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MARYLAND DEPARTMENT OF THE ENVIRONMENT 1800 Washington Boulevard, Suite 750 • Baltimore Maryland 21230 (410) 537-3193 • 1-800-633-6101 • http://www.mde.state.md.us

RADIOLOGICAL HEALTH PROGRAM RADIATION MACHINE FACILITY REGISTRATION INSTRUCTIONS PLEASE READ INSTRUCTIONS CAREFULLY BEFORE COMPLETING THE ATTACHED FORM

01. Facility Name, Telephone, Fax, E-mail Address

Print the name of the legal or business entity which owns or controls the use of the x-ray machines, including telephone number. If there is a fax number and e-mail address, enter in the spaces provided.

02. Street Address

Print the street address or location where the above facility is physically located.

03. Mailing Address

Print the mailing address if that address is different from the street address.

04. Contact Person

Indicate the person that the State should contact regarding registration, inspection, and compliance issues, along with title where appropriate.

05. Profession

Choose profession from menu. If none of the categories applies, choose other.

06. Federal Tax ID

Insert the Federal Tax Identification number or Social Security number and indicate which it is.

Privacy Act Notice: This Notice is provided pursuant to the Federal Privacy Act of 1974, 5 U.S.C. § 552a. Disclosure of your Social Security or Federal Tax Identification on this form is mandatory pursuant to the provisions of § 1-203 (2003) of Environment Article, Annotated Code of Maryland, which requires MDE to verify that an applicant for a permit or license has paid all undisputed taxes and unemployment insurance. Social Security and Federal Tax Identification Nos. will not be used for any purposes other than those described in this Notice.

07. County

Insert the county where the x-ray machine(s) is/are physically located.

08. Machine Group/Number

Leave this area BLANK - For agency or private inspector use.

09. Component Use

See attached menu. Use only one line for each machine or processor.

10. Control or Processor

Select the number of the manufacturer of the source of radiation or processor from the attached menu. If the manufacturer is other, enter the number of other and specify manufacturer.

11. Tube Serial Number Processor Model

Supply a tube or control serial number to identify the equipment – not all processors have serial numbers, so specify the model of the processor.

12. Room Identification Location

Enter the name of the room or the specific location where the component can be found. These names are those commonly used...Blue Suite, Room 202, etc.

13. Manufacturer’s Preventative Maintenance Schedule

Provide the preventative maintenance schedule, in months, of each radiation machine to ensure compliance with the regulations.

Return All Three Copies

A validated copy will be returned bearing an assigned registration number.

MDE/ARMA/PERMIT#007 (MDE RX1) Revised 8/20/10 TTY Users 1-800-201-7165

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