Form SFN60265 "Application for Tenorm Transporter Radioactive Material License" - North Dakota

What Is Form SFN60265?

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 March 1, 2018;
  • 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 fillable version of Form SFN60265 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 SFN60265 "Application for Tenorm Transporter Radioactive Material License" - North Dakota

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APPLICATION FOR TENORM TRANSPORTER RADIOACTIVE MATERIAL LICENSE
NORTH DAKOTA DEPARTMENT OF HEALTH
RADIATION CONTROL PROGRAM
SFN 60265(03/2018)
INSTRUCTIONS: TECHNICALLY ENHANCED NORMALLY OCCURRING RADIOACTIVE MATERIAL (TENORM) USAGE
ONLY. EMAIL A COPY OF THE COMPLETED APPLICATION TO
RAM@ND.GOV
2.
Name and Mailing Address of Applicant (include ZIP Code)
1.
A. New License
B. Amendment to License Number _______________________
C. Renewal of License Number _________________________
3.
Name of Person to be Contacted about this Application
Business Telephone Number
Business Cell Phone Number
Business Email Address
SUBMIT DOCUMENTION FOR ITEMS 4 THROUGH 7. THE TYPE AND SCOPE OF INFORMATION TO BE PROVIDED IS
DESCRIBED IN SECTION 8 OF LICENSE APPLICATION GUIDE NUREG-1556, VOLUME 18.
4.
Radioactive Material
a.
Element and mass number (e.g. TENORM);
b.
Chemical and/or physical form (e.g. filter socks)
5.
Purpose(s) for which Licensed Material will be Used (e.g. pickup for disposal only).
6.
Individual(s) Responsible for Radiation Safety Training Program.
7.
Radiation Safety Training Program
8.
License Fee (See North Dakota Radiological Health Rule 33-10-11)
Fee Category
Amount Enclosed
4.C
$7988.00
9.
Obtain a “Certificate Of Authority” from the North Dakota Secretary of State to operate in North Dakota. Call (800) 352-0867 Ext. 4284 for
more information.
10. Obtain a “Permit for Transporting Solid Waste” from the North Dakota Department of Health, Division of Waste Management. Call (701)
328-5166 for more information.
11. Certification (must be completed by 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 certification on behalf of the applicant, named in item 2, certify that this application is prepared in
conformity with Radiation Health Chapters 33-10-3.1, -4.2, -11, -13.1 and that all information contained herein is true and correct to
the best of their knowledge and belief.
Certifying Officer – Typed/Printed Name and Title
Signature
Date
(Must Sign in Blue Ink)
A hard copy of this form shall be signed, dated and submitted to the Department along with the appropriate license fee. Payment
shall be in the form of a check or money order payable to the North Dakota Department of Health. Send to:
North Dakota Department of Health
nd
Division of Air Quality, 2
Floor
918 East Divide Ave.
Bismarck, ND 58501-1947
Phone: 701-328-5188
Fax: 701-328-5185
FOR DEPARTMENT USE ONLY
TYPE OF FEE
FEE CATEGORY
AMOUNT RECEIVED
Check Number
Comments
$
Date
APPLICATION FOR TENORM TRANSPORTER RADIOACTIVE MATERIAL LICENSE
NORTH DAKOTA DEPARTMENT OF HEALTH
RADIATION CONTROL PROGRAM
SFN 60265(03/2018)
INSTRUCTIONS: TECHNICALLY ENHANCED NORMALLY OCCURRING RADIOACTIVE MATERIAL (TENORM) USAGE
ONLY. EMAIL A COPY OF THE COMPLETED APPLICATION TO
RAM@ND.GOV
2.
Name and Mailing Address of Applicant (include ZIP Code)
1.
A. New License
B. Amendment to License Number _______________________
C. Renewal of License Number _________________________
3.
Name of Person to be Contacted about this Application
Business Telephone Number
Business Cell Phone Number
Business Email Address
SUBMIT DOCUMENTION FOR ITEMS 4 THROUGH 7. THE TYPE AND SCOPE OF INFORMATION TO BE PROVIDED IS
DESCRIBED IN SECTION 8 OF LICENSE APPLICATION GUIDE NUREG-1556, VOLUME 18.
4.
Radioactive Material
a.
Element and mass number (e.g. TENORM);
b.
Chemical and/or physical form (e.g. filter socks)
5.
Purpose(s) for which Licensed Material will be Used (e.g. pickup for disposal only).
6.
Individual(s) Responsible for Radiation Safety Training Program.
7.
Radiation Safety Training Program
8.
License Fee (See North Dakota Radiological Health Rule 33-10-11)
Fee Category
Amount Enclosed
4.C
$7988.00
9.
Obtain a “Certificate Of Authority” from the North Dakota Secretary of State to operate in North Dakota. Call (800) 352-0867 Ext. 4284 for
more information.
10. Obtain a “Permit for Transporting Solid Waste” from the North Dakota Department of Health, Division of Waste Management. Call (701)
328-5166 for more information.
11. Certification (must be completed by 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 certification on behalf of the applicant, named in item 2, certify that this application is prepared in
conformity with Radiation Health Chapters 33-10-3.1, -4.2, -11, -13.1 and that all information contained herein is true and correct to
the best of their knowledge and belief.
Certifying Officer – Typed/Printed Name and Title
Signature
Date
(Must Sign in Blue Ink)
A hard copy of this form shall be signed, dated and submitted to the Department along with the appropriate license fee. Payment
shall be in the form of a check or money order payable to the North Dakota Department of Health. Send to:
North Dakota Department of Health
nd
Division of Air Quality, 2
Floor
918 East Divide Ave.
Bismarck, ND 58501-1947
Phone: 701-328-5188
Fax: 701-328-5185
FOR DEPARTMENT USE ONLY
TYPE OF FEE
FEE CATEGORY
AMOUNT RECEIVED
Check Number
Comments
$
Date