Get A-04 Radioactive Material Sublicense Amendment/renewal Request

The A-04 Radioactive Material Sublicense Amendment/Renewal Request is an essential document for organizations managing radioactive materials. This guide provides a clear and user-friendly walkthrough to assist users in completing the form online efficiently.

Follow the steps to successfully complete the A-04 form online.

1. Click ‘Get Form’ button to access the form and open it for editing.
2. Identify the ‘Sublicensee’ field and clearly enter the name of the entity or organization making the request.
3. In the ‘Department’ section, specify the department associated with the sublicensee.
4. Fill in the ‘Office Phone’ field with the contact number for the department, ensuring accuracy.
5. Select whether you are requesting a renewal or an amendment. For renewal, check item 1 and ensure required signatures are obtained; attach a copy of the current sublicense. For an amendment, complete the applicable sections and gather necessary signatures before submission.
6. If there are changes to Radiation Laboratories or Radiation Storage Rooms, list them in the provided fields, indicating additions and deletions. Include maps for new areas.
7. Specify changes in isotopes, including current and proposed activity. Fill out the table indicating isotopes, current activity, and desired changes.
8. Detail any changes to Radiation Workers. List additions and deletions along with documentation of their experience and training.
9. Ensure to attach the ‘Application for Personal Dosimetry Service’ (Form A-8) and verification of radiation safety training for any new Radiation Workers.
10. Lastly, obtain signatures from the sublicensee and department chair, including the date and typed or printed name of the department chair before finalizing.
11. Once the form is completed, users have the option to save changes, download, print, or share the form as needed.

Complete your A-04 Radioactive Material Sublicense Amendment/Renewal Request online today to ensure compliance and safety.