Indiana Administrative Code › Title 410 - INDIANA DEPARTMENT OF HEALTH › Article 5 - RADIOLOGICAL HEALTH › Rule 3 - Licensing of Radioactive Material › Section 3-32 - Certification of use of depleted uranium under general license (form W)

Current through July 10, 2024
Authority: IC 16-41-35-26; IC 16-41-35-29
Affected: IC 16-41-35
Sec. 32.
Board Form "W"
(Date)
REGISTRATION CERTIFICATE-USE OF DEPLETED URANIUM UNDER
				  GENERAL LICENSE
410 IAC
				  5-3-6(d)  establishes a general
				  license authorizing the use of depleted uranium contained in industrial
				  products or devices for mass-volume applications. This form W shall be
				  submitted within 30 days after the first receipt or acquisition of such
				  depleted uranium.
INSTRUCTIONS
1.
				Submit this form in triplicate to: Medical Radiology Services Division Indiana
				department of health 2 North Meridian Street Indianapolis, Indiana
				46204
2. Please print or type the
				name and address (including ZIP Code) of the registrant for whom this form is
				filed. Position the first letter of the address below the left dot and do not
				extend the address beyond the right dot. (A file number will be assigned and a
				copy of form W will be returned.)
3. I hereby file form W pursuant to
				410 IAC
				5-3-6(d), for use of depleted uranium
				contained in industrial products or devices for mass-volume
				applications.
4. To be completed by
				the board.
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5. Name and/or title, address, and telephone
				number of the individual duly authorized to act for and on behalf of the
				registrant in supervising the procedures identified in
				410 IAC
				5-3-6(d).
____________
6. Certification:
I hereby certify that:
a. All information in this registration
				certificate is true and complete.
b. The registrant has developed and will
				maintain procedures designed to establish physical control over the depleted
				uranium described in
				410 IAC
				5-3-6(d)  and designed to prevent
				transfer of such depleted uranium in any form, including metal scrap, to
				persons not authorized to receive the depleted uranium.
c. I understand that board rules require that
				any changes in information furnished by a registrant on this registration
				certificate be reported in writing to the board within 30 days after the
				effective date of such change.
d. I
				understand that the registrant is required to comply with the provisions of
				410 IAC
				5-3-6(d)  (reprinted as part of this
				form) with respect to all depleted uranium which he receives, acquires, uses,
				or transfers under the general license for which this registration certificate
				is filed with the board.
Date:_By:________
(Signature of person filing form)
_________________________________________________
(Printed name and title of person filing form) Depleted
				  Uranium in Industrial Products and Devices
(1) A general license is hereby issued to
				receive, acquire, possess, use, or transfer, in accordance with the provisions
				of
				410 IAC
				5-3-6(d)(2), (3), (4), and (5),
				depleted uranium contained in industrial products or devices for the purpose of
				providing a concentrated mass in a small volume of the product or
				device.
(2) The general license in
				410 IAC
				5-3-6(d)(1)  applies only to
				industrial products or devices which have been manufactured either in
				accordance with a specific license issued to the manufacturer of the products
				or devices pursuant to
				410
				IAC 5-3-13(m)  or in accordance with
				a specific license issued to the manufacturer by the U.S. Nuclear Regulatory
				Commission or an agreement state which authorizes manufacture of the products
				or devices for distribution to persons generally licensed by the U.S. Nuclear
				Regulatory Commission or an agreement state.
(3)
(i)
				Persons who receive, acquire, possess, or use depleted uranium pursuant to the
				general license established by
				410 IAC
				5-3-6(d)(1)  shall file board form W
				"Registration Certificate-Use of Depleted Uranium Under General License," with
				the board. The form shall be submitted within 30 days after the first receipt
				or acquisition of such depleted uranium. The registrant shall furnish on board
				form W the following information and such other information as may be required
				by that form:
(A) Name and address of the
				registrant;
(B) A statement that
				the registrant has developed and will maintain procedures designed to establish
				physical control over the depleted uranium described in
				410 IAC
				5-3-6(d)(1)  and designed to prevent
				transfer of such depleted uranium in any form, including metal scrap, to
				persons not authorized to receive the depleted uranium; and
(C) Name and/or title, address, and telephone
				number of the individual duly authorized to act for and on behalf of the
				registrant in supervising the procedures identified in
				410 IAC
				5-3-6(d)(3)(i)(B).
(ii) The registrant possessing or using
				depleted uranium under the general license established by
				410 IAC
				5-3-6(d)(1)  shall report in writing
				to the board any changes in information furnished by him in board form W
				"Registration Certificate-Use of Depleted Uranium Under General License." The
				report shall be submitted within 30 days after the effective date of such
				change.
(4) A person who
				receives, acquires, possesses or uses depleted uranium pursuant to the general
				license established by
				410 IAC
				5-3-6(d)(1):
(i) Shall not introduce such depleted
				uranium, in any form, into a chemical, physical, or metallurgical treatment or
process, except a treatment or process for repair or
				  restoration of any plating or other covering of the depleted uranium.
(ii) Shall not abandon such
				depleted uranium.
(iii) Shall
				transfer or dispose of such depleted uranium only by transfer in accordance
				with the provisions of
				410 IAC
				5-3-22. In the case where the transferee receives the
				depleted uranium pursuant to the general license established by
				410 IAC
				5-3-6(d)(1), the transferor shall
				furnish the transferee a copy of 410 IAC 5 and a copy of board form W. In the
				case where the transferee receives the depleted uranium pursuant to a general
				license contained in the U.S. Nuclear Regulatory Commission's or agreement
				state's regulation equivalent to
				410 IAC
				5-3-6(d)(1), the transferor shall
				furnish the transferee a copy of 410 IAC 5 and a copy of board form W
				accompanied by a note explaining that use of the product or device is regulated
				by the U.S. Nuclear Regulatory Commission or agreement state under requirements
				substantially the same as those in 410 IAC 5.
(iv) Within 30 days of any transfer, shall
				report in writing to the board the name and address of the person receiving the
				depleted uranium pursuant to such transfer.
(v) Shall not export such depleted uranium
				except in accordance with a license issued by the U.S. Nuclear Regulatory
				Commission pursuant to 10 CFR Part 110.
(5) Any person receiving, acquiring,
				possessing, using, or transferring depleted uranium pursuant to the general
				license established by
				410 IAC
				5-3-6(d)(1)  is exempt from the
				requirements of 410 IAC 5-4 and 410 IAC 5-10 with respect to the depleted
				uranium covered by that general license.