Get IL IEMA 473-0013 2010-2024

State of Illinois Illinois Emergency Management Agency - Division of Nuclear Safety REGISTRATION RADIATION MACHINE INSTALLATION ILLINOIS EMERGENCY MANAGEMENT AGENCY DIVISION OF NUCLEAR SAFETY 1035 OUTER PARK DR SPRINGFIELD IL 62704 ORIGINAL REGISTRATION AMEND REGISTRATION change of operator/address IEMA will assign if new change of equipment The following information is provided in accordance with 32 Ill. Adm. Code 320. 10 a regarding radiation machines. OPERATOR Name and Title FACILITY NAME STREET ADDRESS CITY STATE FEIN/TAX FILING TELEPHONE E-MAIL FAX EQPT. REF* NUMBER Check here if new ZIP COUNTY MANUFACTURER NAME MODEL NAME/NUMBER CONTROL SERIAL NUMBER ACQUISITION DATE LOCATION STATUS OF UNIT Operable Sold to supplier Inoperable Stored Junked Traded Sold / Private radiographic flouroscopic dual purpose mobile therapy dental CT UNIT TYPE mammography industrial This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under 420 ILCS 40/1 - 40/44 1992. Disclosure of this information is required* Failure to provide any information will result in this form not being processed and is a Class A misdemeanor. This form has been approved by the Forms Management Center. IL 473-0013 Rev* 6/2010 IOCI1026-10 PRINT OR TYPE NAME SIGNATURE DATE COMMENTS. 10 a regarding radiation machines. OPERATOR Name and Title FACILITY NAME STREET ADDRESS CITY STATE FEIN/TAX FILING TELEPHONE E-MAIL FAX EQPT. REF* NUMBER Check here if new ZIP COUNTY MANUFACTURER NAME MODEL NAME/NUMBER CONTROL SERIAL NUMBER ACQUISITION DATE LOCATION STATUS OF UNIT Operable Sold to supplier Inoperable Stored Junked Traded Sold / Private radiographic flouroscopic dual purpose mobile therapy dental CT UNIT TYPE mammography industrial This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under 420 ILCS 40/1 - 40/44 1992. REF* NUMBER Check here if new ZIP COUNTY MANUFACTURER NAME MODEL NAME/NUMBER CONTROL SERIAL NUMBER ACQUISITION DATE LOCATION STATUS OF UNIT Operable Sold to supplier Inoperable Stored Junked Traded Sold / Private radiographic flouroscopic dual purpose mobile therapy dental CT UNIT TYPE mammography industrial This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under 420 ILCS 40/1 - 40/44 1992. Disclosure of this information is required* Failure to provide any information will result in this form not being processed and is a Class A misdemeanor. Disclosure of this information is required* Failure to provide any information will result in this form not being processed and is a Class A misdemeanor. This form has been approved by the Forms Management Center. IL 473-0013 Rev* 6/2010 IOCI1026-10 PRINT OR TYPE NAME SIGNATURE DATE COMMENTS. 10 a regarding radiation machines. OPERATOR Name and Title FACILITY NAME STREET ADDRESS CITY STATE FEIN/TAX FILING TELEPHONE E-MAIL FAX EQPT. REF* NUMBER Check here if new ZIP COUNTY MANUFACTURER NAME MODEL NAME/NUMBER CONTROL SERIAL NUMBER ACQUISITION DATE LOCATION STATUS OF UNIT Operable Sold to supplier Inoperable Stored Junked Traded Sold / Private radiographic flouroscopic dual purpose mobile therapy dental CT UNIT TYPE mammography industrial This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under 420 ILCS 40/1 - 40/44 1992. Disclosure of this information is required* Failure to provide any information will result in this form not being processed and is a Class A misdemeanor. .