SUBLICENSE RENEWAL OR CHANGE IN STATUS
Date _______________________
To: All Radiation Safety Program Sublicensees
From: Hal Barrett, Radiation Safety Officer
In accordance with the UA Radiation Safety Program Manual, August 31 is the designated expiration date for all sublicenses to the State of Alabama license #164 RM. To apply for the renewal of your sublicense for another year, please provide the following information, and return it to the RSO no later than five working days prior to the expiration date. Sublicensees who allow their sublicense to expire must reapply through the Sublicense Approval process. To apply for status change, provide the following information and refer to items 11 and 12.
Sublicensee name ____________________ Dept. _________ Lab(s) __________________
License # _______________ License type: Unsealed S. ____ Sealed S. ____ X-ray ____
Present License Status: Active ____ Inactive _____
Request license termination _____ Request license renewal without alteration _____
Request license renewal with the following changes:
|
Requires amendment approval* |
Requires RSO approval only |
|
1. Additional isotope(s) __________ |
1. Increase amount of isotope________ |
|
2. Change of proposed use ________ |
2. Different form of isotope _________ |
|
3. Transport off campus __________ |
3. Change in location _____________ |
|
4. Authorized representative_______ |
4. Other _______________________ |
|
5. New x-ray instrument __________ |
5.Status change to inactive_________ |
|
6. New sealed source ____________ |
6. Status change to active__________ |
*Attach Amendment Application
STATUS CHANGE
11. Inactive status may be used when an individual wishes to maintain the privileges of a Sublicensee but does not currently possess any radioactive material or radiation producing machines.
12. As a Sublicensee who does not currently possess any radioactive materials or radiation producing machines, I have been classified as inactive status. However, since I intend to resume work with RM or radiation producing machines, I request to be approved for re-instatement of active status. I understand that once active status is approved, it shall remain in effect until Aug. 31.
Signature of applicant_____________________________________ Date__________________
Approved by ___________________________________________ Date___________________