辐射安全许可证延续申请表

辐射安全许可证延续申请表 受理编号: 受理日期: 年 月 日 辐射安全许可证延 续 申 请 表 申请文号: 申请单位 ,盖章, 申请日期 the responsible unit fined 200 Yuan, construction person in charge a fine of 50 Yuan. (8) no permit to work and the job in accordance with the provisions, on the job unit fined 300 yuan, the unit will charge a fine of 100 Yuan. 7.5.3 accident penalties (1) injuries fatalities directly punished 1~2 million. Direct responsibility for the accident and have the corresponding responsibility of leadership, such as concerning administrative sanctions, should be brought to the company or the relevant Department. (2) personal injury accident occurred, the direct punishment 0.5-10,000 yuan, responsible for the direct responsibility for the accident and the responsibility of leadership, such as concerning administrative sanctions should be dealt with by the personnel Department of the company. (3) personal injury accident occurs, the direct punishment 500-1000, who is directly responsible for the accident responsibility, give notice of criticism and 50-100 economic sanctions against them. (4) to conceal the accident, reported without undue delay or false, to inform the administrative leadership of the criticism, resulting in serious consequences, the pursuit of leadership, along with 500-1000 punishment. (5) significant near miss should be attempted as the case of responsible for the accident and construction team injuries accident penalty provisions, mutatis mutandis. Eight, should perform in the construction standards and specifications, serial number a 1 GB3323-2005 填 表 说 明 一、本表用于申请延续辐射工作安全许可证～此表一式两份～许可证审批机关及其下一级环境保护行政主管部门各存一份备案。 二、申请表封面右上角框内内容由环境保护主管部门填写。 二、申请单位应如实填写～内容准确完整～涂改无效。所附材料均使用A4规格纸打印,宋体小4号,或复印～并加盖申请单位骑缝章。 四、申请单位填写完毕～报国家审批的～送交所在地省环保行政部门～由省环保行政部门初审合格后报送国家环保部～经批准后发给许可证,报省级审批的～送交所在地省辖市环保行政部门～由设区的市级环保行政部门初审合格后报送省环保行政部门～经批准后发给许可证。 三、申请活动的种类和范围 ,一,申请活动种类分为生产、销售、使用。 ,二,申请活动范围分为?类放射源、?类放射源、?类放射源、?类放射源、?类放射源、?类射线装置、?类射线装置、?类射线装置。(具体分类见附件1～2) ,三,申请活动种类和范围填写申请许可种类和申请许可范围的组合～如生产?类放射源和?类放射源～使用?类射线装置。 ,四,特别的～生产、销售、使用非密封放射性物质的～申请活动种类和范围填写甲级非密封放射性物质工作场所、乙级非密封放射性物质工作场所或丙级非密封放射性物质工作场所。,具体分类见附件3, 建造?类射线装置的～填写销售,含建造,?类射线装置。 四、辐射安全许可内容延续申请应按环境影响评价文件中的放射性同位素与射线装置生产、销售、使用规模和内容进行填写。 2005-is. Eight, should perform in the construction standards and specifications, serial number a 1 GB3323n team injuries accident penalty provisions, mutatis mutand1000 punishment. (5) significant near miss should be attempted as the case of responsible for the accident and constructio-ting in serious consequences, the pursuit of leadership, along with 500strative leadership of the criticism, resul100 economic sanctions against them. (4) to conceal the accident, reported without undue delay or false, to inform the admini-s directly responsible for the accident responsibility, give notice of criticism and 501000, who i-e dealt with by the personnel Department of the company. (3) personal injury accident occurs, the direct punishment 500ct responsibility for the accident and the responsibility of leadership, such as concerning administrative sanctions should b10,000 yuan, responsible for the dire-or the relevant Department. (2) personal injury accident occurred, the direct punishment 0.5 the corresponding responsibility of leadership, such as concerning administrative sanctions, should be brought to the companyhave n. 7.5.3 accident penalties (1) injuries fatalities directly punished 1~2 million. Direct responsibility for the accident andto work and the job in accordance with the provisions, on the job unit fined 300 yuan, the unit will charge a fine of 100 Yuathe responsible unit fined 200 Yuan, construction person in charge a fine of 50 Yuan. (8) no permit 2 附件1 放 射 源 分 类 表 I类源 II类源 III类源 IV类源 V类源 核素名称 (贝可) (贝可) (贝可) (贝可) (贝可) 13111084Am-241 ?6×10 ?6×10 ?6×10 ?6×10 ?1×10 13111084Am-241/Be ?6×10 ?6×10 ?6×10 ?6×10 ?1×10 14121196Au-198 ?2×10 ?2×10 ?2×10 ?2×10 ?1×10 14121196Ba-133 ?2×10 ?2×10 ?2×10 ?2×10 ?1×10 161413117C-14 ?5×10 ?5×10 ?5×10 ?5×10 ?1×10 161413116Cd-109 ?2×10 ?2×10 ?2×10 ?2×10 ?1×10 151312107Ce-141 ?1×10 ?1×10 ?1×10 ?1×10 ?1×10 14121195Ce-144 ?9×10 ?9×10 ?9×10 ?9×10 ?1×10 13111084Cf-252 ?2×10 ?2×10 ?2×10 ?2×10 ?1×10 161413116Cl-36 ?2×10 ?2×10 ?2×10 ?2×10 ?1×10 13111085Cm-242 ?4×10 ?4×10 ?4×10 ?4×10 ?1×10 13111084Cm-244 ?5×10 ?5×10 ?5×10 ?5×10 ?1×10 14121196Co-57 ?7×10 ?7×10 ?7×10 ?7×10 ?1×10 13111085Co-60 ?3×10 ?3×10 ?3×10 ?3×10 ?1×10 151312107Cr-51 ?2×10 ?2×10 ?2×10 ?2×10 ?1×10 13111084Cs-134 ?4×10 ?4×10 ?4×10 ?4×10 ?1×10 14121194Cs-137 ?1×10 ?1×10 ?1×10 ?1×10 ?1×10 13111086Eu-152 ?6×10 ?6×10 ?6×10 ?6×10 ?1×10 13111086Eu-154 ?6×10 ?6×10 ?6×10 ?6×10 ?1×10 171514126Fe-55 ?8×10 ?8×10 ?8×10 ?8×10 ?1×10 151312107Gd-153 ?1×10 ?1×10 ?1×10 ?1×10 ?1×10 14121195Ge-68 ?7×10 ?7×10 ?7×10 ?7×10 ?1×10 181615139H-3 ?2×10 ?2×10 ?2×10 ?2×10 ?1×10 14121195Hg-203 ?3×10 ?3×10 ?3×10 ?3×10 ?1×10 14121196I-125 ?2×10 ?2×10 ?2×10 ?2×10 ?1×10 14121196I-131 ?2×10 ?2×10 ?2×10 ?2×10 ?1×10 13111084Ir-192 ?8×10 ?8×10 ?8×10 ?8×10 ?1×10 2005-r a 1 GB3323bedent penalty provisions, mutatis mutandis. Eight, should perform in the construction standards and specifications, serial num(5) significant near miss should be attempted as the case of responsible for the accident and construction team injuries acci 1000 punishment.-strative leadership of the criticism, resulting in serious consequences, the pursuit of leadership, along with 500100 economic sanctions against them. (4) to conceal the accident, reported without undue delay or false, to inform the admini-1000, who is directly responsible for the accident responsibility, give notice of criticism and 50-curs, the direct punishment 500ing administrative sanctions should be dealt with by the personnel Department of the company. (3) personal injury accident oc10,000 yuan, responsible for the direct responsibility for the accident and the responsibility of leadership, such as concern-t 0.5ons, should be brought to the company or the relevant Department. (2) personal injury accident occurred, the direct punishmensanctit responsibility for the accident and have the corresponding responsibility of leadership, such as concerning administrative he unit will charge a fine of 100 Yuan. 7.5.3 accident penalties (1) injuries fatalities directly punished 1~2 million. Direccordance with the provisions, on the job unit fined 300 yuan, tthe responsible unit fined 200 Yuan, construction person in charge a fine of 50 Yuan. (8) no permit to work and the job in ac — 3 — 161413114Kr-85 ?3×10 ?3×10 ?3×10 ?3×10 ?1×10 14121196Mo-99 ?3×10 ?3×10 ?3×10 ?3×10 ?1×10 13111086Nb-95 ?9×10 ?9×10 ?9×10 ?9×10 ?1×10 161413118Ni-63 ?6×10 ?6×10 ?6×10 ?6×10 ?1×10 Np-237 13111083?7×10 ?7×10 ?7×10 ?7×10 ?1×10 (Pa-233) 161413115P-32 ?1×10 ?1×10 ?1×10 ?1×10 ?1×10 161413118Pd-103 ?9×10 ?9×10 ?9×10 ?9×10 ?1×10 161413117Pm-147 ?4×10 ?4×10 ?4×10 ?4×10 ?1×10 13111084Po-210 ?6×10 ?6×10 ?6×10 ?6×10 ?1×10 13111084Pu-238 ?6×10 ?6×10 ?6×10 ?6×10 ?1×10 13111084Pu-239/Be ?6×10 ?6×10 ?6×10 ?6×10 ?1×10 13111084Pu-239 ?6×10 ?6×10 ?6×10 ?6×10 ?1×10 13111083Pu-240 ?6×10 ?6×10 ?6×10 ?6×10 ?1×10 13111084Pu-242 ?7×10 ?7×10 ?7×10 ?7×10 ?1×10 13111084Ra-226 ?4×10 ?4×10 ?4×10 ?4×10 ?1×10 151312105Re-188 ?1×10 ?1×10 ?1×10 ?1×10 ?1×10 Ru-103 14121196?1×10 ?1×10 ?1×10 ?1×10 ?1×10 (Rh-103m) Ru-106 14121195?3×10 ?3×10 ?3×10 ?3×10 ?1×10 (Rh-106) 161413118S-35 ?6×10 ?6×10 ?6×10 ?6×10 ?1×10 14121196Se-75 ?2×10 ?2×10 ?2×10 ?2×10 ?1×10 161413116Sr-89 ?2×10 ?2×10 ?2×10 ?2×10 ?1×10 Sr-90 151312104?1×10 ?1×10 ?1×10 ?1×10 ?1×10 (Y-90) m14121197Tc-99 ?7×10 ?7×10 ?7×10 ?7×10 ?1×10 Te-132 13111087?3×10 ?3×10 ?3×10 ?3×10 ?1×10 (I-132) 13111084Th-230 ?7×10 ?7×10 ?7×10 ?7×10 ?1×10 161413114Tl-204 ?2×10 ?2×10 ?2×10 ?2×10 ?1×10 161413116Tm-170 ?2×10 ?2×10 ?2×10 ?2×10 ?1×10 2005-is. Eight, should perform in the construction standards and specifications, serial number a 1 GB3323n team injuries accident penalty provisions, mutatis mutand1000 punishment. (5) significant near miss should be attempted as the case of responsible for the accident and constructio-ting in serious consequences, the pursuit of leadership, along with 500strative leadership of the criticism, resul100 economic sanctions against them. (4) to conceal the accident, reported without undue delay or false, to inform the admini-s directly responsible for the accident responsibility, give notice of criticism and 501000, who i-e dealt with by the personnel Department of the company. (3) personal injury accident occurs, the direct punishment 500ct responsibility for the accident and the responsibility of leadership, such as concerning administrative sanctions should b10,000 yuan, responsible for the dire-or the relevant Department. (2) personal injury accident occurred, the direct punishment 0.5 the corresponding responsibility of leadership, such as concerning administrative sanctions, should be brought to the companyhave n. 7.5.3 accident penalties (1) injuries fatalities directly punished 1~2 million. Direct responsibility for the accident andto work and the job in accordance with the provisions, on the job unit fined 300 yuan, the unit will charge a fine of 100 Yuathe responsible unit fined 200 Yuan, construction person in charge a fine of 50 Yuan. (8) no permit 4 151312105Y-90 ?5×10 ?5×10 ?5×10 ?5×10 ?1×10 151312106Y-91 ?8×10 ?8×10 ?8×10 ?8×10 ?1×10 14121197Yb-169 ?3×10 ?3×10 ?3×10 ?3×10 ?1×10 14121196Zn-65 ?1×10 ?1×10 ?1×10 ?1×10 ?1×10 13111086Zr-95 ?4×10 ?4×10 ?4×10 ?4×10 ?1×10 5 注:1(Am-241用于固定式烟雾报警器时的豁免值为1×10贝可。 2(核素份额不明的混合源～按其危险度最大的核素分类～其总活度视为该核素的活 10度。3. 1Ci=3.7×10Bq 附件2 射 线 装 置 分 类 装置类别 医用射线装置 非医用射线装置 生产放射性同位素的加速器,不含制备 PET用放射性药物的加速器, ?类射线装置 能量大于100兆电子伏的加速器 放射治疗用加速器 工业探伤加速器 制备正电子发射计算机断层 显像装置,PET,用放射性药安全检查用加速器 物的加速器 质子治疗装置 辐照装置用加速器 ?类射线装置 重离子治疗加速器 其他非医用加速器 其他医用加速器 中子发生器 X射线深部治疗机 工业用X射线CT机 数字减影血管造影装置 X射线探伤机 医用X射线CT机 行李包裹X射线安检装置 放射诊断用普通X射线机 X射线衍射仪 ?类射线装置 计算机X射线摄影装置 兽医用X射线机 数字化X射线摄影装置 其他非医用X射线机 牙科X射线机 2005-r a 1 GB3323bedent penalty provisions, mutatis mutandis. Eight, should perform in the construction standards and specifications, serial num(5) significant near miss should be attempted as the case of responsible for the accident and construction team injuries acci 1000 punishment.-strative leadership of the criticism, resulting in serious consequences, the pursuit of leadership, along with 500100 economic sanctions against them. (4) to conceal the accident, reported without undue delay or false, to inform the admini-1000, who is directly responsible for the accident responsibility, give notice of criticism and 50-curs, the direct punishment 500ing administrative sanctions should be dealt with by the personnel Department of the company. (3) personal injury accident oc10,000 yuan, responsible for the direct responsibility for the accident and the responsibility of leadership, such as concern-t 0.5ons, should be brought to the company or the relevant Department. (2) personal injury accident occurred, the direct punishmensanctit responsibility for the accident and have the corresponding responsibility of leadership, such as concerning administrative he unit will charge a fine of 100 Yuan. 7.5.3 accident penalties (1) injuries fatalities directly punished 1~2 million. Direccordance with the provisions, on the job unit fined 300 yuan, tthe responsible unit fined 200 Yuan, construction person in charge a fine of 50 Yuan. (8) no permit to work and the job in ac — 5 — 乳腺X射线机 放射治疗模拟定位机 其他医用X射线机 附件3 非 密 封 源 工 作 场 所 的 分 级 级别 日等效最大操作量～Bq 9 甲 ,4×10 79乙 2×10，4×10 7丙 豁免活度值以上，2×10 注:放射性核素的日等效操作量等于放射性核素的实际日操作量,Bq,与该核素毒性组别修正因子的积除以与操作方式有关的修正因子所得的商。放射性核素毒性组别修正因子～操作方式有关的修正因子及放射性核素的毒性分组～根据《电离辐射防护与辐射源安全基本标准》,GB18871-2002,附录C～附录D确定。 辐射安全许可证延续申请表 申请单位名称 申请单位地址 邮 编 名称 地址 负责人 工作场所 名称 地址 负责人 名称 地址 负责人 姓名 单位电话 法定代表人 证件类型 号 码 申请延续的活动许可证编号 川环辐证[ ] 种类和范围 原有效期 年 月 日 至 年 月 日 环评批复时间 环评批复文号 2005-is. Eight, should perform in the construction standards and specifications, serial number a 1 GB3323n team injuries accident penalty provisions, mutatis mutand1000 punishment. (5) significant near miss should be attempted as the case of responsible for the accident and constructio-ting in serious consequences, the pursuit of leadership, along with 500strative leadership of the criticism, resul100 economic sanctions against them. (4) to conceal the accident, reported without undue delay or false, to inform the admini-s directly responsible for the accident responsibility, give notice of criticism and 501000, who i-e dealt with by the personnel Department of the company. (3) personal injury accident occurs, the direct punishment 500ct responsibility for the accident and the responsibility of leadership, such as concerning administrative sanctions should b10,000 yuan, responsible for the dire-or the relevant Department. (2) personal injury accident occurred, the direct punishment 0.5 the corresponding responsibility of leadership, such as concerning administrative sanctions, should be brought to the companyhave n. 7.5.3 accident penalties (1) injuries fatalities directly punished 1~2 million. Direct responsibility for the accident andto work and the job in accordance with the provisions, on the job unit fined 300 yuan, the unit will charge a fine of 100 Yuathe responsible unit fined 200 Yuan, construction person in charge a fine of 50 Yuan. (8) no permit 6 验收批复时间 验收批复文号 联 系 人 联系电话 所附材料:(请在所提供材料前的?内打“?”) ?1.辐射安全许可证正、副本复印件 ?2各年度辐射安全和防护状况年度自查评估报告 ?3.各年度市级(含)以上环境保护部门辐射环境监测机构出具的辐射环境与辐射防护效果监测报告 ?4.各年度辐射工作单位开展的辐射环境与辐射防护效果自我检测报告 ?5.各年度辐射工作人员个人剂量监测报告 ?6.环境保护主管部门提供的其他资料: 详见《辐射安全许可证》延续办事指南 。 所附申报材料应按以上顺序排列，使用明显的标志区分，并装订成册。 法定代表人声明:本申请表所提供的全部资料均为真实信息。本人已熟悉《放射性同位素与射线装置安全和防护条例》(国务院令第449号)的要求，愿依法对本申请表的申请事项的安全和防护工作负责，并依法对其造成的放射性危害承担责任。 法定代表人签字: 日期: 2005-r a 1 GB3323bedent penalty provisions, mutatis mutandis. Eight, should perform in the construction standards and specifications, serial num(5) significant near miss should be attempted as the case of responsible for the accident and construction team injuries acci 1000 punishment.-strative leadership of the criticism, resulting in serious consequences, the pursuit of leadership, along with 500100 economic sanctions against them. (4) to conceal the accident, reported without undue delay or false, to inform the admini-1000, who is directly responsible for the accident responsibility, give notice of criticism and 50-curs, the direct punishment 500ing administrative sanctions should be dealt with by the personnel Department of the company. (3) personal injury accident oc10,000 yuan, responsible for the direct responsibility for the accident and the responsibility of leadership, such as concern-t 0.5ons, should be brought to the company or the relevant Department. (2) personal injury accident occurred, the direct punishmensanctit responsibility for the accident and have the corresponding responsibility of leadership, such as concerning administrative he unit will charge a fine of 100 Yuan. 7.5.3 accident penalties (1) injuries fatalities directly punished 1~2 million. Direccordance with the provisions, on the job unit fined 300 yuan, tthe responsible unit fined 200 Yuan, construction person in charge a fine of 50 Yuan. (8) no permit to work and the job in ac — 7 — 辐射安全许可内容 ,一,放射源 ,本表按设计规模量填写, 规划生产、销售、 规划生产、销售、 规划设计的 规划装置 工作场所 使用的放射性 使用的放射性 放射性总活度 活动种类 名 称 名 称 核素名称 核素类别 (贝可) 8 辐射安全许可内容 ,二,非密封放射性物质 ,本表按规划设计规模量填写, 规划设计的 规划设计的 工作场工作场所 规划设计的 日等效最大操作量 最大等效年用量 活动种类 所名称 等 级 放射性核素名称 (贝可) (贝可) — 9 — 辐射安全许可内容 ,三,射线装置 ,本表按规划设计规模量填写, 规划装置 规划生产、销售、 规划生产、销售、 工作场所 活动种类 名 称 使用的射线装置类别 使用的射线装置数量 名 称 10 辐射安全与环境保护管理机构 及专/兼职管理人员表 机构名称 电 话 管理人员 姓 名 性别 职务或职称 工作部门 专/兼职 负责人 负责人 负责人 成 员 成 员 成 员 成 员 成 员 成 员 成 员 成 员 成 员 — 11 — 监测设备、报警仪器和辐射防护用品登记表 仪器名称 型 号 购置日期 仪 器 状 态 备 注 辐射防护用品 (含个人剂量 监测) 12 辐射工作人员登记表 辐射安全性年工作岗姓 名 毕 业 学 校 学历及专业 与防护培备 注 别 龄 位 训时间 — 13 — 下一级环境保护行政主管部门意见: (公章) 负责人: 年 月 日 经办人: 年 月 日 负责审批许可证的环境保护行政主管部门意见: (公章) 负责人: 年 月 日 经办人: 年 月 日 14