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KVp Max. mA Fixed Mobile Portable Use Column 10 Use Cardiac Cath. /Interventional CC Diagnostic Rad DR Therapeutic TH Chiropractic CH Dental DT Podiatry PD Veterinary VT Signature of User STATE BOARD OF HEALTH ADPH-RAD-69/Rev. 11-04 I. STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH Registration Number Date Registered APPLICATION FOR REGISTRATION OF SOURCES OF RADIATION see reverse for instruction Under the provisions of Title 22 Chapter 14 of Alabama the State Board of Health is designated as the State Radiation Control Agency and authorized to maintain a file of registrants possessing x-ray machines or other machines and devices producing ionizing radiation* The applicant applies for registration pursuant to 420-3-26. 05 a or b. I. Applicant Person Corporation Agency etc* County Address Street City Zip Phone II. Location of unit if different from above address III. Person responsible for radiation control IV. X-ray equipment and fluoroscopes Room Manufacturer control panel Model Serial Machine Type Number of Tubes Column 5 Machine Type Bone Densitometer BD Computed Tomography CT Mammography Mam Therapy Ther Date Combination Comb Fluoroscopic Fluor Radiographic Rad Max. The legal name and address of the facility. Please include any titles M. D. etc* II. The physical location of the facility if different from I. Note P. O. Boxes are not acceptable but route boxes are. III. The management representative responsible for the operation of the x-ray equipment. IV. Column 1. Room location of the unit registered if applicable. See code on front. Number of tubes operated by the control panel* Column 7. STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH Registration Number Date Registered APPLICATION FOR REGISTRATION OF SOURCES OF RADIATION see reverse for instruction Under the provisions of Title 22 Chapter 14 of Alabama the State Board of Health is designated as the State Radiation Control Agency and authorized to maintain a file of registrants possessing x-ray machines or other machines and devices producing ionizing radiation* The applicant applies for registration pursuant to 420-3-26. 05 a or b. I. Applicant Person Corporation Agency etc* County Address Street City Zip Phone II. Location of unit if different from above address III. 05 a or b. I. Applicant Person Corporation Agency etc* County Address Street City Zip Phone II. Location of unit if different from above address III. Person responsible for radiation control IV. X-ray equipment and fluoroscopes Room Manufacturer control panel Model Serial Machine Type Number of Tubes Column 5 Machine Type Bone Densitometer BD Computed Tomography CT Mammography Mam Therapy Ther Date Combination Comb Fluoroscopic Fluor Radiographic Rad Max. The legal name and address of the facility. Please include any titles M. D. etc* II. The physical location of the facility if different from I. Note P. O. Boxes are not acceptable but route boxes are. III. The management representative responsible for the operation of the x-ray equipment.

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Keywords relevant to Adph Rad 69

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  • III
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  • Densitometer
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