Form RH2261W "Radiation Machine Registration Form for Withdrawal of Registration" - California

Form RH2261W is a California Department of Public Health form also known as the "Radiation Machine Registration Form For Withdrawal Of Registration". The latest edition of the form was released in June 1, 2017 and is available for digital filing.

Download an up-to-date Form RH2261W in PDF-format down below or look it up on the California Department of Public Health Forms website.

Step-by-step Form 2261W instructions can be downloaded by clicking this link.

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Download Form RH2261W "Radiation Machine Registration Form for Withdrawal of Registration" - California

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State of California – Health and Human Services Agency
California Department of Public Health
Radiologic Health Branch
RADIATION MACHINE REGISTRATION FORM
FOR WITHDRAWAL OF REGISTRATION
Please read the
instructions
before completing this form.
A: REGISTRANT INFORMATION
Registrant (name of facility, business, or practice)
Registration Number
M
ammography
Provider
Physical Address (street number and name)
City
State
Zip Code
B: REASON FOR WITHDRAWAL Check the appropriate box. See instructions for details.
Registrant
is no longer in possession of any radiation machines.
All
radiation machines that the registrant is in possession of have been made incapable of
producing radiation.
C: WITHDRAWAL DATE
D: SIGNATURE OF AUTHORIZED REPRESENTATIVE
I declare under penalty of perjury under the laws of the State of California that the information
submitted on this form and on any attachments is true and correct. I agree to abide by all laws and
regulations that pertain to the operation and registration of the radiation machine(s) for which I am
applying.
Name
Title/Position
Signature
E-mail Address
Phone Number
Date
E: RECORDKEEPING/SUBMISSION Keep a copy for your records. Do not submit multiple copies of
the same completed form. Mail the original with supporting documents to:
If sending by regular mail, send it to
If sending by express mail, send it to
Registration and Certification Support Unit
Registration and Certification Support Unit
California Department of Public Health
California Department of Public Health
Radiologic Health Branch, MS 7610
Radiologic Health Branch
th
P.O. Box 997414
1500 Capitol Avenue, 5
Floor, Building 172
Sacramento, CA 95899-7414
Sacramento, CA 95814-5006
For more information, please visit our website at
http://cdph.ca.gov/rhb
or call (916) 327-5106.
For Radiologic Health Branch Use Only
RH 2261W (06/17)
Page 1 of 1
D
D
D
State of California – Health and Human Services Agency
California Department of Public Health
Radiologic Health Branch
RADIATION MACHINE REGISTRATION FORM
FOR WITHDRAWAL OF REGISTRATION
Please read the
instructions
before completing this form.
A: REGISTRANT INFORMATION
Registrant (name of facility, business, or practice)
Registration Number
M
ammography
Provider
Physical Address (street number and name)
City
State
Zip Code
B: REASON FOR WITHDRAWAL Check the appropriate box. See instructions for details.
Registrant
is no longer in possession of any radiation machines.
All
radiation machines that the registrant is in possession of have been made incapable of
producing radiation.
C: WITHDRAWAL DATE
D: SIGNATURE OF AUTHORIZED REPRESENTATIVE
I declare under penalty of perjury under the laws of the State of California that the information
submitted on this form and on any attachments is true and correct. I agree to abide by all laws and
regulations that pertain to the operation and registration of the radiation machine(s) for which I am
applying.
Name
Title/Position
Signature
E-mail Address
Phone Number
Date
E: RECORDKEEPING/SUBMISSION Keep a copy for your records. Do not submit multiple copies of
the same completed form. Mail the original with supporting documents to:
If sending by regular mail, send it to
If sending by express mail, send it to
Registration and Certification Support Unit
Registration and Certification Support Unit
California Department of Public Health
California Department of Public Health
Radiologic Health Branch, MS 7610
Radiologic Health Branch
th
P.O. Box 997414
1500 Capitol Avenue, 5
Floor, Building 172
Sacramento, CA 95899-7414
Sacramento, CA 95814-5006
For more information, please visit our website at
http://cdph.ca.gov/rhb
or call (916) 327-5106.
For Radiologic Health Branch Use Only
RH 2261W (06/17)
Page 1 of 1
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