Form DRM "Certificate of Disposition of Radioactive Materials" - Alabama

What Is Form DRM?

This is a legal form that was released by the Alabama Department of Public Health - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Alabama Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DRM by clicking the link below or browse more documents and templates provided by the Alabama Department of Public Health.

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Download Form DRM "Certificate of Disposition of Radioactive Materials" - Alabama

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FORM DRM
ALABAMA DEPARTMENT OF PUBLIC HEALTH
CERTIFICATE OF DISPOSITION OF RADIOACTIVE MATERIALS
All items must be completed
Licensee Name
License Number
License Expiration Date
Address
City
State
Zip Code
The licensee, and anyone executing this certificate on behalf of the licensee, certifies that (complete the appropriate items below):
A. Materials information
_____ 1. No radioactive materials have ever been possessed or procured under this license.
_____ 2. All radioactive materials procured and/or possessed by the licensee under the license number stated above have been disposed of by
decay.
_____ 3. All radioactive materials procured and/or possessed by the licensee under the license number stated above have been transferred.
Date Transferred ____________
Transferred to (Name and Address) _______________________________________________________
_______________________________________________________
Transferred to License Number ________
_______________________________________________________
License Issued by (Check One)
Issued by State of:
_______ NRC
_______ Agreement State
_______________________________________________________
_______ 4. Materials have been disposed of in the following manner (Describe specific disposal procedures, attach supplemental sheets if more space is
needed).
B. Other information
_____ 1. Our license has not yet expired; please terminate it.
_____ 2. Were radiation surveys and/or wipe tests conducted to confirm the absence of licensed radioactive materials and to determine if any
contamination remains on the premises covered under the license?
_____ No
_____ Yes (attach a copy of the results)
Name of Person to be Contacted Regarding the Information Provided on this Form
Telephone Number
Mail all Future Correspondence Regarding this License to
Address
City
State
Zip Code
The undersigned, on behalf of the licensee, hereby certifies that licensable quantities of radioactive material under the jurisdiction of the Alabama Office
of Radiation Control are not possessed by the licensee. It is therefore requested that the referenced license be terminated.
Return To:
_______________________________________________________
Alabama Office of Radiation Control
Signature
Date
P.O. Box 303017
Montgomery, AL 36130-3017
_______________________________________________________
Printed Name and Title
FORM DRM
ALABAMA DEPARTMENT OF PUBLIC HEALTH
CERTIFICATE OF DISPOSITION OF RADIOACTIVE MATERIALS
All items must be completed
Licensee Name
License Number
License Expiration Date
Address
City
State
Zip Code
The licensee, and anyone executing this certificate on behalf of the licensee, certifies that (complete the appropriate items below):
A. Materials information
_____ 1. No radioactive materials have ever been possessed or procured under this license.
_____ 2. All radioactive materials procured and/or possessed by the licensee under the license number stated above have been disposed of by
decay.
_____ 3. All radioactive materials procured and/or possessed by the licensee under the license number stated above have been transferred.
Date Transferred ____________
Transferred to (Name and Address) _______________________________________________________
_______________________________________________________
Transferred to License Number ________
_______________________________________________________
License Issued by (Check One)
Issued by State of:
_______ NRC
_______ Agreement State
_______________________________________________________
_______ 4. Materials have been disposed of in the following manner (Describe specific disposal procedures, attach supplemental sheets if more space is
needed).
B. Other information
_____ 1. Our license has not yet expired; please terminate it.
_____ 2. Were radiation surveys and/or wipe tests conducted to confirm the absence of licensed radioactive materials and to determine if any
contamination remains on the premises covered under the license?
_____ No
_____ Yes (attach a copy of the results)
Name of Person to be Contacted Regarding the Information Provided on this Form
Telephone Number
Mail all Future Correspondence Regarding this License to
Address
City
State
Zip Code
The undersigned, on behalf of the licensee, hereby certifies that licensable quantities of radioactive material under the jurisdiction of the Alabama Office
of Radiation Control are not possessed by the licensee. It is therefore requested that the referenced license be terminated.
Return To:
_______________________________________________________
Alabama Office of Radiation Control
Signature
Date
P.O. Box 303017
Montgomery, AL 36130-3017
_______________________________________________________
Printed Name and Title