045-2 Wyo. Code R. § 2-7
The application and permit forms shall be generally as set forth in the following:
WYOMING DEPARTMENT OF TRANSPORTATION
Radioactive Waste Transportation Permit Application Form
for a
PERMANENT PERMIT
TEMPORARY PERMIT (for only one trip as described in the following)
1. ___________________________________________________________________
Name of carrier
2. ___________________________________________________________________
Address and regular business telephone number of carrier
3. ___________________________________________________________________
Contact person and 24-hour emergency telephone number that will always be answered
4. General description of radioactive waste intended for transport, including type of material, estimated number of shipments and packages, description of packages, and estimated radioactivity per shipment (precise information not necessary if unavailable):
_____________________________________________________________________
_____________________________________________________________________
5. Description of mode of transportation, route or routes to be taken, and approximate schedule (precise information not necessary if unavailable):
_____________________________________________________________________
_____________________________________________________________________
6. Describe any violations by applicant of local, state, or federal regulations in the past year relating to radioactive waste transportation. (If none, so state. Completing this section is voluntary except in the case of an accident resulting in the release of radioactivity.):
_____________________________________________________________________
_____________________________________________________________________
7. Other information that might be helpful in case of an accident involving radioactive waste (Completing this section is voluntary.):
_____________________________________________________________________
_____________________________________________________________________
READ CAREFULLY BEFORE SIGNING I hereby certify that the information given to obtain the requested permit is true and correct. I hereby certify that the carrier has a 24-hour telephone number for all persons for whom the carrier is transporting radioactive waste under the permit. The carrier agrees to pay all emergency response fees (at the rate of $200 per package transported) to become due under the rules and reporting requirements of the Wyoming Department of Transportation, Accounting Program, 5300 Bishop Blvd., Cheyenne, Wyoming 82009. The carrier agrees to obey all placarding and safety requirements for transporting radioactive waste as set forth in Title 49 of the Code of Federal Regulations (C.F.R.). I understand that, if this application is for a permanent permit, I may transport radioactive waste within and through Wyoming for 30 days after the application date set forth in the following without a permit, that I shall pay all applicable emergency response fees associated with such transportation, and that I shall obey all applicable radioactive waste transportation safety regulations during this time. I understand the shipper's duty to provide supplemental information under the rules of the Wyoming Department of Transportation. I understand that, if this application is for a temporary permit, I may elect to pay my emergency response fees at the time the permit is granted or to pay quarterly as billed to me by the Wyoming Department of Transportation, Accounting Program, 5300 Bishop Blvd., Cheyenne, Wyoming 82009. Based on the foregoing, I hereby apply for a permanent/temporary (circle one) permit to transport radioactive waste within and through Wyoming.
Carrier
Name: _______________________________________________________________
By: _____________________________________________ Date _______________
Signature of Authorized Representative
Wyoming DOT Docket No. M- ____________________ Permit No. _______________
PERMIT TO TRANSPORT RADIOACTIVE WASTE
(Issued pursuant to W.S. 37-14-103 )
Granted to the preceding carrier, for radioactive waste transportation as described in this application, on _______________ , ____, at ________ am pm (circle one) by ______________________ at ___________________ , Wyoming. (Station and clerk number [for temporary permit] if applicable: ___________________________ .)
___________________________________
SIGNATURE OF ISSUING AUTHORITY
SHIPPER PLEASE NOTE: This is one of two documents that shall be carried to transport radioactive waste within or through Wyoming. Both the Emergency Response Fee Report for the load being transported and a copy of the Permit to Transport Radioactive Waste shall be carried with the load being transported.
Wyo DOT Form RWT-1 (10-91) Motor Carrier
045-2 Wyo. Code R. § 2-7