Form CDPH8219 "Application for Radioactive Materials - Industrial Radiographer Trainer" - California

What Is Form CDPH8219?

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

Form Details:

  • Released on September 1, 2017;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form CDPH8219 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form CDPH8219 "Application for Radioactive Materials - Industrial Radiographer Trainer" - California

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State of California--Health and Human Services Agency
California Department of Public Health
Radiologic Health Branch
Radioactive Materials Licensing Unit
Application for Radioactive Materials
Industrial Radiographer Trainer
Radioactive Materials Radiographer Trainer Requirements
(Title 17, Section 30333.05)
Confirm and provide documentation that the radioactive materials radiographer
trainer(s) has met the following requirements:
Is certified pursuant to Title 17, Section 30335.2 or is in compliance with Title 17,
Section 30335.3,
Has complied with the requirements of Title 17, Section 30333(a)(1) and (2) and
Has at least 2,000 hours of experience as a radiographer using sealed sources,
performing radiographic operations, radiation surveys and radiation safety related
activities.
*NOTE*: The experience may not include film development and interpretation, darkroom
activities, travel, safety meetings, classroom training and any work activity not related to
the performance of industrial radiography.
List of Radiographer Trainers
Radioactive
Licensee Name:
Materials License #:
Dates of Experience
Trainer’s
per 30333.05
Name:
(a)(1)(B)&(C):
Beginning (MM/DD/YY) –
End (MM/DD/YY)
Radiographer’s Certificate
#:
Or a copy of both sides of the certification identification card issued by one of the listed
entities in Title 17, Section 30335.3 (b).
Exposure Device
used:
Model:
Manufacturer’s
Name:
FedEx Mailing Address:
Radiologic Health Branch
Mailing Address:
Radiologic Health Branch
Industrial Licensing Unit
Industrial Licensing Unit
th
1500 Capitol Ave, 5
Floor, MS 7610
Mail Station 7610 (MS 7610)
Sacramento, CA 95814-5006
P.O. Box 997414
Sacramento, CA 95899-7414
RHB Website
(www.cdph.ca.gov/rhb)
1
CDPH 8219 (9/17)
State of California--Health and Human Services Agency
California Department of Public Health
Radiologic Health Branch
Radioactive Materials Licensing Unit
Application for Radioactive Materials
Industrial Radiographer Trainer
Radioactive Materials Radiographer Trainer Requirements
(Title 17, Section 30333.05)
Confirm and provide documentation that the radioactive materials radiographer
trainer(s) has met the following requirements:
Is certified pursuant to Title 17, Section 30335.2 or is in compliance with Title 17,
Section 30335.3,
Has complied with the requirements of Title 17, Section 30333(a)(1) and (2) and
Has at least 2,000 hours of experience as a radiographer using sealed sources,
performing radiographic operations, radiation surveys and radiation safety related
activities.
*NOTE*: The experience may not include film development and interpretation, darkroom
activities, travel, safety meetings, classroom training and any work activity not related to
the performance of industrial radiography.
List of Radiographer Trainers
Radioactive
Licensee Name:
Materials License #:
Dates of Experience
Trainer’s
per 30333.05
Name:
(a)(1)(B)&(C):
Beginning (MM/DD/YY) –
End (MM/DD/YY)
Radiographer’s Certificate
#:
Or a copy of both sides of the certification identification card issued by one of the listed
entities in Title 17, Section 30335.3 (b).
Exposure Device
used:
Model:
Manufacturer’s
Name:
FedEx Mailing Address:
Radiologic Health Branch
Mailing Address:
Radiologic Health Branch
Industrial Licensing Unit
Industrial Licensing Unit
th
1500 Capitol Ave, 5
Floor, MS 7610
Mail Station 7610 (MS 7610)
Sacramento, CA 95814-5006
P.O. Box 997414
Sacramento, CA 95899-7414
RHB Website
(www.cdph.ca.gov/rhb)
1
CDPH 8219 (9/17)
Dates of Experience
Trainer’s
per 30333.05
Name:
(a)(1)(B)&(C):
Beginning (MM/DD/YY) –
End (MM/DD/YY)
Radiographer’s Certificate
#:
Or a copy of both sides of the certification identification card issued by one of the listed
entities in Title 17, Section 30335.3 (b).
Exposure Device
used:
Model:
Manufacturer’s
Name:
Dates of Experience
Trainer’s
per 30333.05
Name:
(a)(1)(B)&(C):
Beginning (MM/DD/YY) –
End (MM/DD/YY)
Radiographer’s Certificate
#:
Or a copy of both sides of the certification identification card issued by one of the listed
entities in Title 17, Section 30335.3 (b).
Exposure Device
used:
Model:
Manufacturer’s
Name:
FedEx Mailing Address:
Radiologic Health Branch
Mailing Address:
Radiologic Health Branch
Industrial Licensing Unit
Industrial Licensing Unit
th
1500 Capitol Ave, 5
Floor, MS 7610
Mail Station 7610 (MS 7610)
Sacramento, CA 95814-5006
P.O. Box 997414
Sacramento, CA 95899-7414
RHB Website
(www.cdph.ca.gov/rhb)
2
CDPH 8219 (9/17)
Radioactive Materials Radiation Safety Officer Requirements
(Title 17, Section 30333.07)
For an individual to be a Radiation Safety Officer for a radioactive materials license,
indicate and provide documentation that the individual has met the following:
Meets the requirements of Section 30333.05(a)(1) (*A provisional radiographer
certificate is not acceptable.*)
Has 2,000 hours of experience as specified in Title 17, Section 30333.05(a)(1)(C)
- No more than 900 hours of experience as a radiographer using radiation
machines may be counted toward meeting the 2,000 hours.
Has completed 4,000 hours of experience using radioactive materials and
experience in radiation protection activities; such as developing or implementing
procedures relating to the protection of workers and the public from radiation
including the development or implementation of procedures for radiation surveys,
leak testing of radioactive sources, assessment of dosimetry for radiation work,
determination of necessary radiation shielding, review of survey, leak testing, and
personnel dose measurements, training of personnel, use and maintenance of
sealed sources and devices, monitoring of radiation emergency events, sealed
source and device security, disposal of radioactive material, audits of
radiographic operations, survey meter maintenance and calibration, and
transportation of radioactive material.
Print Name of Applicant
Signature of Applicant
Date
NOTE: To amend a radioactive materials license, please provide a signed letter from
upper management requesting an amendment to the license, provide the above
information, and provide the RSO duties and responsibilities and delegation of
authority letter. Send information in duplicate to the address below.
FedEx Mailing Address:
Radiologic Health Branch
Mailing Address:
Radiologic Health Branch
Industrial Licensing Unit
Industrial Licensing Unit
th
1500 Capitol Ave, 5
Floor, MS 7610
Mail Station 7610 (MS 7610)
Sacramento, CA 95814-5006
P.O. Box 997414
Sacramento, CA 95899-7414
RHB Website
(www.cdph.ca.gov/rhb)
3
CDPH 8219 (9/17)
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