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DATE SIGNED 21. CERTIFYING ORGANIZATION 22. SIGNATURE OF DESIGNEE ROUTINE 12. LDE NRC FORM 4 08-2014 19. SIGNATURE OF MONITORED INDIVIDUAL INSTRUCTIONS AND ADDITIONAL INFORMATION PERTINENT TO THE COMPLETION OF NRC FORM 4 All doses should be stated in rems 11A. The licensee or employer who chooses to countersign the form should have on file documentation of all the information on the NRC Form 4 being signed. designated representative. PAGE OF NRC .

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