Get CA RH 2050 2007-2024

State of California Health and Human Services Agency California Department of Public Health Radiologic Health Branch RADIOACTIVE MATERIAL LICENSE APPLICATION Instructions 1 Refer to Guide for Applicants RH 2051. 2 Where space provided on this form is insufficient attach supplemental sheets referencing the part being expanded* 3 Submit ALL material in duplicate to California Department of Public Health Radiologic Health Branch Licensing Section MS 7610 P. O. Box 997414 Sacramento CA 95899-7414. For more information go to www. dhs. ca*gov/rhb or phone 916 327-5106. 4 Medical applicants should request other forms if in-vivo use is involved* Name of applicant Telephone number including area code Extension Mailing address/street address number street suite/apartment number/letter P. O. box etc* City State ZIP code Type of business Individual Partnership or association Corporation List all addresses at which radioactive material will be used or stored Address number street Will radioactive material be used at temporary job sites Yes No Type of application New radioactive material license Renewal of radioactive material license number Amendment to radioactive material license number a* Nuclide b. Chemical and/or physical form c* Possession limit Describe the proposed use of this radioactive material 5. Radiation Safety Officer and Individual Users List radiation Safety Officer first. Attach Statement of Training and Experience RH 2050 A for each individual who will use radioactive material* RH 2050 7/07 Page 1 of 2 6. Radiation Detection Instruments Make and Model Number Description Number Available Purpose for Which Used 7. Method frequency and standards used in calibrating instruments listed above 8. Personnel monitoring and bioassay procedures 9. Facilities and equipment 10. Radiation safety program 11. Effluent and environmental monitoring 12. Waste disposal 13. Decommissioning and decontamination plans 14. Certificate The applicant and any official executing this certificate on behalf of the applicant named in item 1 certify that all information contained herein including any supplements attached hereto is true and correct. The individual executing this certificate has authority to commit the applicant relative to matters involved in this application* By Date. 2 Where space provided on this form is insufficient attach supplemental sheets referencing the part being expanded* 3 Submit ALL material in duplicate to California Department of Public Health Radiologic Health Branch Licensing Section MS 7610 P. O. Box 997414 Sacramento CA 95899-7414. For more information go to www. dhs. ca*gov/rhb or phone 916 327-5106. O. Box 997414 Sacramento CA 95899-7414. For more information go to www. dhs. ca*gov/rhb or phone 916 327-5106. 4 Medical applicants should request other forms if in-vivo use is involved* Name of applicant Telephone number including area code Extension Mailing address/street address number street suite/apartment number/letter P. 4 Medical applicants should request other forms if in-vivo use is involved* Name of applicant Telephone number including area code Extension Mailing address/street address number street suite/apartment number/letter P. O. box etc* City State ZIP code Type of business Individual Partnership or association Corporation List all addresses at which radioactive material will be used or stored Address number street Will radioactive material be used at temporary job sites Yes No Type of application New radioactive material license Renewal of radioactive material license number Amendment to radioactive material license number a* Nuclide b. .