
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 ....
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How to fill out the IL IEMA 473-0013 online
Completing the IL IEMA 473-0013 form is an essential step for registering radiation machines in Illinois. This guide will provide you with detailed instructions to help you fill out the form online accurately. Follow these steps to ensure your submission is correct and complete.
Follow the steps to complete your registration form effectively.
- Press the ‘Get Form’ button to obtain the form and display it in the online editor.
- Begin by selecting whether you are submitting an original registration or amending an existing registration. Indicate your choice by checking the appropriate box.
- Fill in your registration number if applicable. This is essential for identifying your record.
- Provide the operator's name and title in the designated fields. Ensure that this information is accurate to avoid processing issues.
- Next, complete the facility name and address sections. Include the street address, city, state, ZIP code, and county to ensure that the location is fully documented.
- Enter your Federal Employer Identification Number (FEIN) or tax filing number in the corresponding field.
- Include your telephone number, email address, and fax number. This information will enable the agency to contact you if necessary.
- Input the equipment reference numbers for the radiation machines you are registering. If this is new equipment, check the appropriate box.
- Fill in the manufacturer's name and model number for each item listed. This information is vital for record-keeping.
- Provide the control serial number and acquisition date for each piece of equipment in the respective fields.
- Specify the location of the equipment in the designated area.
- For each unit, indicate its status by selecting the appropriate option, such as 'Operable,' 'Inoperable,' 'Sold to supplier,' etc.
- Lastly, you can add any comments or additional details relevant to your registration if necessary.
- Once you have completed all fields, review the information for accuracy, then proceed to save changes, download, print, or share the form as needed.
Complete your IL IEMA 473-0013 online today to ensure compliance and efficient processing.
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The Illinois Emergency Management Agency is responsible for protecting Illinois residents from the potentially harmful effects of ionizing radiation. IEMA is recognized across the nation and around the world as a leader in radiation safety.
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