ࡱ> a #bjbj 4hGbhGbC%%z008d0x&">>f}%%%%%%%$N),%9{"{{%00>fE%$;;;{08>(f}%;{}%;;:A#,h#f4Әl@m# i%&xx&w#R,U^,#,#> ,;7$[ %%x&{{{{,B :  DEPARTMENT OF ENVIRONMENTAL QUALITY OFFICE OF ENVIRONMENTAL COMPLIANCE LICENSING & REGISTRATIONS SECTION POST OFFICE BOX 4312 BATON ROUGE, LOUISIANA 70821-4312 PHONE: (225) 219-3041 Office Use Only APPLICATION AI# Registration No. Shielding Date  APPLICATION FOR REGISTRATION OF RADIATION SOURCE DRC-6 (5/19) Must check all that apply: ( New Registration ( Shielding Evaluation Information (see pg 2) j If replacing old machine enter old Registration # __________________ ( Change of Address or other Information (see pg 2) ( Disposition of Equipment, ie. required information if this unit replaces an existing one (See pg 3) FACILITY INFORMATION1. Company Name/Facility Name 2. Name of Owner3. Mailing Address: No. & Street City & StateZip Code4. Contact Email Address 5. Billing Address: No. & Street City & StateZip Code 6. Area Code-Telephone Number of Facility7. Full Address at which x-ray unit will be used Parish8. Room No. & Location where source will be used9. Type of Facility( Hospital (IM)( Medical Clinic (PM)( Private Medical Practice (PM)( Educational Institution (ED)( Industrial (IN)( Industrial Radiography (IR)( Private Dental Practice (PD)( Other (Specify):_________________( Veterinary (VT)( Chiropractic (DC)( Dental Clinic (PD)USER INFORMATION10. Individual in Charge of Source (RSO, operator, etc.) 11. Individual Responsible for Radiation Protection 12. Classification of Individual in Charge of Source( Dentist( General Practitioner( Health Physicist( Registered X-Ray Technologist( Radiologist( Industrial Radiographer( Veterinarian( Non-Registered X-Ray Tech.( Chiropractor( Podiatrist( Osteopath( Other (Specify):______________________SOURCE INFORMATION13. Source A. Medical X-Ray ( Fluoroscopic w/ Image Intensifier ( Fluoroscopic w/o Image Intensifier ( Combination *w/ Image Intensifier ( Combination *w/o Image Intensifier ( Radiographic ( Photofluorographic ( Mammography ( CT *Radiographic & Fluoroscopic Combination( Bone Densitometer ( Deep Therapy ( Superficial Therapy ( Special Procedures B. Dental X-Ray ( Conventional ( Panoramic ( Cephalometric ( CBCT (see shielding pg 2)C. Accelerator ( Neutron Generator ( Van de Graaff ( Linear Accelerator D. Other X-Ray ( Industrial Radiography ( Diffraction Apparatus ( Cabinet ( Other (Specify): _______________E. Educational Institution ( Medical X-Ray ( Dental X-Ray ( Other X-Ray F. Veterinary ( Radiographic ( Dental 14. Source is: (Fixed (Mobile (Handheld (If handheld, attach training documentation from the manufacturer) 15. Control Panel Information (Use one form for each panel): Use only information from Control Panela. Manufacturerb. Model Numberc. Serial Numberd. Number of Tube Headse. Max. kVpf. Max. mA  CERTIFICATION 16. This is to certify that, to the best of my knowledge and belief, all information contained herein, including any supplements attached hereto, is true and correct. _____________________________ _____________________________ _____________________________ _____________________________DatePrimary Contact Person (Print)Applicant (Print)Signature of Responsible PartySubmit the completed original application for each x-ray unit to the above address, and maintain a copy for your files.NOTE: All applications must be signed and dated before a Registration Certificate can be issued. Shielding Evaluation Information  LAC 33:XV.603.C. Plans Review 1. Except for dedicated mammography radiographic systems, podiatric radiographic systems, panoramic dental radiographic systems, and intraoral dental radiographic systems, prior to construction, the floor plans and equipment arrangement of all new installations, or modifications of existing installations, utilizing X-rays for diagnostic or therapeutic purposes shall be submitted to the Office of Environmental Compliance for review and approval. The required information is specified in LAC 33:XV.699.Appendices A and B. 2. The floor plans and equipment arrangement for all new, or modifications of existing, installations for veterinary X-ray systems shall be reviewed for adequacy by the department on a case-by-case basis. If shielding is required for X-ray unit and has already been approved by the Department please attach a copy of the approval letter. If letter is not available, submit the following information: Room Housing Unit (Description or Room Number): Date of the Department approved shielding:( Shielding review form enclosed ( Shielding review form recently submitted and waiting for approval If the machine to be registered requires shielding and it is replacing an old machine that already had a shielding review done or it is a CBCT unit, please submit the following information: Average # of Patients/week: Average kVp used:( Room has not changed since last approved shielding review ( Room has changed since last approved shielding review (please enclosed description of changes) ( CBCT Unit is placed in a room  If the above information is not available, please submit a physicist survey Physicist Survey included Physicist Survey not included For CBCT units, please submit training certificate(s) and Quality Assurance Plan Please provide any other detailed information that will assist the department in registering your machine(s). ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Transfer Information If facility/machines were transferred from a different location that the registrant owns, please provide the following information for the previous location, the new location, and which machines are being transferred. PREVIOUS FACILITY INFORMATION1. Company Name/Facility Name 2. Name of Owner3. Agency Interest No., if known4. Full Address at which x-ray was located: 5. Telephone Number of Facility6. Contact Email Address NEW FACILITY INFORMATION1. Company Name/Facility Name 2. Name of Owner3. Agency Interest No., if known4. Mailing Address: No. & Street City & State Zip Code 5. Contact Email Address 6. Billing Address: No. & Street City & State Zip Code 7. Area Code Telephone Number of Facility 8. Address at which x-ray is located: City & State Zip Code 9. Date of Transfer SOURCE INFORMATION Control Panel Information (Use a separate page for additional units): Use only information from Control Panela. Manufacturerb. Model Numberc. Serial Numberd. Type of Machine NOTE: For any unit that requires shielding, please refer to Shielding Evaluation Information (page 2) for the new location. CERTIFICATION This is to certify that, to the best of my knowledge and belief, all information contained herein, including any supplements attached hereto, is true and correct. __________________ _____________________________ _____________________________ _____________________________DatePrimary Contact Person (Print)Applicant (Print)Signature of Responsible Party NOTE: All applications must be signed and dated before a Registration Certificate can be issued. RADIATION MACHINE DISPOSITION FORM TO AVOID PAYING A FEE ON A RADIATION MACHINE THAT IS NO LONGER IN YOUR POSSESSION OR INOPERABLE IN THE MANNER DESCRIBED BELOW, THE FOLLOWING REQUESTED INFORMATION MUST BE RECEIVED BY THE DEPARTMENT BY THE INVOICE DUE DATE. Registration No. of radiation machine no longer in your possession or deemed inoperable: _____________ Manufacturer of above machine: __________________________ Model Number: _________________________ Serial number: __________________________ If machine was transferred, list person/company and address that machine was transferred to: ______________________________________ ______________________________________ ______________________________________ Indicate if machine is Inoperable in the manner listed below: ( YES ( NO A machine is inoperable only if the machines X-ray tube (insert) has been removed in such a manner that it would require an X-ray company/service person to make it operable. With the X-ray tube in place, the unit is considered to be operable. 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