DEQ Form 410-241 "Report of Proposed Activities in Oklahoma" - Oklahoma

What Is DEQ Form 410-241?

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

Form Details:

  • Released on July 1, 2014;
  • The latest edition provided by the Oklahoma Department of Environmental Quality;
  • 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 DEQ Form 410-241 by clicking the link below or browse more documents and templates provided by the Oklahoma Department of Environmental Quality.

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Download DEQ Form 410-241 "Report of Proposed Activities in Oklahoma" - Oklahoma

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DEQ FORM #410-241 (7/14)
OKLAHOMA DEPARTMENT OF ENVIRONMENTAL QUALITY
REPORT OF PROPOSED ACTIVITIES IN OKLAHOMA
1. NAME OF LICENSEE
2. CONTROL NUMBER
3. TYPE OF REPORT ⇩  
(Person or firm proposing the activities described below)
(Leave blank: number will be assigned)
INITIAL
4. ADDRESS OF LICENSEE
REVISION
(Mailing address or other location where licensee may be located)
CLARIFICATION
5. LICENSEE CONTACT
6. EMAIL ADDRESS
7. TELEPHONE NUMBER
8. FACSIMILE NUMBER
(include area code)
(include area code)
9. CHECK BELOW THE ACTIVITIES TO BE CONDUCTED IN OKLAHOMA UNDER RECIPROCITY RECOGNITION, OAC 252:410-7-31
through 35 and 252:410-10-150(3):
WELL LOGGING
LEAK TESTING AND/OR CALIBRATIONS
TELETHERAPY/IRRADIATOR SERVICE
PORTABLE GAUGES
OTHER (specify):
RADIOGRAPHY 
10. CLIENT NAME, ADDRESS, CITY/COUNTY,
11. WORK LOCATION ADDRESS
(Street and Number or other location. Give as complete an address or
STATE, ZIP CODE
directions as possible.)
12. CLIENT TELEPHONE NUMBER
13. NUMBER OF WORK DAYS
14. WORK LOCATION TECHNICIAN AUTHORIZED
(include area code)
TO PERFORM WORK
15. DATES SCHEDULED
16. WORK LOCATION TELEPHONE NUMBER
(include area code)
FROM
TO
LIST ADDITIONAL WORK SITES ON SEPARATE SHEET TO INCLUDE ALL INFORMATION CONTAINED IN ITEMS 9-16 ABOVE
17. NRC OR AGREEMENT STATE SPECIFIC LICENSE WHICH AUTHORIZES THE UNDERSIGNED TO CONDUCT ACTIVITIES WHICH ARE THE SAME,
EXCEPT FOR LOCATION OF USE, AS SPECIFIED IN ITEM 11, ABOVE.
LICENSE NUMBER
STATE
EXPIRATION DATE
TOTAL USAGE DAYS TO DATE
18. CERTIFICATION
I THE UNDERSIGNED, HEREBY CERTIFY THAT:
a. All information in this report is true and complete
b. I have read and understand the provision of the DEQ reciprocity recognition, OAC 252:410-7-31 through 35 and 252:410-10-150(3), and I understand that I am required to comply with
these provisions as to all byproduct, source, or special nuclear material which I possess and use in Oklahoma under this authorization.
c. I understand that activities, including storage, conducted in Oklahoma under reciprocity recognition are limited to a total of 180 days in calendar year.
d. I understand that I may be inspected by DEQ on activities subject to this reciprocity recognition.
e. I understand that conduct of any activities not described above, including conduct of activities on dates or locations different from those described above without
DEQ authorization, may subject me to enforcement action, including civil or criminal penalties.
CERTIFYING OFFICER--RSO or Management Representative
SIGNATURE
DATE
(Typed/Printed Name and Title)
WARNING: FALSE STATEMENTS IN THIS CERTIFICATE MAY BE SUBJECT TO CIVIL AND /OR CRIMINAL PENALTIES. DEQ REGULATIONS REQUIRE
THAT SUBMISSIONS TO THE DEQ BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECTS
FOR DEQ
AUTHORIZING OFFICIAL
SIGNATURE
DATE
USE ONLY
(Typed/Printed Name and Title)
DEQ FORM #410-241 (7/14)
OKLAHOMA DEPARTMENT OF ENVIRONMENTAL QUALITY
REPORT OF PROPOSED ACTIVITIES IN OKLAHOMA
1. NAME OF LICENSEE
2. CONTROL NUMBER
3. TYPE OF REPORT ⇩  
(Person or firm proposing the activities described below)
(Leave blank: number will be assigned)
INITIAL
4. ADDRESS OF LICENSEE
REVISION
(Mailing address or other location where licensee may be located)
CLARIFICATION
5. LICENSEE CONTACT
6. EMAIL ADDRESS
7. TELEPHONE NUMBER
8. FACSIMILE NUMBER
(include area code)
(include area code)
9. CHECK BELOW THE ACTIVITIES TO BE CONDUCTED IN OKLAHOMA UNDER RECIPROCITY RECOGNITION, OAC 252:410-7-31
through 35 and 252:410-10-150(3):
WELL LOGGING
LEAK TESTING AND/OR CALIBRATIONS
TELETHERAPY/IRRADIATOR SERVICE
PORTABLE GAUGES
OTHER (specify):
RADIOGRAPHY 
10. CLIENT NAME, ADDRESS, CITY/COUNTY,
11. WORK LOCATION ADDRESS
(Street and Number or other location. Give as complete an address or
STATE, ZIP CODE
directions as possible.)
12. CLIENT TELEPHONE NUMBER
13. NUMBER OF WORK DAYS
14. WORK LOCATION TECHNICIAN AUTHORIZED
(include area code)
TO PERFORM WORK
15. DATES SCHEDULED
16. WORK LOCATION TELEPHONE NUMBER
(include area code)
FROM
TO
LIST ADDITIONAL WORK SITES ON SEPARATE SHEET TO INCLUDE ALL INFORMATION CONTAINED IN ITEMS 9-16 ABOVE
17. NRC OR AGREEMENT STATE SPECIFIC LICENSE WHICH AUTHORIZES THE UNDERSIGNED TO CONDUCT ACTIVITIES WHICH ARE THE SAME,
EXCEPT FOR LOCATION OF USE, AS SPECIFIED IN ITEM 11, ABOVE.
LICENSE NUMBER
STATE
EXPIRATION DATE
TOTAL USAGE DAYS TO DATE
18. CERTIFICATION
I THE UNDERSIGNED, HEREBY CERTIFY THAT:
a. All information in this report is true and complete
b. I have read and understand the provision of the DEQ reciprocity recognition, OAC 252:410-7-31 through 35 and 252:410-10-150(3), and I understand that I am required to comply with
these provisions as to all byproduct, source, or special nuclear material which I possess and use in Oklahoma under this authorization.
c. I understand that activities, including storage, conducted in Oklahoma under reciprocity recognition are limited to a total of 180 days in calendar year.
d. I understand that I may be inspected by DEQ on activities subject to this reciprocity recognition.
e. I understand that conduct of any activities not described above, including conduct of activities on dates or locations different from those described above without
DEQ authorization, may subject me to enforcement action, including civil or criminal penalties.
CERTIFYING OFFICER--RSO or Management Representative
SIGNATURE
DATE
(Typed/Printed Name and Title)
WARNING: FALSE STATEMENTS IN THIS CERTIFICATE MAY BE SUBJECT TO CIVIL AND /OR CRIMINAL PENALTIES. DEQ REGULATIONS REQUIRE
THAT SUBMISSIONS TO THE DEQ BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECTS
FOR DEQ
AUTHORIZING OFFICIAL
SIGNATURE
DATE
USE ONLY
(Typed/Printed Name and Title)
OKLAHOMA DEPARTMENT OF ENVIRONMENTAL QUALITY
REPORT OF PROPOSED ACTIVITIES IN OKLAHOMA
PLEASE READ THE INFORMATION AND INSTRUCTIONS BELOW
BEFORE COMPLETING FORM #DEQ 410-241.
Oklahoma Administrative Code (OAC) 252:410-7-31 through 35 and 252:410-10-150(3) establish reciprocity recognition
authorizing any person who holds a specific license from the U. S. Nuclear Regulatory Commission (NRC) or an
“Agreement State”(a State with which the U.S. Nuclear Regulatory Commission has entered into an effective agreement
under subsection 274b of the Atomic Energy Act of 1954) where the licensee maintains an office for directing the licensed
activity and at which radiation safety records are normally maintained, to conduct the same activity in Oklahoma if the
specific license issued by NRC or the Agreement State does not limit the authorized activity to specified locations or
installations.
INSTRUCTIONS
For licensees seeking to conduct activities under reciprocity for the first time in a calendar year, submit this FORM, a copy
of the NRC or Agreement State specific license, and the fee specified in OAC 252:410-10-118.
The Oklahoma
Department of Environmental Quality (DEQ) must receive this filing at least 3 days before the licensee engages in
activities permitted under the reciprocity recognition established by OAC 252:410-7-31 through 35 and 252:410-10-150(3).
In general, the preferred method of filing is through the transmission by facsimile of DEQ FORM #410-241, the NRC or
Agreement State license, and a copy of the check, as this method avoids many timing problems which may be caused by
use of the mail. If the facsimile method is used, the transmission must be received by DEQ 3 days before the licensee
engages in the activity. In addition, the licensee must also file the copy of DEQ FORM #410-241, a copy of the NRC or
Agreement State license, and the check for the fee within 3 days of facsimile transmission. Alternatively, the licensee
may file the required information through the mail or other means, provided DEQ receives the information at least 3 days
before the licensee engages in the activity.
If the facsimile or other acceptable method for filing all of the required information is not available to the licensee due to an
emergency or other reasons, the Executive Director has the discretion to waive the time requirements specified in OAC
252:410-7-34(4) and for the filing of DEQ FORM #410-241, provided that the NRC or Agreement State licensee:
a.
informs the Department by telephone, facsimile, DEQ FORM #410-241, or letter of initial activities or revisions to
the information submitted on the initial DEQ FORM #410-241 (e.g. additional locations or work or changes to the
radioactive material or work activities) and
b.
receives oral or written authorization for the activity(ies) from the Department, and
c.
files a copy of the DEQ FORM #410-241, a copy of the NRC or Agreement State license, and the check for the
fee payment within 3 days after the telephone notification.
For licensees submitting revisions to the information contained in the initial DEQ FORM #410-241, file this Form so that
DEQ receives the filing at least 3 days prior to engaging in such activity.
NOTE: Activities, including storage, conducted in Oklahoma under reciprocity recognition in OAC 252:410-7-31 through
35 and 252:410-10-150(3) are limited to a total of 180 days in any calendar year. Failure to file a DEQ FORM
#410-241 may result in civil or criminal penalties.
NOTE: Inspections by DEQ of activities performed in Oklahoma by NRC or Agreement State licensees operating under
the reciprocity recognition in OAC 252:410-7-31 through 35 and 252:410-10-150(3) may be conducted at the
listed work site locations or at the licensee’s home office address.
NRC or Agreement State licensees seeking to conduct activities under Reciprocity should file this form and the
appropriate fee with:
Oklahoma Department of Environmental Quality
Land Protection Division/Radiation Management Section
P.O. Box 2036, 707 N. Robinson
Oklahoma City, OK 73101-2036
Telephone - (405) 702-5100 Fax - (405) 702-5101
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