Get NM RCB Form 016 2009-2024

RCB Form 016 05/2009 20. 3. 3 NMAC New Mexico Environment Department Submittal of the application is required to determine that the applicant is qualified and that adequate facilities and procedures exist to protect the public health and safety and property. In conformity with 20. 3 NMAC Radiation Protection rules and that all information contained herein is true and correct to the best of their knowledge and belief. PRINTED/TYPED NAME AND TITLE OF CERTIFYING OFFICER SIGNATURE DATE WARNING FALSE STATEMENTS AND INFORMATION PROVIDED IN THIS APPLICATION MAY SUBJECT THE CERTIFYING OFFICIAL TO CIVIL AND/OR CRIMINAL PENALTIES. DEPARTMENT USE ONLY Comments Receipt Date Adm. Complete onPN Outstanding Annual Fees Additional Info Required Application Denied on Application Approved License Issued on RCB FORM 016. Send completed and signed form and attachments to Radiation Control Bureau 1190 St* Francis Drive P. O. Box 5469 Santa Fe New Mexico 87502-5469 FASCIMILE NUMBER 505 476-3232 APPLICATION RADIOACTIVE MATERIALS LICENSE INSTRUCTIONS The appropriate license application guide must be followed when completing this application form* Send two copies of the entire completed application this form and attachments to the Department at the address listed above. The license application guides can be downloaded from the web site http //www. nrc*gov/reading-rm/doc-collections/nuregs/staff/sr1556/ Amendment to a license may be submitted by facsimile listed above. This is an application for Check appropriate item 2. NAME AND MAILING ADDRESS OF THE APPLICANT A. NEW LICENSE PRC No* or Tax Rev* No* FAX NUMBER B. AMENDMENT TO LICENSE NUMBER C. RENEWAL OF LICENSE NUMBER 3. ADDRESS WHERE LICENSED MATERIAL WILL BE USED OR POSSESSED EMAIL 4. NAME OF PERSON TO BE CONTACTED ABOUT THIS TELEPHONE NUMBER Submit Items 5 through 11 as attachments to this application on separate sheets. The type and scope of information to be provided is described in the corresponding license application guide. A web link to the guides is listed above. 6. PURPOSE S FOR WHICH LICENSED MATERIAL WILL a* Element and Mass Number BE USED b. Chemical and/or Physical Form c* Maximum Amount to be Possessed at Any One Time 7. INDIVIDUAL S RESPONSIBLE FOR RADIATION 8. TRAINING FOR INDIVIDUALS WORKING IN OR SAFETY PROGRAM AND THEIR TRAINING EXPERIENCE FREQUENTING RESTRICTED AREAS 9. FACILITIES AND EQUIPMENT 10. RADIATION SAFETY PROGRAM 11. WASTE MANAGEMENT 12. ANNUAL FEES N/A For new applicants only I HAVE PAID ANNUAL FEES DUE I AM ATTACHING PAYMENT WITH THIS APPLICATION 13. CERTIFICATION The applicant understands that all statements and representations made in this application are binding upon the applicant. Send completed and signed form and attachments to Radiation Control Bureau 1190 St* Francis Drive P. O. Box 5469 Santa Fe New Mexico 87502-5469 FASCIMILE NUMBER 505 476-3232 APPLICATION RADIOACTIVE MATERIALS LICENSE INSTRUCTIONS The appropriate license application guide must be followed when completing this application form* Send two copies of the entire completed application this form and attachments to the Department at the address listed above. .