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Get North Dakota General Radioactive Material License Application Form

APPLICATION FOR GENERAL RADIOACTIVE MATERIAL LICENSE NORTH DAKOTA DEPARTMENT OF HEALTH RADIATION CONTROL PROGRAM SFN 60265 11/2012 INSTRUCTIONS TECHNICALLY ENHANCED NORMALLY OCCURRING RADIOACTIVE MATERIAL TENORM USAGE ONLY. EMAIL A COPY OF THE COMPLETED APPLICATION TO RAM ND. GOV A. New License Name and Mailing Address of Applicant include ZIP Code B. Amendment to License Number C. Renewal of License Number Name of Person to be Contacted about this Application Business Telephone Number Business Cell Phone Number Business Email Address SUBMIT DOCUMENTION FOR ITEMS 4 THROUGH 7. THE TYPE AND SCOPE OF INFORMATION TO BE PROVIDED IS DESCRIBED IN SECTION 8 OF LICENSE APPLICATION GUIDE NUREG-1556 VOLUME 18. Radioactive Material a* Element and mass number e*g* TENORM b. Chemical and/or physical form e*g* filter socks Purpose s for which Licensed Material will be Used e*g* pickup for disposal only. Individual s Responsible for Radiation Safety Training Program* Radiation Safety Training Program License Fee See North Dakota Radiological Health Rule 33-10-11 Amount Enclosed Fee Category 5420. 00 4. C Obtain a Certificate Of Authority from the North Dakota Secretary of State to operate in North Dakota* Call 800 352-0867 Ext. 4284 for more information* 10. Obtain a Permit for Transporting Solid Waste from the North Dakota Department of Health Division of Waste Management. Call 701 328-5166 for more information* 11. Certification must be completed by applicant. The applicant understands that all statements and representations made in this application are binding upon the applicant. The applicant and any official executing this certification on behalf of the applicant named in item 2 certify that this application is prepared in conformity with Radiation Health Chapters 33-10-3. 1 -4. 2 -11 -13. 1 and that all information contained herein is true and correct to the best of their knowledge and belief* Signature Certifying Officer Typed/Printed Name and Title Must Sign in Blue Ink Date A hard copy of this form shall be signed dated and submitted to the Department along with the appropriate license fee. Payment shall be in the form of a check or money order payable to the North Dakota Department of Health. Send to North Dakota Department of Health Division of Air Quality 2nd Floor 918 East Divide Ave. Bismarck ND 58501-1947 Phone 701-328-5188 Fax 701-328-5185 FOR DEPARTMENT USE ONLY TYPE OF FEE FEE CATEGORY AMOUNT RECEIVED Check Number Comments. EMAIL A COPY OF THE COMPLETED APPLICATION TO RAM ND. GOV A. New License Name and Mailing Address of Applicant include ZIP Code B. Amendment to License Number C. Renewal of License Number Name of Person to be Contacted about this Application Business Telephone Number Business Cell Phone Number Business Email Address SUBMIT DOCUMENTION FOR ITEMS 4 THROUGH 7. Amendment to License Number C. Renewal of License Number Name of Person to be Contacted about this Application Business Telephone Number Business Cell Phone Number Business Email Address SUBMIT DOCUMENTION FOR ITEMS 4 THROUGH 7. THE TYPE AND SCOPE OF INFORMATION TO BE PROVIDED IS DESCRIBED IN SECTION 8 OF LICENSE APPLICATION GUIDE NUREG-1556 VOLUME 18..

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