Form GEN-4A "Registration of Devices Possessed Under the General License Issued in Section C.4.2(B) of the Rules and Regulations for the Control of Radiation" - Rhode Island

What Is Form GEN-4A?

This is a legal form that was released by the Rhode Island Department of Health - a government authority operating within Rhode Island. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on January 1, 2005;
  • The latest edition provided by the Rhode Island 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 GEN-4A by clicking the link below or browse more documents and templates provided by the Rhode Island Department of Health.

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Download Form GEN-4A "Registration of Devices Possessed Under the General License Issued in Section C.4.2(B) of the Rules and Regulations for the Control of Radiation" - Rhode Island

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RHODE ISLAND RADIATION CONTROL AGENCY
Page
of
REGISTRATION OF DEVICES POSSESSED UNDER THE
GENERAL LICENSE ISSUED IN SECTION C.4.2(b) OF THE
RULES AND REGULATIONS FOR THE CONTROL OF RADIATION
Agency Form GEN-4 Continuation Sheet – New Devices
5. NEW DEVICE INFORMATION:
Manufacturer/Initial Transferor Name:
Manufacturer/Initial Transferor License Number (if known):
Device Model Number:
Device Serial Number:
How was device acquired?
Date Acquired (MM/DD/YYYY):
Manufacturer/Initial Transferor listed above
Other General Licensee
Other Source (Specify below)
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
5. NEW DEVICE INFORMATION:
Manufacturer/Initial Transferor Name:
Manufacturer/Initial Transferor License Number (if known):
Device Model Number:
Device Serial Number:
How was device acquired?
Date Acquired (MM/DD/YYYY):
Manufacturer/Initial Transferor listed above
Other General Licensee
Other Source (Specify below)
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
5 NEW DEVICE INFORMATION:
Manufacturer/Initial Transferor Name:
Manufacturer/Initial Transferor License Number (if known):
Device Model Number:
Device Serial Number:
How was device acquired?
Date Acquired (MM/DD/YYYY):
Manufacturer/Initial Transferor listed above
Other General Licensee
Other Source (Specify below)
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
FORM GEN-4A (January 2005)
RHODE ISLAND RADIATION CONTROL AGENCY
Page
of
REGISTRATION OF DEVICES POSSESSED UNDER THE
GENERAL LICENSE ISSUED IN SECTION C.4.2(b) OF THE
RULES AND REGULATIONS FOR THE CONTROL OF RADIATION
Agency Form GEN-4 Continuation Sheet – New Devices
5. NEW DEVICE INFORMATION:
Manufacturer/Initial Transferor Name:
Manufacturer/Initial Transferor License Number (if known):
Device Model Number:
Device Serial Number:
How was device acquired?
Date Acquired (MM/DD/YYYY):
Manufacturer/Initial Transferor listed above
Other General Licensee
Other Source (Specify below)
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
5. NEW DEVICE INFORMATION:
Manufacturer/Initial Transferor Name:
Manufacturer/Initial Transferor License Number (if known):
Device Model Number:
Device Serial Number:
How was device acquired?
Date Acquired (MM/DD/YYYY):
Manufacturer/Initial Transferor listed above
Other General Licensee
Other Source (Specify below)
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
5 NEW DEVICE INFORMATION:
Manufacturer/Initial Transferor Name:
Manufacturer/Initial Transferor License Number (if known):
Device Model Number:
Device Serial Number:
How was device acquired?
Date Acquired (MM/DD/YYYY):
Manufacturer/Initial Transferor listed above
Other General Licensee
Other Source (Specify below)
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
ISOTOPE
ACTIVITY
UNIT
FORM GEN-4A (January 2005)