IOWA DEPARTMENT OF TRANSPORTATION

OFFICE OF MATERIALS

NUCLEAR TLD BADGE CERTIFICATION

I HEREBY CERTIFY THE FOLLOWING:

1. The operator(s) has attended the training course in nuclear testing conducted by the Central Laboratory.

2. All safety practices outlined in Materials IM 206 have been followed.

3. The following individual(s) was wearing a nuclear exposure badge on his front waist, while operating nuclear testing equipment, and that the exposure as determined on the enclosed badges should be indicative of radiation received for the appropriate time period.

EXPOSURE PERIOD/DATE:           From: ____________________ To:

                                                                                                                                       APPROX.

NAME                                           TLD BADGE NO.      GAUGE NO.     HRS. USED

__________________________        _________________        _____________      

__________________________        _________________        _____________      

__________________________        _________________        _____________      

__________________________        _________________        _____________      

__________________________        _________________        _____________      

__________________________        _________________        _____________      

COMMENTS:

            The above information, to the best of my knowledge, is complete and accurate.

                                                           Engineer in Charge                           Date

cc:    Office of Materials Laboratory

         District File