Form Rhf - 1pg - Application For Radioactive Material License - Portable Gauge
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8RHF – 1PG
Application for
Radioactive Material License
- Portable Gauge
`
Instructions – Complete all items in this application for a new license or the renewal of an existing license. Use supplemental sheets where necessary.
Item 21 must be completed on all applications. Send to Washington State Department of Health in accordance with the directions contained in the
application cover letter. Upon approval of this application, the applicant will receive a State of Washington Radioactive Material License issued in
accordance with the general requirements contained in Washington State Department of Health, Office of Radiation Protection, Radiation Control
Regulations, and the Washington Nuclear Energy and Radiation Control Act, Chapter 70.98 RCW.
1a. NAME AND MAILING ADDRESS OF APPLICANT
1b. STREET ADDRESS(ES) AT WHICH RADIOACTIVE MATERIAL WILL
BE STORED OR USED (if different than 1a) INCLUDE ZIP CODE
1c. Will radioactive material be used at temporary job locations?
Yes
No
2. PERSON TO CONTACT REGARDING THIS APPLICATION
TELEPHONE NUMBER
3. THIS IS AN APPLICATION FOR (check appropriate item)
.
.
A
New License
B
Renewal of License No. WN- _________________
4a. INDIVIDUAL USERS (Need not be specifically named but must
4b. TRAINING AND EXPERIENCE (Check at least one)
be trained as indicated in 4b.)
Approved Certificate(s) of Training for Each User
Individuals trained in In-House Training Program
(Detailed information attached)
Hazmat refresher training within three years
5a. RADIATION SAFETY OFFICER (RSO)
5b. DUTIES OF RADIATION SAFETY OFFICER (check one)
(Person designated as RSO - Include Training Certificates)
Sign and date Attachment ‘A’ and return.
OR
NAME
_________________________________________
RSO FAX
_________________________________________
Equivalent Duties Attached
RSO EMAIL _________________________________________
6. RADIOACTIVE MATERIAL
7. SEALED SOURCE MANUFACTURER
8. MAXIMUM ACTIVITY OF EACH SOURCE
(elements and Mass number of each.)
AND MODEL NUMBER
A. _________________________________
A. ____________________________________
A. ____________________________________
_________________________________
_____________________________________
____________________________________
B. _________________________________
B. ____________________________________
B. ____________________________________
_________________________________
_____________________________________
____________________________________
C. _________________________________
C. ____________________________________
C. ____________________________________
_________________________________
_____________________________________
____________________________________
9. DEVICE AND USE DESCRIPTION (Make lettering correspond to lettering in Items 6. 7. and 8 above.)
MANUFACTURER OF DEVICE
MODEL NUMBER.OF DEVICE
USE (Check all boxes that apply)
A.
surface moisture measurement
soil
in
density measurement
construction materials
depth moisture measurement
B.
surface moisture measurement
soil
in
density measurement
construction materials
depth moisture measurement
C.
surface moisture measurement
soil
in
density measurement
construction materials
depth moisture measurement
*LICENSE FEE REQUIRED WITH NEW LICENSE APPLICATION (Complete Item No. 20)
322-028 JAR 4/17/12 Page 1 of 8
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