Form MDE/ARMA/LIC.001 "Application for a Radioactive Materials License" - Maryland

What Is Form MDE/ARMA/LIC.001?

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

Form Details:

  • Released on February 17, 2017;
  • The latest edition provided by the Maryland Department of the Environment;
  • 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 fillable version of Form MDE/ARMA/LIC.001 by clicking the link below or browse more documents and templates provided by the Maryland Department of the Environment.

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Download Form MDE/ARMA/LIC.001 "Application for a Radioactive Materials License" - Maryland

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MARYLAND DEPARTMENT OF THE ENVIRONMENT
1800 Washington Boulevard
Baltimore Maryland 21230
www.mde.maryland.gov
(410) 537-3000
1-800-633-6101
APPLICATION FOR A RADIOACTIVE MATERIALS LICENSE
1. THIS IS AN APPLICATION FOR: Check appropriate item
A. New license (supply Federal ID number below)
B. Amendment to license number
MD-
C. Renewal of license number
MD-
D. Termination
MD-
2. NAME, MAILING ADDRESS, FACSIMILE NUMBER, ELECTRONIC MAIL AND FEDERAL TAX ID NUMBER OF
APPLICANT:
Privacy Act Notice: This Notice is provided
pursuant to the Federal Privacy Act of 1974,
5 U.S.C. § 552a. Disclosure of your Social
Security or Federal Tax Identification on this
form is mandatory pursuant to the provisions
3. ADDRESS(ES) WHERE LICENSED MATERIAL WILL BE USED OR POSSESSED:
of § 1-203 (2003) of Environment Article,
Annotated Code of Maryland, which requires
MDE to verify that an applicant for a permit
or license has paid all undisputed taxes and
unemployment insurance. Social Security
and Federal Tax Identification Nos. will not
4. NAME & TELEPHONE NUMBER OF PERSON TO BE CONTACTED ABOUT
be used for any purposes other than those
THIS APPLICATION:
described in this Notice.
**SUBMIT ITEMS 5 THROUGH 11 ON 8-1/2 X 11" PAPER. THE TYPE AND SCOPE OF INFORMATION TO BE PROVIDED IS
DESCRIBED IN THE LICENSE APPLICATION GUIDE.**
5. RADIOACTIVE MATERIAL
A. Element & mass number;
B. Chemical and/or physical form; and
C. Maximum amount which will be possessed at any one time.
6. PURPOSE(S) FOR WHICH LICENSED MATERIAL WILL BE USED.
7. INDIVIDUAL(S) RESPONSIBLE FOR RADIATION SAFETY PROGRAM AND THEIR TRAINING EXPERIENCE.
8. TRAINING FOR INDIVIDUALS WORKING IN OR FREQUENTING RESTRICTED AREAS.
9. FACILITIES AND EQUIPMENT
10. RADIATION SAFETY PROGRAM
11. WASTE MANAGEMENT
12. CERTIFICATION: (Must be completed by the applicant)
THE APPLICANT UNDERSTANDS THAT ALL STATEMENTS AND REPRESENTATIONS MADE IN THIS APPLICATION
ARE BINDING UPON THE APPLICANT. THE APPLICANT AND ANY OFFICIAL EXECUTING THIS CERTIFICATE ON
BEHALF OF THIS APPLICANT NAMED IN ITEM 1, CERTIFY THAT THIS APPLICATION IS PREPARED IN CONFORMITY
WITH MARYLAND REGULATIONS FOR CONTROL OF IONIZING RADIATION AND THAT ALL INFORMATION
CONTAINED HEREIN IS TRUE AND CORRECT TO THE BEST OF OUR KNOWLEDGE AND BELIEF.
CERTIFYING OFFICER’S TYPED OR PRINTED NAME , TITLE AND SIGNATURE
DATE
Form Number MDE/ARMA/
Page 1 of 1
LIC.001 Revision Date 2/17/17
Recycled Paper
TTY Users 1-800-201-7165
MARYLAND DEPARTMENT OF THE ENVIRONMENT
1800 Washington Boulevard
Baltimore Maryland 21230
www.mde.maryland.gov
(410) 537-3000
1-800-633-6101
APPLICATION FOR A RADIOACTIVE MATERIALS LICENSE
1. THIS IS AN APPLICATION FOR: Check appropriate item
A. New license (supply Federal ID number below)
B. Amendment to license number
MD-
C. Renewal of license number
MD-
D. Termination
MD-
2. NAME, MAILING ADDRESS, FACSIMILE NUMBER, ELECTRONIC MAIL AND FEDERAL TAX ID NUMBER OF
APPLICANT:
Privacy Act Notice: This Notice is provided
pursuant to the Federal Privacy Act of 1974,
5 U.S.C. § 552a. Disclosure of your Social
Security or Federal Tax Identification on this
form is mandatory pursuant to the provisions
3. ADDRESS(ES) WHERE LICENSED MATERIAL WILL BE USED OR POSSESSED:
of § 1-203 (2003) of Environment Article,
Annotated Code of Maryland, which requires
MDE to verify that an applicant for a permit
or license has paid all undisputed taxes and
unemployment insurance. Social Security
and Federal Tax Identification Nos. will not
4. NAME & TELEPHONE NUMBER OF PERSON TO BE CONTACTED ABOUT
be used for any purposes other than those
THIS APPLICATION:
described in this Notice.
**SUBMIT ITEMS 5 THROUGH 11 ON 8-1/2 X 11" PAPER. THE TYPE AND SCOPE OF INFORMATION TO BE PROVIDED IS
DESCRIBED IN THE LICENSE APPLICATION GUIDE.**
5. RADIOACTIVE MATERIAL
A. Element & mass number;
B. Chemical and/or physical form; and
C. Maximum amount which will be possessed at any one time.
6. PURPOSE(S) FOR WHICH LICENSED MATERIAL WILL BE USED.
7. INDIVIDUAL(S) RESPONSIBLE FOR RADIATION SAFETY PROGRAM AND THEIR TRAINING EXPERIENCE.
8. TRAINING FOR INDIVIDUALS WORKING IN OR FREQUENTING RESTRICTED AREAS.
9. FACILITIES AND EQUIPMENT
10. RADIATION SAFETY PROGRAM
11. WASTE MANAGEMENT
12. CERTIFICATION: (Must be completed by the applicant)
THE APPLICANT UNDERSTANDS THAT ALL STATEMENTS AND REPRESENTATIONS MADE IN THIS APPLICATION
ARE BINDING UPON THE APPLICANT. THE APPLICANT AND ANY OFFICIAL EXECUTING THIS CERTIFICATE ON
BEHALF OF THIS APPLICANT NAMED IN ITEM 1, CERTIFY THAT THIS APPLICATION IS PREPARED IN CONFORMITY
WITH MARYLAND REGULATIONS FOR CONTROL OF IONIZING RADIATION AND THAT ALL INFORMATION
CONTAINED HEREIN IS TRUE AND CORRECT TO THE BEST OF OUR KNOWLEDGE AND BELIEF.
CERTIFYING OFFICER’S TYPED OR PRINTED NAME , TITLE AND SIGNATURE
DATE
Form Number MDE/ARMA/
Page 1 of 1
LIC.001 Revision Date 2/17/17
Recycled Paper
TTY Users 1-800-201-7165