Arizona Administrative Code
Title 9 - HEALTH SERVICES
Chapter 7 - DEPARTMENT OF HEALTH SERVICES - RADIATION CONTROL
Article 14 - REGISTRATION OF NONIONIZING RADIATION SOURCES AND STANDARDS FOR PROTECTION AGAINST NONIONIZING RADIATION
Appendix B - Application Information

The Department shall issue a registration if an applicant provides the following information and fee as required in R9-7-1401(D). The Department shall provide an application form to the applicant with a guide and upon request, assist the applicant to ensure that correct information is provided on the application form.

Name and mailing address of applicant

Personresponsible for radiation safety program

Typeof facility

Legal structure and ownership

Radiation source information Shielding information

Equipment operator instructions and restrictions

Classification of professional in charge

Type of request: amendment, new, or renewal

Protection survey results, if applicable

Radiation Safety Officer name if applicable

Laser class and type, if applicable

Information required by Article 14 for the specific source

Use location

Telephone number

Facility sub type

Signature of certifying agent

Equipment identifiers

Scale drawing

Physicist name and training, if applicable

Contact person

Applicable fee listed in Article 13 schedule