the
Radiation Safety Act 1975 and the
Radiation Safety (General) Regulations 1983 . | ||||
Form RS 9
Certificate of registration of premises in which radioactive substances (in
gaseous self luminous devices) are or are to be used or stored
It is hereby certified that the premises referred to below have been
registered under the Radiation Safety Act 1975 for the use or storage of
the radioactive substances (in gaseous self luminous devices) listed below.
The registration is subject to all applicable regulations under that Act and
to any conditions, restrictions or limitations specified below or in any
attachments hereto.
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1. Name of owner of premises: | ||||||
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2. Address: | ||||||
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3. Registration No.: |
Registration expires: |
Fee: $ | ||||
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4. Occupation: | |
5. Telephone No.: | ||||
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6. Particulars of GASEOUS SELF LUMINOUS DEVICES: |
||||||
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Number |
Make and type |
Purpose or wording |
Location* | |||
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| ||||||
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7. Particulars and location of premises subject of
registration: | ||||||
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8. Name and position of person responsible for the
gaseous self luminous devices at premises referred to in 7: | ||||||
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DATE .....................................
............................................................. | ||||||
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DATE .....................................
............................................................. (This registration is not valid until it is signed
by the Secretary, Radiological Council.) | ||||||
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* If space is insufficient for any item, attach
supplementary lists. | ||||||
NOTE: As defined in the
Radiation Safety Act 1975 , owner includes hirer, lessee, borrower,
bailee or mortgagee in possession and any attorney, agent, manager, foreman,
supervisor or other person in charge or having control or management and any
person acting or representing himself to be acting for an owner.
Form RS 10
Application for registration of premises in which radioactive substances (not
in gaseous self luminous devices) are to be manufactured, used or stored
TO: The RADIOLOGICAL COUNCIL,
First Application
Box C134, G.P.O.
Fee: $ ...............
PERTH, W.A. 6001.
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1. Name of applicant: | |||
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2. Address: | |||
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3. Telephone No: | |||
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4. Occupation, nature of business, etc.: | |||
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5. Name and title of applicant for correspondence:
| |||
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6. PARTICULARS OF RADIOACTIVE SUBSTANCES TO BE
MANUFACTURED, USED OR STORED ON PREMISES: | |||
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Sealed/unsealed |
Isotope |
Quantity and form* |
Location of manufacture, use or storage |
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| |||
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* State maximum quantity to be on premises at any
one time. | |||
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7. If regular use or storage is to be made of
radioactive substances, state quantity in each shipment and frequency of
arrival of shipments: | |||
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8. Locations where radioactive substances are to
be manufactured, used or stored: | |||
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9. Purpose for which radioactive substances are to
be manufactured, used or stored: | |||
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10. Protective equipment and handling techniques
proposed: | |||
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11. Location and construction of storage
facilities: | |||
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12. Nature and proposed method of disposal of
radioactive waste: | |||
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13. Proposed manner of disposal of sealed sources
no longer required: | |||
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14. Names, positions, qualifications and
experience of persons who will manufacture or use the radioactive substances
for radiation work (including persons holding licences under the
Radiation Safety Act 1975 ): | |||
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15. Name, qualifications and experience of
radiation safety officer: | |||
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16. Monitoring instruments: | |||
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17. Arrangements made for personnel monitoring: | |||
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DATE .....................................
........................................................ | |||
NOTE: An application for registration must be made
by the owner of the premises where the radioactive substances are to be
manufactured, used or stored. As defined in the Radiation Safety Act 1975
, owner includes hirer, lessee, borrower, bailee or mortgagee in possession
and any attorney, agent, manager, foreman, supervisor or other person in
charge or having control or management and any person acting or representing
himself to be acting for an owner. The attention of applicants is drawn to the
responsibilities of the person in whose name the premises are registered as
set out in the Radiation Safety Act 1975 and the Radiation Safety
(General) Regulations 1983 .
Form RS 11
Application for renewal of registration of premises in which radioactive
substances (not in gaseous self luminous devices) are manufactured, used or
stored
Renewal Application
Fee: $ .....................
TO: The RADIOLOGICAL COUNCIL,
Box C134, G.P.O.
PERTH, W.A. 6001.
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1. Name of Applicant: | |||||
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2. Address: | |||||
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3. Registration No.: |
Registration expires: | ||||
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4. Occupation: |
5. Telephone No.: | ||||
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6. Name and title of representative of applicant
for correspondence: | |||||
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7. PARTICULARS OF RADIOACTIVE SUBSTANCES*
MANUFACTURED, USED OR STORED IN PREMISES: | |||||
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Type of source (Sealed/unsealed) |
Radioactive substance |
Quantity and form |
Purpose |
Location on premises | |
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| |||||
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8. Place of manufacture, use or storage (if this
differs from address in 2): | |||||
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9. Names and qualifications of persons*
manufacturing or using radioactive substances for radiation work (including
persons holding licences under the Radiation Safety Act 1975 ): | |||||
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10. Name of radiation safety officer: | |||||
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11. Have any changes been made in the premises,
facilities or procedures for manufacture, use or storage of radioactive
substances which have not been notified to and approved by the Council? If so,
give details. | |||||
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DATE ...................................
........................................................... | |||||
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* If space is insufficient for any item, attach
supplementary lists signed by the applicant. | |||||
NOTE: An application for renewal of registration
must be made by the person in whose name the premises are registered. The
attention of applicants is drawn to the responsibilities of that person as set
out in the Radiation Safety Act 1975 and the Radiation Safety (General)
Regulations 1983 .
Form RS 12
Certificate of registration of premises in which radioactive substances
(not in gaseous self luminous devices) are or are to be manufactured, used or
stored
It is hereby certified that the premises referred to below have been
registered under the Radiation Safety Act 1975 for the manufacture, use,
storage or other dealing in radioactive substances. The registration is
subject to all applicable regulations under that Act and to any conditions,
restrictions or limitations specified below or in any attachments hereto.
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1. Name of owner of premises: | |||||
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2. Address: | |||||
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3. Occupation: |
4. Telephone No.: | ||||
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5. Registration No.: |
Registration expires: |
Fee: $ | |||
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6. PARTICULARS OF RADIOACTIVE SUBSTANCES TO BE
MANUFACTURED, USED OR STORED IN PREMISES: | |||||
|
Sealed/unsealed |
Isotope |
Quantity and form* |
Location of manufacture, use or storage | ||
|
| |||||
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* State maximum quantity to be on premises at any
one time. | |||||
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7. Particulars and location of premises subject of
registration: | |||||
|
8. Purpose for which radioactive substances are to
be manufactured, used or stored: | |||||
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9. Name of radiation safety officer: | |||||
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10. Names of persons licensed or otherwise
authorised to use radioactive substances in the premises: | |||||
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11. Conditions, restrictions, or limitations: | |||||
|
.................................................
.............................................................. | |||||
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(This certificate is not valid until it has been
signed by the Secretary, Radiological Council.) | |||||
NOTE: As defined in the Radiation Safety Act 1975 , owner includes hirer,
lessee, borrower, bailee or mortgagee in possession and any other attorney,
agent, manager, foreman, supervisor or other person in charge or having
control or management and any person acting or representing himself to be
acting for an owner.
Form RS 13
Application for registration of premises and irradiating apparatus/electronic
products to be operated or used therein
First Application
Fee: $ ...............
TO: The RADIOLOGICAL COUNCIL,
Box C134, G.P.O.,
PERTH, W.A. 6001.
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1. Name of applicant: | ||||
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2. Address: | ||||
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3. Telephone No.: | ||||
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4. Occupation, nature of business, etc.: | ||||
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5. Name and title of representative of applicant
for correspondence: | ||||
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6. PARTICULARS OF IRRADIATING APPARATUS OR
ELECTRONIC PRODUCTS* TO BE OPERATED OR USED IN THE PREMISES: | ||||
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Number |
Maker and type |
Type of radiation** |
Purpose |
Location on premises |
|
| ||||
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7. Location of premises to be registered: | ||||
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8. Radiation protection provision i.e. structural,
fixed and movable screens, safety devices, etc.: | ||||
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9. Names, positions, qualifications and experience
* of persons to operate or use the irradiating apparatus/electronic products
for radiation work (other than licence holders under the
Radiation Safety Act 1975 ): | ||||
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10. Names of persons licensed to operate or use
irradiating apparatus/electronic products: | ||||
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11. Name, qualifications and experience of
radiation safety officer: | ||||
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12. Monitoring instruments available on premises: | ||||
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13. Arrangements made for personnel monitoring: | ||||
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DATE ...........................................
......................................................... | ||||
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* If space is insufficient for any item, attach
supplementary lists signed by the applicant. * * If irradiating apparatus, enter maximum
kilovolts and milliamps: if electronic products, describe the radiation by its
common name and give wavelength or frequency, if known. | ||||
|
NOTE: An application for registration must be made
by the owner of the premises, irradiating apparatus or electronic products. As
defined in the Radiation Safety Act 1975 , owner includes hirer, lessee,
borrower, bailee or mortgagee in possession and any attorney, agent, manager,
foreman, supervisor or other person in charge or having control or management
and any person acting or representing himself to be acting for an owner. The
attention of applicants is drawn to the responsibilities of the person in
whose name the premises, irradiating apparatus or electronic products are
registered as set out in the Radiation Safety Act 1975 and the
Radiation Safety (General) Regulations 1983 . | ||||
Form RS 14
Application for renewal of registration of premises and irradiating
apparatus/electronic products operated or used therein
Renewal Application Fee: $ ...............
TO: The RADIOLOGICAL COUNCIL,
Box C134, G.P.O.,
PERTH, W.A. 6001.
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1. Name of applicant: | |||||
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2. Address: | |||||
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3. Registration No: |
Registration expires: | ||||
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4. Occupation: |
5. Telephone No.: | ||||
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6. Name and title of representative of applicant
for correspondence: | |||||
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7. PARTICULARS OF IRRADIATING APPARATUS OR
ELECTRONIC PRODUCTS OPERATED OR USED IN THE PREMISES: | |||||
|
Number |
Maker and type |
Type of radiation** |
Purpose |
Location on premises | |
|
| |||||
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8. Location of use or operation: | |||||
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9. Names, positions, qualifications and
experience* of persons operating or using the irradiating apparatus/electronic
products for radiation work (other than licence holders under the
Radiation Safety Act 1975 ): | |||||
|
10. Names of persons licensed to operate or use
irradiating apparatus/electronic products: | |||||
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11. Name of radiation safety officer: | |||||
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12. Have any changes been made in the premises,
irradiating apparatus or electronic products which have not been notified to
and approved by the Council? If so, give details: | |||||
|
DATE .................................
............................................................. | |||||
|
* If space is insufficient for any item, attach
supplementary lists signed by the applicant. | |||||
|
* * If irradiating apparatus, enter maximum
kilovolts and milliamps: if electronic products, describe the radiation by its
common name and give wavelength or frequency, if known. | |||||
NOTE: An application for renewal of registration
must be made by the person in whose name the premises, irradiating apparatus
or electronic products are registered. The attention of applicants is drawn to
the responsibilities of that person as set out in the
Radiation Safety Act 1975 and the
Radiation Safety (General) Regulations 1983 .
Form RS 15
Certificate of registration of premises and irradiating apparatus/electronic
products operated or used therein
It is hereby certified that the premises, irradiating apparatus or electronic
products referred to hereunder have been registered under the
Radiation Safety Act 1975 . The registration is subject to all applicable
regulations under that Act and to any conditions, restrictions or limitations
specified below or in any attachments hereto.
|
1. Name of owner of premises, irradiating
apparatus or electronic products*: | ||||
|
2. Address: | ||||
|
3. Occupation: |
4. Telephone No.: | |||
|
5. Registration No.: |
Registration expires: |
Fee: $ | ||
|
6. Particulars and location of premises subject of
registration: | ||||
|
7. PARTICULARS OF IRRADIATING APPARATUS OR
ELECTRONIC PRODUCTS OPERATED OR USED IN PREMISES: | ||||
|
Number |
Maker and type |
Type of radiation |
Purpose |
Location on premises |
|
| ||||
|
8. Name of radiation safety officer: | ||||
|
9. Names of persons licensed or otherwise
authorised to operate or use the irradiating apparatus or electronic products
in the premises: | ||||
|
10. Conditions, restrictions or limitations: | ||||
|
.................................................
............................................................. (This certificate is not valid until it has been
signed by the Secretary of the Radiological Council.) | ||||
|
* As defined in the Radiation Safety Act 1975
, the owner of the premises, irradiating apparatus or electronic products,
includes hirer, lessee, borrower, bailee or mortgagee in possession and any
attorney, agent, manager, foreman, supervisor, or other person in charge or
having control or management and any person acting or representing himself to
be acting for an owner. | ||||
Form RS 16
|
_________________ holds a licence under the Act
for the use of RADIOACTIVE SUBSTANCES (LS / ) IRRADIATING APPARATUS (LX / ) (Delete whichever is not applicable) for the purpose of INDUSTRIAL RADIOGRAPHY _________________ | |
|
Licences held under the Radiation Safety Act 1975 are subject to all
applicable regulations under the Act and to any conditions, restrictions or
limitations imposed when the licence was issued. ....................................................... |
Activity Limits Expiry date Chairman, |
[Schedule II amended: Gazette
29 Nov 1991 p. 5990.]