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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

1 Name of Facility

Telephone No.

Fax No.:

E-mail Address:

2 Street Address (machine location)

Suite

City

State

Zip Code

3 Mailing Address (if different)

Suite

City

State

Zip Code

4 Contact Person:

Title:

Contact Ph.#1:

Contact Ph.#2:

5 Profession (from menu):

6 (check as appropriate and enter number) Fed Tax ID#: SS#:

7 County:

8 Machine Group:

9 (menu)

10 (menu)

11

12

13

Machine Number

Suffix

Component Use

Control or Processor Manufacturer

Tube Serial Number Processor Model

Room Location

PM Schedule (months)

I hereby certify that the information above is true and complete to the best of my knowledge.

Signature

Registrant's Name (print)

Date

Document and Date appropriate change to facility: REGISTRATION DOES NOT IMPLY APPROVAL OR DISAPPROVAL

New Facility Date of appropriate change: Renewal / Relocation / Replacement of tube ____ ____ ____ ____ ____ ____

Additional tube

Removal of tube

For Official Use Only

For Office Use Only Date Received

Reg. No.:

-

____ ____ ____ ____ ____ ____

Initial of Approval:

//

____ ____

____ ____

____ ____

MM

DD

YY

Date

Inspector’s #:

Date of Approval:

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

Inspectors Copy

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