Form RSR-EPR10: HASS recordOfficial sensitive- REGULATORY (when filled in)

HASS Record

RSR‐EPR10, Version 29 January 2014 (based on EA Version 2 April 2011) Offical Sensitive- REGULATORY (when filled in) page 1 of 3

Form RSR-EPR10: HASS recordOfficial sensitive- REGULATORY (when filled in)

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

1Making and amending records

2Identifying the source

3Identifying the HASS holder

4Location of HASS

5Your permit

6Operational information

7Characterising the source

8Receipt of HASS

9Source transfer

10Further information

RSR‐EPR10, Version 29 January 2014 (based on EA Version 2 April 2011) Offical Sensitive- REGULATORY (when filled in) page 1 of 3

Form RSR-EPR10: HASS recordOfficial sensitive- REGULATORY (when filled in)

1Making and amending records

1aDate record made

1bReplaces record made on

1cAmends information about

1dBelow exemption level on

1eContact name for this record

1fContact’s telephone number

2Identifying the source

2aSource identifying number

2bName of source manufacturer or supplier

2cAddress of source manufacturer or supplier

Postcode

2dEquipment identifying number

2eName of equipment manufacturer

2fEquipment manufacturer’s address

Postcode

2Identifying the source, continued

2gPractice

2hAssociated activity

3Identifying the HASS holder

3aHolder’s name

3bHolder’s address

Postcode

3cOrganisation’s identifier

3dType of holder

ManufacturerSupplier

UserStorage

4Location of HASS

4aUse

FixedMobile

4bUsual source location

Postcode

4Location of HASS, continued

4cOther source location

Postcode

5Your permit

5aPermit number

5bDate it became effective

5cDate of expiry

6Operational information

7Characterising the source

7aRadionuclide

7bDate of manufacture7cActivity at that date

7dOther reference date7eActivity at that date

7fPhysical and chemical characteristics

7gSource type

7hCapsule identification

7iISO classification

7jANSI classification

7kSpecial form certificate number

7Characterising the source, continued

7lDate of expiry of special form certificate

8Receipt of HASS

8aDate of receipt of this source

8bName of consignor

8bAddress of consignor

Postcode

8dType of consignor

ManufacturerSupplier

User

9Source transfer

9aDate of transfer of this source

9bName of recipient

9cAddress of recipient

Postcode

9dType of recipient

ManufacturerSupplier

UserStorage

RecycleDisposal

9eRecipient’s permission number

10Further information

10aDate of loss10bDate of theft

10cDate of recovery

RSR‐EPR10, Version 29 January 2014 (based on EA Version 2 April 2011) Offical Sensitive- REGULATORY (when filled in) page 1 of 3

Form RSR-EPR10: HASS recordOfficial sensitive- REGULATORY (when filled in)

For regulator’s use only

RSR‐EPR10, Version 29 January 2014 (based on EA Version 2 April 2011) Offical Sensitive- REGULATORY (when filled in) page 1 of 3

Form RSR-EPR10: HASS recordOfficial sensitive- REGULATORY (when filled in)

Premises regulator

Date regulator’s record made

Date report received

RSR‐EPR10, Version 29 January 2014 (based on EA Version 2 April 2011) Offical Sensitive- REGULATORY (when filled in) page 1 of 3