Application Number: 19-530889(25/10/2019)
APPLICATION TO ATOMIC ENERGY REGULATORY BOARD (AERB) FOR LICENCE FOR
OPERATION OF MEDICAL DIAGNOSTIC X-RAY EQUIPMENT
Application Number
Date of Application
: 19-530889
: 25/10/2019
Part A
Institute Details:
Name
: SARASWATI HOSPITAL
Permanent Address
: NR SHIVALIK SATYAME ,
Landmark
: VAKIL SAHEB BRIDGE S P RING ROAD
City
: AHMEDABAD
State
: GUJARAT
Postal Code
: 380058
Telephone Number
: 09825445497
Fax Number
:
Email Id
: chintan010@gmail.com
Head of the Institute Details:
Name
: MAKKHANLAL AGARWAL
Designation
: PROPRIETOR
Telephone Number(Office)
: 09825445497
Mobile Number
: 9825445497
Email Id
: chintan010@gmail.com
Licensee Details:
Name
: MAKKHANLAL AGARWAL
Designation
Telephone Number(Office)
Mobile Number
Email Id
:
:
:
:
PROPRIETOR
09825445497
9825445497
chintan010@gmail.com
Part B
Employee Details (Radiation Professionals) :
SRL
No
Name
Date of Birth
Name
Designation
Designation
Qualification
Experience
PMS No.
RSO Details :
SRL
NO
PMS No.
Valid Till
Email Id (Off)
Employee Details (Radiation Workers) :
SRL
Name of Radiation Worker
Role
Page 1 of 3
Eduactional
PMS No.
Application Number: 19-530889(25/10/2019)
NO
Qualifications
Safety Tool Details:
SRL
No
Instrument ID
Instrument
Type
Make
Model
Type Of
Detector
Sr. No.
Availability
1
SE-0109187
Protective
Apron
NA
NA
NA
Available
2
SE-0108939
Mobile
NA
Protective
Barrier with
Viewing
Window
NA
NA
Available
3
SE-0108938
Protective
Apron
NA
NA
Available
NA
Last
Calibration
Date
Part C
Equipment Details:
Application for
:
Equipment Id
:
Type of equipment
:
Manufacturer name
:
Model name
:
Name of the person designated as RSO for this :
equipment
Service Agency responsible for QA
:
Licence for operation of new x-ray equipment
G-XR-119744
C-Arm
M/s. Skanray Technologies Private Limited
SKAN C
MAKKHANLAL AGARWAL
MH-35537, RADIATION
Mumbai, Mumbai
PROTECTION
SERVICES,
Part D
UNDERTAKING
I hereby certify that
1.All the information submitted in this application is correct to the best of my knowledge and belief
2.Applicable provisions of the Atomic Energy (Radiation Protection) Rules, 2004 will be strictly complied
with.
3.Applicable provisions of AERB Safety Code on Medical Diagnostic X-ray Equipment and Installations,
AERB/SC/MED- 2 or the revised version, currently in force, will be complied with
4.The equipment will be put into operation only after obtaining 'Licence' from the Competent Authority.
5.Full facilities will be accorded by me/us to any authorised representatives of the competent authority to
inspect this installations at any time;
6.All necessary facilities will be provided to the RSO to discharge his duties and functions effectively.
7.On receipt of 'Licence', I will abide by the Terms and Conditions of 'Licence'
8.Will ensure that I/ nominated RSO will observe 'Duties and Responsibilities of RSO'
9.Keep AERB informed about any changes in the information furnished.
In case, it is found, at any stage, that the information provided by me/us is false and/ or not authentic, then I hereby
accept that appropriate regulatory actions may be initiated against me and my institution, in accordance with the
Page 2 of 3
Application Number: 19-530889(25/10/2019)
applicable Rules.
----------------------------------------------End of Application---------------------------------------------
Page 3 of 3