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Environmental Health,Safety & Risk |
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Radioactive
Material Transfer Form
Form 103 |
| Instructions: To comply with 17 CCR 30210, Items 1 through 6 of this form must be completed and submitted to the CSUN Radiation Safety Officer, before transferring the radioactive material specified below. |
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I.
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Isotope: | ||
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II.
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Chemical Form: | ||
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III.
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Activity: | uCi mCi | |
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IV.
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Transferred From: | Environmental Health & Safety | |
| CALIFORNIA STATE UNIVERSITY, NORTHRIDGE | |||
| 18111 NORDHOFF STREET | |||
| NORTHRIDGE, CA 91330-8284 | |||
| STATE OF CALIFORNIA LICENSE #0319-19 | |||
| EXPIRATION DATE: MAY 15, 2007 | |||
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V.
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Transferred To: | ||
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LICENSEE:
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ADDRESS:
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LICENSE
NUMBER:
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EXP. DATE: | ||
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VI.
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CSUN
RSO Approval:
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Signature: _________________________ | Date: _______ |
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VII.
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Transferred By: | Signature: _________________________ | Date: _______ |
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VIII.
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Received By: | Signature: _________________________ | Date: _______ |