Form RSR-EPR16: HASS record OFFICIAL - SENSITIVE (when filled in)

High Activity Sealed Source (HASS) record Form RSR-EPR16

Please read the guidance notes on this form carefully before you complete this record.

This form should be submitted in hard copy only – and not electronically.

Contents

1 Making and amending records2 Identifying the source3 Identifying the HASS holder4 Location of HASS5 Your permit6 Operational information7 Characterising the source8 Receipt of HASS9 Source transfer10 Further information

1 Making and amending records1a Date record made

1b Replaces record made on

1c Amends information about

1d Below HASS activity threshold level on

1e Contact name for this record

1f Contact’s telephone number

2 Identifying the source2a Source identifying number

2b Name of source manufacturer or supplier

2c Address of source manufacturer or supplier

Postcode

2d Equipment identifying number

2e Name of equipment manufacturer

2f Equipment manufacturer’s address

Postcode

RSR-EPR16, NRW Version 2 May 2018 OFFICIAL – SENSITIVE (when filled in) page 1 of 3

Form RSR-EPR16: HASS record OFFICIAL - SENSITIVE (when filled in)

2 Identifying the source, continued2g Practice

2h Associated activity

3 Identifying the HASS holder3a Holder’s name

3b Holder’s address

Postcode

3c Organisation’s identifier

3d Type of holderManufacturer Supplier User Storage

4 Location of HASS4a UseFixed Mobile

4b Usual source location

Postcode

4 Location of HASS, continued4c Other source location

Postcode

5 Your permit5a Permit number

5b Date it became effective

5c Date of expiry

6 Operational information

7 Characterising the source7a Radionuclide

7b Date of manufacture 7c Activity at that date

7d Other reference date 7e Activity at that date

7f Physical and chemical characteristics

7g Source type

7h Capsule identification

7i ISO classification

7j ANSI classification

7k Special form certificate number

RSR-EPR16, NRW Version 2 May 2018 OFFICIAL – SENSITIVE (when filled in) page 2 of 3

Form RSR-EPR16: HASS record OFFICIAL - SENSITIVE (when filled in)

7 Characterising the source, continued7l Date of expiry of special form certificate

8 Receipt of HASS8a Date of receipt of this source

8b Name of consignor

8b Address of consignor

Postcode

8d Type of consignorManufacturer Supplier User

9 Source transfer9a Date of transfer of this source

9b Name of recipient

9c Address of recipient

Postcode

9d Type of recipientManufacturer Supplier User Storage Recycle Disposal

9e Recipient’s permission number

10 Further information10a Date of loss 10b Date of theft

10c Date of recovery

For regulator’s use onlyPremises regulator

Date regulator’s record made

Date report received

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