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Consignor’s Declaration

This is to certify that the package containing radioactive material as identified by the
following details is safe for transport by rail,road,sea or air.
Package forwarded by ( Consignor) : M/s. Board of Radiation & Isotope
BRIT.BARC Vashi Complex, Sector 20,
Vashi, Navi Mumbai- 400703
Package address to ( Consignee) : M/s. Patels Radiography Services,
C/21, GIDC, Phase-II, Nr. New Samrat
Namkin, Naroda, Ahmedabad-382330
M. No. 9624000860
Proper Shipping Name : Radioactive Material Type B(U) Package
UN Class of dangerous goods : 7
United Nations No. : UN No. 2916
Subsidiary risk : Nil
Name Of Radioactive Material : IR-192
Quantity/ Activity of Radioactive :
Package details 02 Wooden Box
Dimension of the package : 19”Lx13”Wx13”H & 24”Lx18”Wx9.5”H
Weight of the package : 75 KG.
Type of the package : B(U)
Radiatio level on the surface of the : 0.05mSv/h
package in mSv/h
Transport index of the package : I
Category of the package : II- Yellow

In case of Type B(U)/(M) package , Competent Authority identification number should

also be given
I here by declare that the contents of this consignment are fully and accurately
described above by the proper shipping name and are classified, packed, marked and
labeled, and are in all respects in proper condition for transport according to the AERB
Safety Coad , AERB/SC/TR-I,

Signature of RSO

Date: Name And Address

Seal of the Institution