Form MDE/ARMA/PER.036 "Transfer Declaration Form for General Licensed Radiation Devices" - Maryland

What Is Form MDE/ARMA/PER.036?

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 November 8, 2006;
  • 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/PER.036 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/PER.036 "Transfer Declaration Form for General Licensed Radiation Devices" - Maryland

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MARYLAND DEPARTMENT OF THE ENVIRONMENT
● Baltimore Maryland 21230
1800 Washington Boulevard
(410) 537-3000 ● 1-800-633-6101 ●
www.mde.maryland.gov
TRANSFER DECLARATION FORM
FOR
GENERAL LICENSED RADIATION DEVICES
(Please Complete and Return)
To:
From:
Charles Cox
Company Name
Radiological Health Program/ARMA
Mailing Address
Maryland Dept. of the Environment
City
1800 Washington Blvd., Suite 750
State
Baltimore, Maryland 21230
Zip Code
Phone (410) 537-3300; Fax (410) 537-3198 Responsible Person
Title
Telephone Number
Storage Address
County of Storage
Address of Use
The above-named entity is no longer in possession of the general licensed device(s) listed in the
following table. The name of the licensee or manufacturer that received the device(s) and the date
of transfer are also provided in this table.
NEVER POSSESSED GENERAL LICENSE DEVICES (type an X if true)
UPDATES REGISTRATION NO.
-GL-
Model
Activity
Date of
Transfer
Manufacturer
No.
Serial No.
Radioisotope
(mCi)
Transfer
Recipient
Prepared by (type name)
Use an additional
Title
form if greater than
Date
8 devices
Telephone No.
transferred out.
Signature____________________________________
Form Number MDE/ARMA/PER.036
Page 1 of 1
Revision Date 11/08/06
Recycled Paper
TTY Users 1-800-735-2258
MARYLAND DEPARTMENT OF THE ENVIRONMENT
● Baltimore Maryland 21230
1800 Washington Boulevard
(410) 537-3000 ● 1-800-633-6101 ●
www.mde.maryland.gov
TRANSFER DECLARATION FORM
FOR
GENERAL LICENSED RADIATION DEVICES
(Please Complete and Return)
To:
From:
Charles Cox
Company Name
Radiological Health Program/ARMA
Mailing Address
Maryland Dept. of the Environment
City
1800 Washington Blvd., Suite 750
State
Baltimore, Maryland 21230
Zip Code
Phone (410) 537-3300; Fax (410) 537-3198 Responsible Person
Title
Telephone Number
Storage Address
County of Storage
Address of Use
The above-named entity is no longer in possession of the general licensed device(s) listed in the
following table. The name of the licensee or manufacturer that received the device(s) and the date
of transfer are also provided in this table.
NEVER POSSESSED GENERAL LICENSE DEVICES (type an X if true)
UPDATES REGISTRATION NO.
-GL-
Model
Activity
Date of
Transfer
Manufacturer
No.
Serial No.
Radioisotope
(mCi)
Transfer
Recipient
Prepared by (type name)
Use an additional
Title
form if greater than
Date
8 devices
Telephone No.
transferred out.
Signature____________________________________
Form Number MDE/ARMA/PER.036
Page 1 of 1
Revision Date 11/08/06
Recycled Paper
TTY Users 1-800-735-2258