APPLICATION FOR DELAWARE RADIOACTIVE MATERIAL REGISTRATION PLEASE READ ATTACHED INSTRUCTIONS PRIOR TO COMPLETING CURRENT/FORMER DELAWARE REGISTRATION/LICENSE NO. _______________________________ 1. FACILITY: (The official License/Notice of Registration shall be sent to this address.) Name: __________________________________________________________________________ Address: _______________________________________________________________________ City: ________________________ State: ____________ Zip: ______________ Phone: ________________________________ Fax: ________________________________ 2. OWNER OF RADIOACTIVE MATERIAL FACILITY: Name: ___________________________ EIN or Social Security No.: ________________ Company Name: __________________________________________________________________ Address: _______________________________________________________________________ City: ________________________ State: ____________ Zip: ______________ Phone: ________________________________ 3. INDIVIDUAL RESPONSIBLE FOR RADIATION PROTECTION [RADIATION SAFETY OFFICER]: Name: _______________________________________ Phone No.: _____________________ Title: _________________________________________________________________________ 4. NAME(S) OF AUTHORIZED USERS OF MATERIAL ________________________________________________________________________________ ________________________________________________________________________________ 5. RADIOACTIVE MATERIAL LICENSE NO.: EXPIRATION DATE: ________________________________________________________________________________ Note – A copy of a valid NRC or Agreement State Radioactive Material License must accompany each new application. 6. WASTE DISPOSAL METHOD: Select waste disposal method for radioactive material (see instructions). Check applicable methods used. Decay–in–Storage Treatment Sanitary Sewer Incineration Transfer Return to Manufacturer Land Disposal Other (please specify) __________________________ 7. Radioactive Materials stored, used or transported in Delaware: NRC ELEMENT/MASS # PHYSICAL FORM MAX AMT. POSSESSION Example: Am-241 (gas, liquid, solid) (mCi) LIMIT PURPOSE* 1. 2. 3. 4. 5. 6. *Purpose - Education, Industrial, Radiography, Research, Scientific Studies, Public Health, Healing Arts - Diagnostic, Healing Arts – Therapeutic, Security or Military. I certify that the information provided is true to the best of my knowledge. SIGNATURE OF OWNER/MANAGER : ____________________________________ DATE: ________ PLEASE PRINT NAME (LEGIBLY): ___________________________________________________ INSTRUCTIONS FOR COMPLETING FORM ORC-R2 APPLICATION FOR A RADIOACTIVE MATERIAL REGISTRATION The Owner/Manager is the "Applicant" 1. Facility means the complete name and address of the principal location where material is used or stored. The owner (item 2) is responsible for providing the complete address (including department number and/or name of the department head) of the intended recipient of the official registration. The information in item 1 will be used as the mailing label content. 2. Owner means the complete name and IRS Employee Identification Number (EIN) or Social Security #, street and number or P.O. Box, City, Zip Code, and telephone number of the Owner (applicant). If the owner designates another individual as "Owner"; a copy of the written designation should be enclosed with this application. The radioactive material owner (applicant) signs the ORC-R2 Form. 3. Individual Responsible for Radiation Protection means the complete name, street and number or P.O. Box, city, zip code and telephone number in Delaware for the Radiation Safety Officer responsible for the use of the subject radioactive material. 4. User of Material means the names of ALL individual(s) who are authorized to use the referenced radioactive material. 5. Radioactive Material License means the number and expiration date of a radioactive materials license issued to you or your company by the U.S. Nuclear Regulatory Commission (NRC) or by a State other than Delaware. A copy of a valid NRC or Agreement State Radioactive Material License must be submitted with this application. 6. Waste Disposal Method means the method of disposing of radioactive material by checking the applicable method, e.g., Decay – in – Storage, Treatment, Sanitary Sewer, Incineration, Transfer, Return to Manufacturer, Land Disposal, or other (must specify). 7. Element and Mass # means the element and atomic mass number, for example, Americium 241 is expressed as Am-241. All Radioisotopes stored, used, or transported in Delaware must be listed in this table in item 7. Physical Form means the physical form of the radioactive material: solid, liquid, or gas. Maximum Amount means the maximum amount of each radioisotope to be possessed or used at any one time at this location in millicuries (mCi). NRC Possession Limit means the maximum amount of each radioisotope that can be possessed, consistent with NRC License conditions in millicuries (mCi). Purpose briefly describes the application for which the radioactive material is to be used, e.g., education, industrial, radiography, research, scientific studies, public health, healing arts - diagnostic, healing arts – therapeutic, security or military. The application form must be signed by the Facility Owner/Manager. The registration is not valid until a "Notice of Registration" has been issued. In order to facilitate processing, please be sure that all items on the application have been completed before sending to the agency. Incomplete applications will be returned. Please allow a minimum of three (3) weeks for processing. This form may be photocopied, and applicants should retain a copy for their records. If you have any questions, please contact the Office of Radiation Control at 302-744-4546. To download forms or obtain a copy of the regulations, please visit our web site at http://www.dhss.delaware.gov/dhss/dph/hsp/orc.html Completed applications should be mailed to: Delaware Division of Public Health Office of Radiation Control 417 Federal Street Dover, DE 19901