《环境影响登记表》(范例)

核技术应用项目

环境影响登记表

项目名称放射科XX螺旋CT机应用

填表人联系电话

项目联系人联系电话

填报单位全名称崇左市XXX医院

填报单位公章

二O一O年十二月

国家环境保护部监制

填表说明

1.本登记表一式5份，由建设单位填报，报有审批权的环境保护主管部门签署审批意见。

2.凡生产、销售、使用III类射线装置，销售、使用V类放射源的核技术应用项目，均填报本表。

一、项目概况

二、项目拟建设地址及邻近环境状况示意图（如非占用整栋厂房，须注明上下层使用情况）

厚的铅皮、外包不锈钢。防护门上方设有“正在工作”警示信号灯及“当心电离辐射”的警示标志，以防人员误入。该CT机所在的医技楼一层放射科平面布置图见图2。

放射科在用XX层螺旋CT机实物见图3、图4。

图 1 崇左市XXX医院总平面布置示意图

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三、组织结构（一）组织结构图【】（二）组织机构的职责【】组织机构的职责如下：四、控股股东、实际控制人简介【】

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