Application For Amendment - North Carolina Radioactive Materials Branch
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1NORTH CAROLINA
(RMB USE ONLY)
RADIOACTIVE MATERIALS BRANCH
D
RADIATION PROTECTION SECTION
LN
APPLICATION FOR AMENDMENT
R
(other than renewal)
INSTRUCTIONS:
Complete Items 1 through 7, using additional sheets as necessary. Item 7 MUST be completed on all applications. E-Mail ONE copy
of this application and a single copy of all supporting information to: LICENSING.RAM@DHHS.NC.GOV. Upon approval of the complete application, the
applicant will receive an amended Radioactive Materials or Accelerator License issued in accordance with the requirements contained in Chapter 104E of the
North Carolina General Statutes and Title 10A, Chapter 15, of the North Carolina Administrative Code.
1.
License No.:
2.
Amendment No. (of current license):
3.
Expiration Date:
4.
Licensee name as it currently appears on the license:
5a.
RADIATION SAFETY OFFICER (as listed on current
5b. INDIVIDUAL TO BE CONTACTED ABOUT THIS APPLICATION
license):
(if other than the Radiation Safety Officer):
Name
Name
Phone No.
Phone No.
e-mail addr.
e-mail addr.
6a.
Description of Action(s) Requested
6b. Brief Explanation of Requested Action(s) – attach extra pages if needed:
(check all that apply)
Licensee Name Change
Change of Physical or Mailing Address(es)
Change or Transfer of Ownership
Radiation Safety Officer Change
Add/Delete Authorized Users/Physicists/Pharmacists
Add/Delete/Modify Procedures
Corrections(s) to Existing License
Temporarily Suspend Use (change to possession only)
Decommissioning/Termination
Add/Delete Radioactive Material
*
Add/Delete Accelerators (Receipt/Start-up testing only)
Change Accelerator Status (from Receipt/Start-up
Testing to Use)
Modify Accelerator Output/Energy/Equipment/Vault
Other
You may be subject to 10A NCAC 15 .1700 requirements if you possess the types and quantities of material shown in Appendix A to 10 CFR Part 37
*
IN ORDER TO COMPLETE THIS LICENSE APPLICATION YOU NEED TO SUBMIT ALL SUPPORTING INFORMATION
CERTIFICATION
(MUST be completed by the applicant before this application can be processed by the agency)
7.
THE APPLICANT AND ANY OFFICIAL EXECUTING THIS CERTIFICATE ON BEHALF OF THE APPLICANT NAMED IN ITEM 1,
CERTIFY THAT ALL INFORMATION CONTAINED HEREIN, INCLUDING ANY SUPPLEMENTS ATTACHED HERETO, HAS BEEN
PREPARED IN CONFORMITY WITH ALL APPLICABLE NORTH CAROLINA LAWS AND REGULATIONS AND IS TRUE AND
CORRECT TO THE BEST OF OUR KNOWLEDGE AND BELIEF.
BY:
Signature of Certifying Official
Date Signed
Printed Name and Title of Certifying Official
FOR RPS USE ONLY
Comments:
Revised August 2016
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