Office Symbol
( ) Date: 5 Sep 08_
MEMORANDUM FOR Commander, I Corps and Fort Lewis, ATTN: IMNW-LEW-SO (Mr. Last Name),
MS 66, Bldg 2007A, Ft. Lewis, WA 98433-5000
Subject: Military Movement of Radioactive Material
1. Unit: __2/75 Ranger Battalion (Airborne)_____
2. UIC: _AORG-SN____
3. Purpose of movement: __Repair or Proper Disposal___
4. Date of departure: __________________ 5. Date of Return:__________________
6. Departing from: __Fort Lewis Washington_______________________
7. Destination: ____________________________________________________________
8. Military Personnel responsible for Items during movement:
Name/Rank:___________________________Phone:_______________________________
9. Visual inspection required of devices containing radioactive material. Inspect for cracks, deformity,
leaks, or power. If found, contact RSO for assistance.
a. Prior to departure: _________________________________ Date:_____________
b. On arrival Location: ________________________________ Date:_____________
c. Prior to return: _____________________________________ Date:_____________
d. On arrival at Home Station:_________________________ Date:_____________
10. Inventory of end Items containing radioactive material:
Item SN: Cell SN: Nomenclature QTY Radionuclide Activity
005174 N/A
ACOG
NSN: 1240-01-412-6608 1 ea H-3 100 mCI
Printed Name: First Mi. Last////Signature:___________________________
“THIS PACKAGE CONFORMS TO CONDITIONS AND LIMITATIONS SPECIFIED IN 49 CFR 173.424 FOR
RADIOACTIVE MATERIAL, EXEPTED PACKAGE FOR ARTICLES AND INSTRUMENTS, Per Table 7, “declare that
all of the applicable air transport requirements have been met.” UN2911
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