Form Mrcp 120.100-4 - Radioactive Materials License Application
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4RADIOACTIVE MATERIALS LICENSE APPLICATION
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH, RADIATION CONTROL PROGRAM
INSTRUCTIONS - Complete all items in this application for a new license or the renewal of an existing license. Use supplemental
sheets where necessary. Item 13 must be completed on all applications. Mail the completed application to: Radiation Control Program,
Schrafft Center, Suite 1M2A, 529 Main Street, Charlestown, MA 02129. Upon approval of this application, the applicant will receive
a Commonwealth of Massachusetts Radioactive Material License.
1. THIS IS AN APPLICATION FOR
2.
NAME AND MAILING ADDRESS OF APPLICANT
(Include zip code)
A. NEW LICENSE
B. AMENDMENT TO LIC.NO.
C. RENEWAL OF LICENSE NO.
3. ADDRESSES WHERE LICENSED MATERIAL WILL BE USED OR POSSESSED.
4. NAME OF PERSON TO BE CONTACTED ABOUT THIS
TELEPHONE NUMBER
E-MAIL(OPTIONAL)
APPLICATION
SUBMIT ITEMS 5 THROUGH 12 ON 8½ x 11" PAPER. THE TYPE AND SCOPE OF INFORMATION TO BE PROVIDED IS
DESCRIBED IN THE LICENSE APPLICATION GUIDE.
5. RADIOACTIVE MATERIAL
6.
PURPOSE(S) FOR WHICH LICENSED MATERIAL
a.
Element & mass number;
WILL BE USED.
b. Chemical and/or physical form;
c.
Maximum amount that will be possessed at any one
time.
7. INDIVIDUAL(S) RESPONSIBLE FOR RADIATION
8.
TRAINING FOR INDIVIDUALS WORKING IN OR
SAFETY PROGRAM AND THEIR TRAINING AND
FREQUENTING RESTRICTED AREAS.
EXPERIENCE.
9. FACILITIES AND EQUIPMENT.
10. RADIATION SAFETY PROGRAM
11. WASTE MANAGEMENT (INCLUDE MINIMIZATION
12. CORPORATE STRUCTURE
STATEMENT/PLAN)
ITEM 13 – CERTIFICATE
(This item must be completed)
THE APPLICANT AND ANY OFFICIAL EXECUTING THIS CERTIFICATE ON BEHALF OF THE APPLICANT NAMED IN
ITEM 1, CERTIFY THAT THIS APPLICATION IS PREPARED IN CONFORMITY WITH APPLICABLE STATE
REGULATIONS AND THAT ALL INFORMATION CONTAINED HEREIN, INCLUDING ANY SUPPLEMENTS ATTACHED
HERETO, IS TRUE AND CORRECT TO THE BEST OF OUR KNOWLEDGE AND BELIEF.
By:
TYPE OR PRINT NAME OF CERTIFYING OFFICIAL
SIGNATURE
Date:
TITLE OF CERTIFYING INDIVIDUAL
MRCP 120.100-4
JULY 2006
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