410 IAC 5-3-32 - Certification of use of depleted uranium under general license (form W)

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.

Click here to view image

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.

Notes

410 IAC 5-3-32

Indiana State Department of Health; 410 IAC 5-3-32; filed Feb 29, 1984, 10:10 am: 7 IR 895; readopted filed Jul 11, 2001, 2:23 p.m.: 24 IR 4234; readopted filed May 22, 2007, 1:44 p.m.: 20070613-IR-410070141RFA; errata filed Feb 3, 2010, 2:21 p.m.: 20100224-IR-410100062ACA; readopted filed Sep 11, 2013, 3:19 p.m.: 20131009-IR-410130346RFA Readopted filed 11/13/2019, 3:14 p.m.: 20191211-IR-410190391RFA Errata filed 7/28/2021, 8:26 a.m.: 20210811-IR-410210309ACA