Free Certificate - Use of Depleted Uranium under General License, DPH 45023 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 45023 (02/04)

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

CERTIFICATE ­ USE OF DEPLETED URANIUM UNDER GENERAL LICENSE
No person may receive, acquire, possess or use depleted uranium under a general license, as specified by s. HFS 157.11(1)(c)3, until this form has been filed with the State of Wisconsin Department of Health and Family Services (DHFS) and DHFS has returned a copy of this form with a certificate number. Instructions ­ Complete all items. Retain one copy and submit original to the 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 Contact Person - Name:

Item 3 Contact Person ­ Telephone Number (Include area code):

LOCATION OF RADIOACTIVE MATERIAL
Item 4 Address(es) where radioactive material will be used (Do not use Post Office Box): Address Telephone Number (Include area code):

Address

Telephone Number (Include area code):

RADIOACTIVE MATERIAL
Item 5 Please provide a description of the radioisotopes that will be used and a description of their use. Radioisotope Description of use

(Attach additional sheets if necessary)

DPH 45023 (02/04)

Page 2

CERTIFICATION (To be completed by an individual authorized to make binding commitments on behalf of the applicant.)
Item 6 The undersigned, on behalf of the applicant hereby certifies all the following: A. B. All information in this application is true and complete. Radiation safety procedures have been developed and implemented to establish physical control over the depleted uranium, as described in s. HFS 157.11(1)(c)3.b. C. I understand that the department requires that any changes in the information furnished on this application be reported to DHFS within 30 days from the effective date of such change (s. HFS 157.11(1)(c)4). D. I have read and understand the provisions of the general license for use of depleted uranium, as specified in s. HFS 157.11(1)(c)). I also understand that compliance with these provisions is required for all radioactive material that is received, acquired, possessed, used, or transferred under this general license. SIGNATURE (Applicant or Authorized Individual): Date signed:

Print Name and Title of above signatory

LEAVE THE SECTION BELOW BLANK ­ NUMBER TO BE ASSIGNED BY DHFS CERTIFICATE NUMBER: EXPIRES: