Form SFN7590 (RCP-5) "Registration - Radiation Machines" - North Dakota

What Is Form SFN7590 (RCP-5)?

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

Form Details:

  • Released on January 1, 2016;
  • The latest edition provided by the North Dakota 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 SFN7590 (RCP-5) by clicking the link below or browse more documents and templates provided by the North Dakota Department of Health.

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Download Form SFN7590 (RCP-5) "Registration - Radiation Machines" - North Dakota

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DEPARTMENT USE ONLY
REGISTRATION - RADIATION MACHINES
NORTH DAKOTA DEPARTMENT OF HEALTH
Number
AIR QUALITY
SFN 7590 (RCP-5)(01-16)
Director, Air Quality
By
Number
Application For Radiation Machine Reciprocity Privileges
Company Name
Street Address
City
State
Zip Code
Name of Person in Charge
Title
Type of Use




Medical
Dental
Industrial
Other (Specify):
33-10-02-11, “Out of state radiation machines.”
Whenever any radiation machine is to be brought into the state, for any temporary* use, the person proposing to bring such machine into
the state shall give written notice to the Department at least three days before such machine is to be used in the state. The notice shall
include the type of radiation machine; the nature, duration, and scope of use, the exaction location where the radiation machine is to be
used, the names and addresses where the machine users can be reached while in the state, and submit the specified annual fee of $530.00
per machine (33-10-11 Appendix B).
&
CONSOLE MODEL
NUMBER OF
ROOM NO.
RATED
MANUFACTURER
NUMBER
SERIAL NUMBER
TUBES
LOCATION
TYPE OF USE
kvp
mA
To the best of my knowledge, the above information is true and correct.
Name (type or print)
Title
Signature
Date
*Note: Routine use; each day-week-month-list the facility and frequency below.
DEPARTMENT USE ONLY
REGISTRATION - RADIATION MACHINES
NORTH DAKOTA DEPARTMENT OF HEALTH
Number
AIR QUALITY
SFN 7590 (RCP-5)(01-16)
Director, Air Quality
By
Number
Application For Radiation Machine Reciprocity Privileges
Company Name
Street Address
City
State
Zip Code
Name of Person in Charge
Title
Type of Use




Medical
Dental
Industrial
Other (Specify):
33-10-02-11, “Out of state radiation machines.”
Whenever any radiation machine is to be brought into the state, for any temporary* use, the person proposing to bring such machine into
the state shall give written notice to the Department at least three days before such machine is to be used in the state. The notice shall
include the type of radiation machine; the nature, duration, and scope of use, the exaction location where the radiation machine is to be
used, the names and addresses where the machine users can be reached while in the state, and submit the specified annual fee of $530.00
per machine (33-10-11 Appendix B).
&
CONSOLE MODEL
NUMBER OF
ROOM NO.
RATED
MANUFACTURER
NUMBER
SERIAL NUMBER
TUBES
LOCATION
TYPE OF USE
kvp
mA
To the best of my knowledge, the above information is true and correct.
Name (type or print)
Title
Signature
Date
*Note: Routine use; each day-week-month-list the facility and frequency below.