Form 314 "Certificate - Disposition of Radioactive Materials" - Minnesota

What Is Form 314?

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

Form Details:

  • Released on December 1, 2008;
  • The latest edition provided by the Minnesota Department of 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 314 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form 314 "Certificate - Disposition of Radioactive Materials" - Minnesota

Download PDF

Fill PDF online

Rate (4.8 / 5) 55 votes
Radioactive Materials Unit
625 Robert Street North
PO Box 64975
St. Paul, MN 55164-0975
Telephone (651) 201-4400
Fax: (651) 201-4606
CERTIFICATE – DISPOSITION OF RADIOACTIVE MATERIALS
Licensee name and address:
Person to contact regarding the information provided on this
form:
Contact's phone number:
(
)
License or registration number:
RADIOACTIVE MATERIALS DISPOSAL INFORMATION
(Check and complete as necessary.)
No radioactive material has ever been acquired, received, possessed, used, stored, or transferred by the licensee
under the authorization granted by the above referenced license.
All radioactive material acquired, received, possessed, used, stored or transferred has been disposed of as follows.
(Check all that apply)
Decayed, surveyed, and disposed of as non-radioactive waste. (Attach survey records.)
Materials acquired, received, used, possessed or stored has been transferred to:
(Attach documents that verify receipt by another licensee. If additional space is needed, use the reverse of this form
or provide attachments.)
Name and address of licensee or waste contractor:
License Number:
Issued by:
Date of Transfer:
Materials have been disposed of in the following alternative manner.
(Describe specific disposal procedures - if additional space is needed, use the reverse of this form or provide
attachments.)
Form 314 (12/08)
1
Radioactive Materials Unit
625 Robert Street North
PO Box 64975
St. Paul, MN 55164-0975
Telephone (651) 201-4400
Fax: (651) 201-4606
CERTIFICATE – DISPOSITION OF RADIOACTIVE MATERIALS
Licensee name and address:
Person to contact regarding the information provided on this
form:
Contact's phone number:
(
)
License or registration number:
RADIOACTIVE MATERIALS DISPOSAL INFORMATION
(Check and complete as necessary.)
No radioactive material has ever been acquired, received, possessed, used, stored, or transferred by the licensee
under the authorization granted by the above referenced license.
All radioactive material acquired, received, possessed, used, stored or transferred has been disposed of as follows.
(Check all that apply)
Decayed, surveyed, and disposed of as non-radioactive waste. (Attach survey records.)
Materials acquired, received, used, possessed or stored has been transferred to:
(Attach documents that verify receipt by another licensee. If additional space is needed, use the reverse of this form
or provide attachments.)
Name and address of licensee or waste contractor:
License Number:
Issued by:
Date of Transfer:
Materials have been disposed of in the following alternative manner.
(Describe specific disposal procedures - if additional space is needed, use the reverse of this form or provide
attachments.)
Form 314 (12/08)
1
SURVEYS AND RECORDS
A radiation survey was not conducted because only sealed sources were possessed under this license.
A radiation survey was conducted.
The surveys confirm the absence of licensed radioactive materials.
The surveys verify that all remaining radioactivity is within the limits of Minnesota Radioactive Materials Rules,
Chapter 4731.
Copies of the survey records are attached.
Survey records are not attached. (Provide an explanation.)
Records required to be maintained for the license termination requested are available at the following location:
(List company name and address.)
CERTIFICATION
(To be completed by an individual authorized to make binding commitments on behalf of the applicant.)
I hereby certify that the information provided was prepared in conformance with Minnesota Radioactive Materials Rules,
Chapter 4731, and that all information contained herein, including any supplements attached hereto, is true and correct to
the best of my knowledge and belief.
Signature:
Date:
Name (Pint or type):
Title:
Form 314 (12/08)
2
Page of 2