Reciprocity Notification Form - 2016
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1Colorado Department of Public Health and Environment
Radioactive Materials Unit
Reciprocity Notification Form
This form, or a letter with all of the applicable information, must be sent to the Colorado Department of Public Health and Environment,
Radioactive Materials Unit for reciprocity notification. A copy of your license along with user authorizations (if not named on the license) must
be provided. A Reciprocal Recognition Fee must be paid prior to approval. The Reciprocal Recognition Fee is 75% of the appropriate
annual fee listed in Part 12, Appendix A of the Colorado Rules and Regulations Pertaining to Radiation Control. Detailed requirements for
reciprocal recognition of a radioactive material license can be found in Part 3.24 of the Regulations. A copy of the State of Colorado Rules and
Regulations Pertaining to Radiation Control must be in the user’s possession while on the job. These regulations are available at the following
https://
URL:
Please submit your form via E-Mail to:
cdphe_reciprocity@state.co.us
Send by regular mail to:
CDPHE; HAZ-RAD-3220
Phone: 303-692-3349 (leave message if after hours)
Attn: Nick Dorrell
Emergency Only: 303-877-9757
4300 Cherry Creek Drive South
Denver, CO 80246-1530
Date Submitted:____________________________
Enter Job Number if making a change to an existing notification:____________
Requester Information
Company Name: ____________________________________________ Address: ________________________________________________________
Radiation Safety Officer: _____________________________________ email: ____________________________________ Phone:_______________
Company Contact: __________________________________________ email: ____________________________________ Phone:_______________
Radioactive Materials License
Number:__________________________________
Issued by:____________________________
Lic. Exp. Date:_________________
Activity to be performed:
Well logging/tracer studies
Field flooding tracer studies
Industrial Radiography
Portable gauge
Fixed gauge (on truck or pipe)
Waste
Service Provider (describe service):___________________________________________________________________________________________
Job
Other (describe):__________________________________________________________________________________________________________
Job Site Information
I have verified with the client or land owner that the location below does not fall under exclusive federal (NRC) jurisdiction:
Signature:________________________________________________________
Date:__________________________________
(for locations on tribal lands/reservations, BLM land, National Parks & National Forests, military bases, or any other location which may be
under exclusive federal jurisdiction)
Client Contact:______________________________________
Phone:___________________ Company:_____________________
Work Location (Address, GPS coordinates & nearest town, or directions to site must be included):
____________________________________________________________________________________________________________
Dates in Colorado
Begin date:___________________ End date:________________________ Emergency phone contact:______________________
Address of after-hours storage location:_________________________________________________________________________
Description of after-hours material storage:______________________________________________________________________
(After-hours storage must meet the requirements of 6 CCR 1007-01, Part 22: “Physical Protection of Category 1 and
Category 2 Quantities of Radioactive Materials” if applicable. https:// )
April 2016
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