Free Certificate of Disposition of Materials, DPH 45007 - Wisconsin


File Size: 8.3 kB
Pages: 2
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHFS/Radiation Protection Section
Word Count: 430 Words, 2,916 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms/DPH/dph45007.pdf

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DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 45007 (03/04)

STATE OF WISCONSIN Bureau of Environmental Health Radiation Protection Section (608) 267-4797

CERTIFICATE OF DISPOSITION OF MATERIALS
Completion of this form is required to complete termination of a Radioactive Material License as outlined in Chapter HFS 157.13 (11). Failure to provide information will result in this request for termination of a specific license not being processed. Instructions ­ Complete all items. Retain one copy and submit original to State of Wisconsin, Department of Health and Family Services (DHFS), P.O. Box 2659, Madison, WI 53701-2659. Telephone (608) 267-4797 Fax (608) 267-3695.

CONTACT INFORMATION
Item 1 Name and Mailing Address of Applicant: Item 2 Wisconsin Radioactive Material License Number

Item 3 Contact Person ­ Name

Contact Person - Telephone Number (Include area code)

TERMINATION AND DISPOSITION INFORMATION
The following information is provided in accordance with s. HFS 157.13 (11) "Expiration and Termination of Licenses." (Check all that apply) Item 4 All use of radioactive material authorized under the above referenced license has been terminated. Item 5 Radioactive contamination has been removed to the levels outlined in s. HFS 157.13 (11). Item 6 All radioactive material previously procured and/or possessed under the authorization granted by the above referenced license has been disposed of as follows. (Check all that apply) Transferred to: Name Address

Who is(are) authorized to possess such material under Licensed Number Issued by (Licensing Agency) Decayed, surveyed and disposed of as non-radioactive waste. No radioactive material has ever been procured and/or possessed by the licensee under the authorization granted by the above referenced license. Other (Attach additional pages) Item 7 Attached are radiation surveys or equivalent as specified in s. HFS 157.13 (11) (L) (2). Specify the survey instrument(s) used and certify that each instrument is properly calibrated as required in s. HFS 157.13(11) (L) 4.

DPH 45007 (03/04)

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Item 8 Records required to be maintained for the license termination requested are available at the following locations: Name Address

Contact Person Telephone Number (Include area code) Additional remarks (Attach additional pages if necessary.)

CERTIFICATION (To be completed by an individual authorized to make binding commitments on behalf of the applicant.)
Item 10. The undersigned, on behalf of the licensee, hereby certifies that licensable quantities of radioactive material under the jurisdiction of the State of Wisconsin, Department of Health and Family Services are not possessed by the licensee. It is therefore requested that the above referenced radioactive material license be terminated. SIGNATURE - Applicant or Authorized Individual Date signed

Print Name and Title of above signatory