Form Rx 2 - Radiation Machine Inspection Summary Page 3
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3MARYLAND DEPARTMENT OF THE ENVIRONMENT
1800 Washington Boulevard
Baltimore Maryland 21230
(410) 537-3193
1-800-633-6101
Radiation Machine Inspection Summary
Form RX 2
A. ADMINISTRATIVE INFORMATION
1. Facility Registration No. __ __ - __ __ __ __
2. Facility Name______________________________________________________________________________________________________________
3. Component Location___________________________________ Component Use or Other_______________________________________________
4. Radiation Machine Number ______________________________ Component suffix ___________________________________________________
B. INSTRUCTION TO THE REGISTRANT
1. If violations of regulatory requirements are found during an inspection, they are cited below and this form will serve as a NOTICE OF
VIOLATION. All violations must be corrected and documentation of correction provided to the Department. You are directed to submit
available documentation of resolution of the cited violation(s) within 20 days so that the Department will have the most up-to-date information
when we review your file for any potential further action. Any violation found may subject you to a financial penalty. The Department is
authorized to assess an administrative penalty of up to $1,000 per violation per day of violation or a civil penalty of up to $10,000 per day for
each violation. If assessed, penalties accrue from the date the violation occurred. Failure to correct the violations cited below will result in this
matter being referred to the Office of the Attorney General for formal legal action, which may result in the issuance of an order to revoke your
registration.
If you cannot correct a violation within 20 days, provide a written statement identifying each item number, the corrective action, and its
anticipated completion date and attach the statement to this form. Again, for reasons noted above, you are directed to submit this information
within 20 days. If you wish clarification on any or all these findings or have evidence that contradicts our findings, you may contact the
Radiological Health Program.
2. CORRECTION RECORD
VETERINARY FACILITIES: When corrections are made, initial and date each item below, and return this form with a copy of all
service repair receipts. This form and accompanying receipts must be returned within 20 days.
ALL FACILITIES SUBJECT TO CERTIFICATION: When corrections are made, have the inspector initial and date each item when
corrected. This form must be returned within 30 days.
C. INSPECTION FINDING REQUIREMENT CORRECTIVE ACTION
D. CORRECTION RECORD
ITEM# DESCRIPTION OF VIOLATIONS AND COMMENTS
REGULATION #
RGSTRNT
INSP
DATE
_______________________________________________________ ______________________________________ ________________________
INSPECTOR SIGNATURE
LICENSE NUMBER
DATE
The registrant is required to sign below in recognition of the inspection findings and an understanding of the instructions above.
______________________________________________________ _____________________________________
SIGNATURE OF REGISTRANT OR AGENT
DATE
INSPECTOR’S COPY
Form Number MDE/ARMA/COM.011 (RX 2)
Page 3 of 3
Revision Date 2/1/16
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