1. ANNUAL REGISTRATION OF GENERALLY LICENSED DEVICES
      1. Bureau of Radiation Protection
      2. General License Program
      3. P.O. Box 8469
      4. Harrisburg, PA 17105-8469
  2. The current annual REGISTRATION FEE is $480.00 per location address.
    1. THIS APPLICATION MUST BE COMPLETED EVERY YEAR FOR YOUR DEVICE RENEWAL.
      1. IMPORTANT
      2. INSTRUCTIONS FOR COMPLETING BRP FORM 2900-FM-RP0664
      3. "GENERAL LICENSEE REGISTRATION”
      4. Table 1. Criteria for Registration
      5. Table 2. Isotope Codes for Sections 2 and 3
      6. Table 3. Unit Codes for Section 2
      7. Unit
      8. Code for form
      9. Unit
      10. Code for form
      11. RETURN THE COMPLETED FORM IN A LARGE ENVELOPE WITH PROPER POSTAGE.
      12.  
      13. GENERAL LICENSEE REGISTRATION
      14. SECTION 1 - GENERAL LICENSEE INFORMATION
      15. Complete all five sections of this registration form. USE CAPITAL LETTERS.
      16. General License Registration Number:        Date:       
      17. SECTION 2 – DEVICES SUBJECT TO REGISTRATION
      18. General License Registration Number:        Date:       
      19. SECTION 3 – DEVICES NOT SUBJECT TO REGISTRATION
      20. SECTION 5 – CERTIFICATION

2900-FM-BRP0664 11/2017   COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF RADIATION PROTECTION

 
 
2900-FM-BRP0664 11/2017
 
 


 

 
ANNUAL REGISTRATION OF GENERALLY LICENSED DEVICES

 

As a U.S. Nuclear Regulatory Commission (NRC) Agreement State, The Commonwealth of Pennsylvania Department of Environmental Protection (DEP), Bureau of Radiation Protection (BRP) requires annual registration of certain devices that are possessed under the general license issued in Section 31.5 of Title 10 U.S. Code of Federal Regulations (10 CFR 31.5). Devices subject to registration include those containing the radioactive material and activity listed in Table 1. You are receiving this notice because BRP records indicate that you have one or more such devices. Information about the general license registration program is available on the internet at http://www.nrc.gov/materials/miau/miau-reg-initiatives/gen-license.html and www.dep.state.pa.us , keyword: Radiation Protection.
 
Note that under 10 CFR 31.5(c)(11), the attached General Licensee Registration Package must be completed, signed, and returned to the BRP within 30 days from the date of this letter. READ ALL OF THE INSTRUCTIONS PRIOR TO COMPLETING THE PACKAGE. Mail the registration fee (check or money order payable to the PA DEP) and the completed package in a large envelope to:
 



Bureau of Radiation Protection



General License Program



P.O. Box 8469



Harrisburg, PA 17105-8469
 
Registration Fee: BRP regulations (25 Pa Code Chapter 218 Appendix A, Category 3Q) require that you submit a registration fee on an annual basis with each registration that covers all certificate eligible devices at a single location address. The registration fee is subject to change. For your convenience, the current registration fee is shown below.
 

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The current annual REGISTRATION FEE is $480.00 per location address.

 



THIS APPLICATION MUST BE COMPLETED EVERY YEAR FOR YOUR DEVICE RENEWAL.
 



IMPORTANT

TO HELP ENSURE YOUR PAYMENT IS PROPERLY CREDITED TO YOUR ACCOUNT, PUT YOUR GENERAL LICENSE CERTIFICATE NUMBER (GL-XXXXX-X) ON PAYMENTS MADE BY CHECK, AS YOU MAY HAVE MULTIPLE REGISTRATION CERTIFICATES FOR LOCATIONS WHERE OTHER DEVICES ARE REGISTERED. IF YOU HAVE NOT BEEN ASSIGNED A GL CERTIFICATE NUMBER, WRITE “GL LICENSE PROGRAM FEE.”
 
 
If you have any questions regarding general licensed devices, please contact the BRP Radioactive Materials Section via telephone at 717-787-3720 or via email at RA-EPRadiationContro@state.pa.us . Also, please be aware more information about BRP can be found at www.dep.pa.gov , search: Radiation Protect.

 


INSTRUCTIONS FOR COMPLETING BRP FORM 2900-FM-RP0664



"GENERAL LICENSEE REGISTRATION”
 
 

            
Review all sections of this registration form. If any information is incorrect or missing, make corrections in the applicable boxes. If you have more devices than space provided in the form, copy the form before starting, as needed. Print or type in black ink using CAPITAL LETTERS. Start information in the first box provided. Use the "Ø" character to represent the number 0 (zero).
Verify information about the devices by reviewing the label on the outside of the device. For safety reasons, DO NOT TRY TO TAKE APART any device to verify this information. If you are uncertain how to identify the device's label, contact the device's manufacturer or an authorized service agent for this information. Also, contact the manufacturer for any additional information about BRP requirements. You may review 10 CFR 31.5 and other applicable regulations on the NRC web site at http://www.nrc.gov/reading-rm/doc-collections/cfr/ , or review specific information about the general licensee project at http://www.nrc.gov/materials/miau/miau-reg-initiatives/gen-license.html .
Note to specific licensees: If you believe the device(s) you possess are contained under your specific license, then verify the device label does not state the device is subject to a general license. If the labels indicate the device is subject to a general license, then complete the registration form as instructed below.
Section 1 - General Licensee Information. Provide the requested information about you, the general licensee.
Provide the street address/location where your device(s) are used. For portable devices, provide the storage location. P.O. Box addresses are not allowed.
Do not write in the box marked For BRP Use Only.
Provide the name, telephone number, and title of the individual responsible for your device(s), and a mailing address where correspondence about your device(s) can be sent. The mailing address should be specific to the physical location where the devices are used and/or stored (P.O. boxes may be used if this is the only available mailing address). The individual indicated in this section as responsible for your device(s) must also verify and sign the form in Section 5.
Section 2 - Devices. If you have generally licensed devices that meet the conditions for registration listed in Table 1, provide information about each device. Before starting, copy this section as needed for your additional devices. Also, indicate how you acquired each device by marking the proper box.
When entering isotope and unit information for your device(s), use the codes listed in Table 2 for isotope information, and use the codes from Table 3 for unit information.


Table 1. Criteria for Registration
Radionuclide
Activity greater than or equal to:
Strontium-90, Radium-226
3.7 megabecquerel (0.1 millicurie)
Cobalt-60, Curium-244, Americium-241, Californium-252 , Cobalt-57, Cadmium-109, Iron-55
37 megabecquerel (1 millicurie)
Cesium-137
370 megabecquerel (10 millicurie)

 
Use the codes from Table 2 when correcting isotope information for devices in this section.

 


Table 2. Isotope Codes for Sections 2 and 3

Radionuclide Code for form Radionuclide Code for form
Americium-241 AM241 Curium-244 CM244
Californium-252 CF252 Strontium-90 SR90
Cesium-137 CS137 Radium-226 RA226
Cobalt-60 CO60 Cobalt-57 CO57
Cadmium-109 CD109 Iron-55 FE55

 

 


Table 3. Unit Codes for Section 2


Unit


Code for form


Unit


Code for form
picocurie PCI becquerel BQ
nanocurie NCI kilobecurel KBQ
microcurie UCI megabecurel MBQ
millicurie MCI gigabecurel GBQ
curie CI terabecurel TBQ
pound LB microgram UG
milligram MG gram G
kilogram KG    

 

 

 

 
Section 3 - Devices Not Subject to Registration. Please list devices in your possession, but are not subject to registration. If you no longer have a device, you are required to make a transfer report to BRP in accordance with 10 CFR 31.5(c)(8) or (9), as applicable. This section does not list any static eliminators containing polonium-210 (Po-210), or luminous exit signs containing tritium (H-3). These devices are not subject to registration, and are not included in this section in an effort to reduce the length of this form.
 
Section 4 – Not in Possession of Device. Use this section to report any devices that are listed in Sections 2 or 3, but that you are no longer in possession of. Before starting, copy this section as needed for additional devices that are not in your possession. Enter the device serial number, as listed in Section 2 or 3. Blacken the square (choose only one) the best describes the disposition of the device and complete the rest of the section as appropriate.
 
Section 5 - Certification and Signature. The responsible individual must certify, sign, and date Section 5.

 
 



RETURN THE COMPLETED FORM IN A LARGE ENVELOPE WITH PROPER POSTAGE.
 
 

 

General License Registration Number:          Date:      



 

 
 



GENERAL LICENSEE REGISTRATION



SECTION 1 - GENERAL LICENSEE INFORMATION

 



Complete all five sections of this registration form. USE CAPITAL LETTERS.

 

Enter the company name and street address for the physical location of use for the device(s). For portable devices, specify the primary storage location. Do not use P. O. Boxes.

 

Company Name:      
Employer ID # (EIN):      
Department:      
Address Line 1:      
Address Line 2:      

City:       State:       Zip Code:      

 

Enter the name, telephone number, and title of the person who is the responsible individual for the device(s).

 

Last Name:       First Name:       Middle Initial:      

Telephone:       Extension:      

Enter Title:      
E-Mail Address:      

Enter the name, telephone number, and title of a knowledgeable alternate contact at your facility.

Last Name:       First Name:       Middle Initial:      

Telephone:       Extension:      

Enter Title:      
E-mail Address:      
Enter the mailing address where correspondence regarding your device(s) should be sent, if different from above.

Department:      
Address Line 1:      
Address Line 2:      

City:       State:       Zip Code:      

 



General License Registration Number:          Date:        

 



SECTION 2 – DEVICES SUBJECT TO REGISTRATION
 

 

Please copy and complete this sheet for each device in your inventory. Do not report specifically licensed devices.
 

Manufacturer Name:      
Initial Transferor Name:      

Initial Transferor License Number (if known)

     

Device Model (Not Source Model):

     

Device Serial Number:

     

How acquired and date (e.g., from a distributor/manufacturer, other licensee, other source)?
Manufacturer/Initial Transferor listed above

Other General License

Other source

Date Transferred (mm/dd/yyyy):      
Method of Leak test: (check one)

wipes counted in house

commercial

consultant

manufacturer

Will this device be used at temporary job sites?      

 

 
Isotope (e.g., AM241)
Activity (e.g., 100)
Unit (e.g., MCI)
1.
                 
2.
                 
3
                 
4
                 
5
                 
6
                 


 



General License Registration Number:          Date:        

 



SECTION 3 – DEVICES NOT SUBJECT TO REGISTRATION

 
 

NRC Device Key:       Manufacturer License No.:      

Manufacturer Name:      

Model Number:       Serial No.:       Transfer Date:     
 

Isotope
Activity
Unit
                 
                 
                 
                 
                 

 

NRC Device Key:       Manufacturer License No.:      

Manufacturer Name:      

Model Number:       Serial No.:       Transfer Date:      
 

Isotope
Activity
Unit
                 
                 
                 
                 
                 

 

NRC Device Key:       Manufacturer License No.:      

Manufacturer Name:      

Model Number:       Serial No.:       Transfer Date:      
 

Isotope
Activity
Unit
                 
                 
                 
                 
                 
                 

General License Registration Number:          Date:        
 
SECTION 4 – NOT IN POSSESSION OF DEVICE
 

Provide information about devices listed in Section 2 or 3, but no longer in your possession.

 
Part 1

Device Serial Number:      Transfer Date (mm/dd/yyyy):      

 
Location of the Device:     

 Whereabouts Unknown

 (Complete Part 1 Only)

 Transferred to Another General License

 (Complete Parts 2 and 3)

 Never Possessed the Device

 (Complete Part 1 Only)

 Transferred to a Specific License

   (Not the Manufacturer) (Complete Part 2)

 Returned to Manufacturer (Complete Part 1 Only)    

 
Part 2
License Number of Recipient (if transferred to a Specific License):      
Company Name:      
Department:      
Address Line 1:      
Address Line 2:      

City:       State:       Zip Code:      

 
Part 3 Enter the name of the individual responsible for this device.

Last Name:       First Name:       Middle Initial:      

Telephone:       Extension:      

Enter Title:      

 

 



SECTION 5 – CERTIFICATION

 

 
I hereby certify that:
 
A.  All information contained in this registration is true and complete to the best of my knowledge and belief.
 
B.  A physical inventory of the devices subject to registration has been completed, and the device information on this form has been checked against the device labeling.
 
C.  I am aware of the requirements of the general license, provided in 10 CFR 31.5. (Copies of applicable regulations may be viewed at the NRC web site at www.nrc.gov/reading-rm/doc-collections/cfr/ .
 
 
 
     
 Signature – Responsible Individual (Listed in Section 1)   Date
 
 
 
WARNING: 18 PA CONSOLIDATED STATUTES SECTION 4904 (a) STATES: REGULATIONS REQUIRE THAT SUBMISSIONS TO THE DEP BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECTS AND MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY

 
 
 
 
 
 
 
 
 

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