1300 W. Park Street | Butte, MT 59701 | mtech.edu | 406.496.4463
Radioactive Shipment Receipt Survey
Package condition: OK Punctured Wet Crushed Other __________
DOT radiation label affixed and transport index indicated:
None (limited quantity) WI YII
YIII
TI
Maximum measured direct radiation levels:
Survey instrument used: __________________________________ Serial #:__________________________________
Background reading: _________________________mR/hr Max at package surface ______________________
Max at 1 meter from package surface: ________________________________________
Maximum wipe results:
Survey instrument used: __________________________________ Serial #:__________________________________
Background count rate: _________________________________cpm=-________________________________dpm
Maximum package outer surface: _________________ net cpm/100cm
2
= -
_________________________
dmp/100cm
2
Maximum final container: __________________________net cpm/100cm
2
= - ________________dmp/100cm
2
All Some smears of the container surface did didn’t show removable radioactivity above
background. Exceptions: ________________________________
Did shipping papers and radioactive contents agree?
Radionuclide(s): Yes No Amount (uCi, ect.): Yes No Phys/chem form: Yes No
List any differences: ________________________________________________________________________________
Survey of packing material and cartons: _______________ net cpm = net dpm __________________
Survey of instruments used: _____________________________ Serial number: ______________________
Disposition of packing materials and cartons:
Radioactive waste Conventional waste (labels destroyed) Stored for reuse
Regulatory agency & carrier notification required? Yes No (If yes, fill in below)
Shipment was received in order. There was no indication of leakage or significant contamination, and
no unexpected or abnormal radiation levels. Yes No
Remarks: _____________________________________________________ Signature of Surveyor: _______________
Disposition of radioactive materials after inspection survey:
Material released to: __________________________________
Location: ____________________________________________ Date and time: ___________________________
I certify that I am authorized to receive the above listed radioactive material in accordance with the
Montana Tech NRC license #____________________ Date/time: _______________________________
Reviewed by Radiation Safety Officer: ________________________________
Date: ___________________
