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RAM LICENSE AMENDMENT REQUEST FORM

* Licensee:
* Date of Request:
    (mm/dd/yyyy)
* Requestor Name:
* Requestor Work Phone #:
* Requestor Email Address:
*Are you adding a radionuclide or changing activity limits?   Yes    No
IF ADDING A RADIONUCLIDE OR CHANGING ACTIVITY LIMITS
Please address only the radionuclides to be added or changed.
Radionuclide
Current poss’n
limit (mCi)
Current annual
limit (mCi)
Requested poss’n
limit (mCi)
Requested
annual limit
(mCi)
If you are adding a radionuclide, please specify the monitoring method that you will use:
Include make, model and probe type:

Please also submit a protocol summary form if you are adding a radionuclide or changing an existing protocol.

* Will the requested increase in activity limits change the existing protocol?:
No   Yes
*Are you adding or deleting a room?   Yes    No
IF ADDING / DELETING ROOMS
Please submit a layout of the new area(s) which indicates work areas, hot sinks, fume hood, radioactive waste areas, and entrances. Please complete a room sign request form for the room if it is not already posted:
http://www.ehrs.upenn.edu/programs/labsafety/chp/appendixi.html.
Room Additions Room Deletions
Building
Room
Building
Room
* Are you inactivating the license? No   Yes
If you are inactivating please state the reason (leaving institution, no planned radioactivity work, etc.):

* Indicates required field

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