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FLORIDA DOH BUREAU OF RADIATION CONTROL (BRC)

ADIOACTIVE

ATERIAL

ICENSE

PPLICATION

HECKLIST

Notes:

– This checklist is for applicants using DOH Form DH-1054 to apply for or renew a license for the following use categories:

1A – 1C, 2A – 2C, 3A, 3B, 3F(1) – 3F(3), 3G, 3H, 3I(1), 3I(2), 3J, 3K, 3L(2), 3L(3), 3L(5), 3M(1), 3N, 3O, 3P, or 6. Refer

to section 64E-5.204, Fla. Admin. Code, for a list of license categories. If additional assistance is needed, call the BRC at

(850) 245-4545 or access the BRC website at <

− The U.S. Nuclear Regulatory Commission’s NUREG-1556 series of technical reports (“Consolidated Guidance About

Materials Licenses”) provide licensing guidance for many of the activities categorized above. The documents are available

on the Internet at <

− U.S. Dept. of Transportation regulations (49 CFR) are available at <

CHECK OFF IF

APPLICATION ITEM

NOTES

ADDRESSED

1.a.

Name/Mailing Address

Unless application is for an individual, list the business name registered with the FL

–

Div. of Corporations; verify name registration by phone (850/488-9000) or online at

If doing business under a fictitious name, verify the name’s registration & include it

–

in Item 1 as a d/b/a name; if fictitious name is not registered, include it in Item 2

List the mailing address for license-related correspondence

–

1.b.

Location of Use

List the street address where RAM will be used & stored, & where records will be

–

available for inspection; 64E-5.208(2), .213(5)

and/or Storage

Indicate if temporary job sites will be used as storage locations

–

License Category/Fee

List appropriate license category & application fee; there is no fee for license renewal

–

applications

Annual/reclamation fees are due within 60 days of license issuance and annually

–

thereafter (an invoice for the fees is included w/ the new license); 64E-5.204

Purpose of Application

Check appropriate box; if applying to renew a license, list the license no.

–

Individual Users

List all authorized users (AUs), including the RSO; a minimum of two AUs is

–

required for fixed devices; 64E-5.208(2), .1313(4)

Rad. Safety Officer (RSO)

List the name of the RSO (must be an AU); 64E-5.208(2)

–

Training and Experience

Enclose relevant documentation on the rad. safety training/experience for the RSO &

–

each authorized user; 64E-5.208(1), .1305, .1307

in Radiation Safety

Radioactive Material (RAM)

List the element/source model no. & maximum activity for each source

–

Use

List the manufacturer, model no. & intended use for each source/device

–

− For renewal applications, include current inventory of all RAM, including exempt,

Current RAM Inventory

generally licensed (GL) & specifically licensed (SL) sources/devices & indicate

their status (exempt, GL or SL); 64E-5.208(2)

Radiation Detection

If applicable, list the manufacturer, model no., detection capability, range & probe

–

specifications (if equipped w/ probe) of each instrument; 64E-5.208(2) .1314, .1318

Instruments

Confirm access to an equivalent backup instrument when the primary meter is out

–

due to calibration or repair; 64E-5.208(2), .1314, .1318

If applicable, list the name & address of the instrument calibration vendor (may

10.

Calibration of Radiation

–

include option of using other licensed vendors) & confirm annual calibration

Detection Instruments

frequency; if conducting in-house cal., submit procedures; 64E-5.208(2), .314

Page 1 of 3

Radioactive Material License Application Checklist - Florida Doh Bureau Of Radiation Control (Brc)

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