citysources.list
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RADIOACTIVEMATERIALREGISTRATIONAPPLICATIONStateForm49771(R5/7-15)INDIANADEPARTMENTOFHOMELANDSECURITYRADIATIONPROGRAMS302WestWashingtonStreetIndianapolis,IN46204INSTRUCTIONS:1.
Typeorclearlyprintallinformation.
REGISTRATIONNUMBER2.
Completeallsections.
Missinginformationmaydelayprocessing.
3.
Sendthecompletedformtotheaddressabove.
XN4.
Ifyouhaveanyquestions,e-mailhazmat@dhs.
in.
gov.
TYPEOFAPPLICATIONNewRegistrationTwo(2)YearRenewalAmendmentREGISTRANTINFORMATIONName(NameofCompany/Corporate)TelephonenumberAddress(numberandstreet,city,state,andZIPcode)NameofRadiationSafetyOfficer(RSO)TitleofRSOTelephonenumberofRSOIncludeacopyofthemostrecentamendmenttoyourUSNRC/AgreementStateLicense.
USNRC/AgreementStateLicenseNumber(s)(ifany)USEOFMATERIALS/SOURCESIfmorethanonefacility/locationofuse,pleasecompleteanapplicationforeach.
Facilitywherematerials/sourceswillbeused(ifdifferentfromlocationabove)TelephonenumberoffacilityAddressoffacility(numberandstreet,city,state,andZIPcode)Listthenamesandtitlesofallindividualswhowilluseordirectlysupervisetheuseofradioactivematerials.
Ifmorespaceisneeded,providethelistonaseparatesheet.
AUTHORIZED/INDIVIDUALUSERSNAMETITLE1.
2.
3.
4.
5.
6.
Describethepurposeorusefortheradioactivematerialsandthedepartment(s)and/orprocess(es)whereused:REGISTRATIONAGREEMENTThisagreementshouldbesignedbyapersonwhohaslegalresponsibilityfortheradioactivematerialsatthefacility(e.
g.
Owner,HospitalAdministrator,CompanyPresident,PlantManager,CEO,etc.
).
IunderstandthatfailuretocomplywithIC10-19-11or410IAC5mayresultinrevocationofmymaterialsregistration.
SignatureofresponsibleindividualDateSigned(month,day,year)Typeorprintednameofresponsibleindividual\Title\ContinuedonothersideLISTOFSEALEDSOURCESListallsealedsources.
Attachanotherstreet,ifneeded.
ELE-MENTMASSNUMBERMAXIMUMACTIVITY(Checktheappropriateunits)NAMEOFMANUFACTURERMODEL&SERIALNUMBERTYPEOFDEVICE(e.
g.
flood,calib.
,density,level,XRF,etc.
)NUMBEROFDEVICES.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCiLISTOFRADIOACTIVEMATERIALSListallradioactivematerials.
Attachanotherstreet,ifneeded.
ELE-MENTMASSNUMBERMAXIMUMACTIVITYPOSSESSED(Checktheappropriateunits)CHEMICALAND/ORPHYSICALFORM.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi
Typeorclearlyprintallinformation.
REGISTRATIONNUMBER2.
Completeallsections.
Missinginformationmaydelayprocessing.
3.
Sendthecompletedformtotheaddressabove.
XN4.
Ifyouhaveanyquestions,e-mailhazmat@dhs.
in.
gov.
TYPEOFAPPLICATIONNewRegistrationTwo(2)YearRenewalAmendmentREGISTRANTINFORMATIONName(NameofCompany/Corporate)TelephonenumberAddress(numberandstreet,city,state,andZIPcode)NameofRadiationSafetyOfficer(RSO)TitleofRSOTelephonenumberofRSOIncludeacopyofthemostrecentamendmenttoyourUSNRC/AgreementStateLicense.
USNRC/AgreementStateLicenseNumber(s)(ifany)USEOFMATERIALS/SOURCESIfmorethanonefacility/locationofuse,pleasecompleteanapplicationforeach.
Facilitywherematerials/sourceswillbeused(ifdifferentfromlocationabove)TelephonenumberoffacilityAddressoffacility(numberandstreet,city,state,andZIPcode)Listthenamesandtitlesofallindividualswhowilluseordirectlysupervisetheuseofradioactivematerials.
Ifmorespaceisneeded,providethelistonaseparatesheet.
AUTHORIZED/INDIVIDUALUSERSNAMETITLE1.
2.
3.
4.
5.
6.
Describethepurposeorusefortheradioactivematerialsandthedepartment(s)and/orprocess(es)whereused:REGISTRATIONAGREEMENTThisagreementshouldbesignedbyapersonwhohaslegalresponsibilityfortheradioactivematerialsatthefacility(e.
g.
Owner,HospitalAdministrator,CompanyPresident,PlantManager,CEO,etc.
).
IunderstandthatfailuretocomplywithIC10-19-11or410IAC5mayresultinrevocationofmymaterialsregistration.
SignatureofresponsibleindividualDateSigned(month,day,year)Typeorprintednameofresponsibleindividual\Title\ContinuedonothersideLISTOFSEALEDSOURCESListallsealedsources.
Attachanotherstreet,ifneeded.
ELE-MENTMASSNUMBERMAXIMUMACTIVITY(Checktheappropriateunits)NAMEOFMANUFACTURERMODEL&SERIALNUMBERTYPEOFDEVICE(e.
g.
flood,calib.
,density,level,XRF,etc.
)NUMBEROFDEVICES.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCiLISTOFRADIOACTIVEMATERIALSListallradioactivematerials.
Attachanotherstreet,ifneeded.
ELE-MENTMASSNUMBERMAXIMUMACTIVITYPOSSESSED(Checktheappropriateunits)CHEMICALAND/ORPHYSICALFORM.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi.
pCimCiμCiCi
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