45 SW Form 2254 "Radiation Use Request/Authorization (Ionizing Machine/Device)"

What Is 45 SW Form 2254?

This is a legal form that was released by the U.S. Air Force - 45th Space Wing on November 1, 1991 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 1991;
  • The latest available edition released by the U.S. Air Force - 45th Space Wing;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;

Download a fillable version of 45 SW Form 2254 by clicking the link below or browse more documents and templates provided by the U.S. Air Force - 45th Space Wing.

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Download 45 SW Form 2254 "Radiation Use Request/Authorization (Ionizing Machine/Device)"

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RADIATION USE REQUEST/AUTHORIZATION (Ionizing Machine/Device)
FROM:
(Name)
ORGN/MAIL CODE
DATE
REFERENCE NUMBER
TO: 45 SW RADIATION PROTECTION OFFICER (45 AMDS/SGPS)
I.
MACHINE/DEVICE DESCRIPTION
MANUFACTURER/YEAR
MODEL NUMBER
SERIAL NUMBER
TYPE OF MACHINE/DEVICE
MAXIMUM RATING
PORTABLE
FIXED
OTHER (Specify)
KVP AT
MA
FLORIDA REGISTRATION
YES
NO
N/A
REGISTRATION NUMBER (Attach Copy)
YES
NO
N/A
II.
AREA CHARACTERISTICS/DESCRIPTION (Attach Sketch Or Drawing)
BUILDING
ROOM NUMBER
AREA ZONE NUMBER
KEY CONTROL
INTERLOCKS ON DOOR TO AREA
YES
NO
YES
NO
BRIEF DESCRIPTION OF PROPOSED PROJECT
III.
SYSTEM USERS
IV.
PROCEDURES
AREA RADIATION OFFICER (ARO)
OPERATING PROCEDURES
ACCIDENT/EMERGENCY PROC
USE SUPERVISOR/CUSTODIAN
MAINTENANCE PROCEDURE
USER(S)
(Submit copies as attachments to this request)
VI.
RADIATION PROTECTION REQUIREMENTS
ACCOUNTABILITY
COMPLIANCE WITH 45SWI 40-201
COMPLIANCE WITH KHB 1860.1 (If applicable)
(Submit completed 45 SW Form 2256 for each individual)
V.
PERIOD OF USE (Maximum 1 year)
OTHER
FROM
TO
VII.
AUTHORIZATIONS
HEALTH PHYSICS (If applicable)
DATE
45 SW RADIATION PROTECTION OFFICER
DATE
DATE
KSC RADIATION PROTECTION OFFICER (If applicable)
45 SW RADIATION PROTECTION COMMITTEE
DATE
45 SW FORM 2254, 19911101 (IMT-V1)
RADIATION USE REQUEST/AUTHORIZATION (Ionizing Machine/Device)
FROM:
(Name)
ORGN/MAIL CODE
DATE
REFERENCE NUMBER
TO: 45 SW RADIATION PROTECTION OFFICER (45 AMDS/SGPS)
I.
MACHINE/DEVICE DESCRIPTION
MANUFACTURER/YEAR
MODEL NUMBER
SERIAL NUMBER
TYPE OF MACHINE/DEVICE
MAXIMUM RATING
PORTABLE
FIXED
OTHER (Specify)
KVP AT
MA
FLORIDA REGISTRATION
YES
NO
N/A
REGISTRATION NUMBER (Attach Copy)
YES
NO
N/A
II.
AREA CHARACTERISTICS/DESCRIPTION (Attach Sketch Or Drawing)
BUILDING
ROOM NUMBER
AREA ZONE NUMBER
KEY CONTROL
INTERLOCKS ON DOOR TO AREA
YES
NO
YES
NO
BRIEF DESCRIPTION OF PROPOSED PROJECT
III.
SYSTEM USERS
IV.
PROCEDURES
AREA RADIATION OFFICER (ARO)
OPERATING PROCEDURES
ACCIDENT/EMERGENCY PROC
USE SUPERVISOR/CUSTODIAN
MAINTENANCE PROCEDURE
USER(S)
(Submit copies as attachments to this request)
VI.
RADIATION PROTECTION REQUIREMENTS
ACCOUNTABILITY
COMPLIANCE WITH 45SWI 40-201
COMPLIANCE WITH KHB 1860.1 (If applicable)
(Submit completed 45 SW Form 2256 for each individual)
V.
PERIOD OF USE (Maximum 1 year)
OTHER
FROM
TO
VII.
AUTHORIZATIONS
HEALTH PHYSICS (If applicable)
DATE
45 SW RADIATION PROTECTION OFFICER
DATE
DATE
KSC RADIATION PROTECTION OFFICER (If applicable)
45 SW RADIATION PROTECTION COMMITTEE
DATE
45 SW FORM 2254, 19911101 (IMT-V1)