PENNSYLVANIA DEPARTMENT OF ENVIRONMENTAL PROTECTION

Transcription

1 2900-PM-BRP0045 Rev. 9/2014 Requirements and Fees PENNSYLVANIA DEPARTMENT OF ENVIRONMENTAL PROTECTION BUREAU OF RADIATION PROTECTION APPLICATION, REQUIREMENTS AND FEES FOR VENDOR/SERVICE PROVIDERS OF RADIATION PRODUCING MACHINES

2 2900-PM-BRP0045 Rev. 9/2014 Requirements and Fees Application for Registration of Vendor/Service Providers A REGISTRATION MUST BE SUBMITTED FOR EACH vendor/service provider who engages in the business of assembling, installing, selling, servicing or furnishing radiation-producing machines. This portion of the application provides general registration information that will be of value to you when you complete the written portion of the application. The Department issues registrations for vendor/service providers under the provisions of the Radiation Protection Act and respective regulations, which set forth requirements both to become and to remain registered. The Department is responsible for enforcing the Radiation Protection Act and our regulations. It is imperative that you become familiar with our radiation protection regulations in the Pennsylvania State Code, Title 25 Environmental Protection, available at or a copy of which is available upon request. Registration Requirements A registration is required for any person or entity who assembles, installs, services, sells, leases or lends radiation-producing machines in the Commonwealth. New Commonwealth vendors/service providers must register prior to operating in Pennsylvania. Notify the Department in writing within 30 days of a change of address or ownership. Have the current valid certificate of registration available for inspection by the Department. Valid Registration The registration becomes valid upon receipt of the properly completed registration form and the fee required under Chapter 218 (related to fees). The Department will issue a certificate of registration to the entity whose registration becomes valid. Transfer or Assignment A certificate of registration issued by the Department may not be transferred, assigned, or in any manner disposed of, either voluntary or involuntarily, to any entity without submitting a written request to the Department

3 2900-PM-BRP0045 Rev. 9/2014 Requirements and Fees Payment of Registration Fees A radiation-producing machine service provider shall pay an annual registration fee of $ Partial payments are not accepted for registration Fees for initial registration are payable upon the filing of the registration. ANNUAL RENEWAL OF REGISTRATION This registration must be renewed annually. The Department will send an application for renewal to the registrant at least two months prior to the expiration date on the certificate of registration. The renewal becomes valid upon receipt of the properly completed application and fees. Verify the renewal form is correct and make any applicable changes necessary. Fees are payable by the last day of the registration month as shown on the registration fee invoice. If you do not receive the renewal form two months prior to expiration, you must notify the Department. If a registration is revoked or voluntarily terminated prior to its expiration date, the registration fee will not be refunded in whole or in part. Termination of Registration The registrant shall notify the Department immediately, in writing, and request termination of the certificate of registration. Prior to termination remit any outstanding registration or renewal of registration fees owed to the Department under (relating to registration, renewal of registration and license fees)

4 2900-PM-BRP0045 Rev. 9/2014 Requirements and Fees How and Where to Pay Please complete the registration form included in this packet. Mail the original registration form, along with a check or money order in the proper amount. You must include payment with your registration or your form will be returned to you and your registration will not be valid. Retain a copy of the registration form with your records. Mail the registration and the check or money order, payable to Commonwealth of Pennsylvania to: DEP Bureau of Radiation Protection PO Box 8469 Harrisburg, PA Failure by Registrant to Pay Required Fee as set forth by Chapter (h) A registrant who fails to pay an annual fee required under this chapter shall be subject to the civil and criminal penalties as provided under the Act. Nonpayment of fees required by this chapter shall be cause for revocation of registration issued by the Department under the Act. Reporting and Recordkeeping Requirements for Registered Radiation-Producing Machine Service Providers. All vendor/service providers must report the service performed to the Department within 15 days of the action. Forms and instructions are included in this package for reporting to the Department. A copy of the assembler's report on U.S. FDA form 2579 will satisfy the reporting requirement. For more information, please visit DEP's website at

5 2900-PM-BRP0045a Rev. 9/2014 COMMONWEALTH OF PENNSYLVANIA Instructions DEPARTMENT OF ENVIRONMENTAL PROTECTION BUREAU OF RADIATION PROTECTION REGISTRATION INSTRUCTIONS FOR VENDOR/SERVICE PROVIDER General Information To speed up the process and assist vendor/service providers in submitting registrations, the Department has made instructions available so applicants may understand the nature of information being sought and thereby respond correctly to the registration information. A registration must be submitted for each Vendor/Service Provider who engages in the business of assembling, installing, selling and or furnishing radiation-producing machines. See PA Title 25 Environmental Protection regulations section a. The most recent copy of the current regulations is available on-line at Instructions: Please type or print all available information when completing the application. Some questions can be answered simply by check-off or with brief answers, but if information needed is more than space allows, copy that question onto a supplemental sheet and complete as required. The fee of $ must be included with the registration submittal. Section (h). 1a. Legal Name of Company The legal name of a person or organization actually owning the business and requesting a registration from the Department to conduct service is required. 1b. The name given to be recorded on the registration or doing business as (dba) 2. Mailing Address Fill in the location of the main office or headquarters of the company, where its usual business affairs are conducted. The mailing address should not include data that is not appropriate for business correspondence. In addition to the street name and number, PO Box number, etc., use any appropriate designation and numbers to further define the mailing address of the applicant (e.g., apartment, floor, building, room, department, suite, etc.). Make sure to include the city, state, and ZIP+4 postal code. Do not use abbreviations for the city name. Use the two-character abbreviation for the state. If other than USA, provide country. 3. Telephone Number / Fax Number The area code, phone number and fax number of the business. 4. Web Address The web address of the business, if available. 5. Address The address of the business. 6. Employer Identification Number (EIN) The Employer Identification Number (EIN) is required in the space provided. The EIN, which is also known as a Tax Identification Number (TIN), is the number assigned to the provider by the Federal Government for tax reporting purposes. 7. Location Address The address of the business, if different then the mailing address. 8. Area of Pennsylvania Served Check all that apply by referring to the attached map for regional areas

6 2900-PM-BRP0045a Rev. 9/2014 Instructions Instructions (continued): 9. Type of Activity Check all that apply. 10. List any other Regional Offices A registration is necessary for all regional offices within the Commonwealth that provide any vendor/service business activities. 11. Service or Services Provided Check all that apply. 12. Types of Equipment Check all types of equipment sold, installed, serviced and repaired. Supply information on any other type of equipment or service provided. 13. Signature Sign and indicate your title or position in the firm. 14. Print Print your name and date the application. Additional Information Inform the Bureau in writing, within 30 days, of any changes in name, address or services rendered. The registration and fee are due annually. Mail the complete application, along with a check or money order for $ payable to: "Commonwealth of Pennsylvania." Department of Environmental Protection Bureau of Radiation Protection P.O. Box 8469 Harrisburg, PA

7 2900-PM-BRP0045a Rev. 9/2014 Instructions - 3 -

8 2900-PM-BRP0045b Rev. 9/2014 COMMONWEALTH OF PENNSYLVANIA Application DEPARTMENT OF ENVIRONMENTAL PROTECTION BUREAU OF RADIATION PROTECTION VENDOR/SERVICE PROVIDER REGISTRATION For DEP Use Only Registration Number 80- Please Type or Print in Ink. Use supplementary sheets if necessary. 1a. Legal Name of Company: 1b. Facility Name (dba ): 2. Mailing Address: City: State: Zip Code: 3. Telephone Number: ( ) Fax Number: ( ) 4. Website: 5. Address: 6. Employer Identification Number (EIN): 7. Location Address (If different from mailing address): City: State: Zip Code: 8. Area of Pennsylvania Served (Check all that apply, see map): All SE NE SC NC SW NW 9. Type of Activity (Check all that apply) Manufacturer Vendor Installer Service/Repair 10. List any other regional offices within the Commonwealth: For DEP Use Only Date Received: Date into efacts: Client No.: Account No.: Check No.: Check Amount: Entered by: - 1 -

9 2900-PM-BRP0045b Rev. 9/2014 Application Registration Number 80- (continued) 11. Service or services provided (Check all that apply): Assembly/Removal Machine Repair Machine Calibration Film Supplies Sales or Demo Machine Loan/Lease Film Processing Other (List): 12. Type of Equipment Sold, Installed, Serviced and Repaired (Check all that apply): Dental Intraoral Industrial Radiographic Diffraction Dental Panoramic Other, Non-medical Analytical Mobile, Other Med Radiographic Accelerator Fluoroscopic R & F Combination Spectroscopy Electron Microscope CT Scanner Cabinet X-ray Bone Densitometer Therapeutic Therapy Simulator Lithotriptor Baggage Inspection Other (Explain): NOTE: ALL DEVICES MUST MEET THE REQUIRMENTS OF OR a Advise the Bureau in writing within 30 days after any changes listed below: The name of the Vendor previously submitted.the address of your office servicing Pennsylvania. The type of service rendered. Note: This is an annual registration, registration fees are due each year. 13. Signature Title or Position in Firm 14. Print Name Date - 2 -

10 2900-PM-BRP0045c Rev. 9/2014 Report COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF ENVIRONMENTAL PROTECTION BUREAU OF RADIATION PROTECTION PA VENDOR/SERVICE PROVIDERS REPORT to BRP For Radiation-Producing Machines BRP assigned Vendor/ Service Registration Number: 80 - Name of Company: Telephone Number (where you can be contacted): ( ) Record the PA X-Ray Registration Number for the facility where service was provided: No Registration (Check if applicable) Note: If no registration, indicate below and advise customer registration is required within 30 days of acquisition Name/ Location: (Address Where Install, Service, Sales, Lease, Was Performed) Date Performed: Telephone Phone #: Service Provided: New Existing Type of Equipment: Manufacturer: Model/Serial Number: Service Technician Print: Signature and Date: Signature The completed form may also be submitted by: ra-epbrpvendor@pa.gov Fax: Date

11 2900-PM-BRP0045c Rev. 9/2014 Report Submit this report to the Department within 15 days of the service date. Fill in your Vendor/Service providers registration number. If no number has been assigned please call the Bureau of Radiation Protection ( ) and request a registration form. Enter your company name as it appears on the registration form. Enter a telephone number where you can be reached. Sign and print your name. Enter today s date. NOTE: No further report is necessary if a copy of the assembler s report on United States Food and Drug Administration (FDA) Form 2579 is submitted for each unit serviced. Continue to complete the PA Vendor/Service Providers Report if a FDA 2579 is not completed. Provide the name, location and telephone number of the facility where the service was performed including date. Record the X-Ray registration number assigned by the Bureau of Radiation Protection for the client s facility work was performed. Indicate on the form if no registration is available. Enter the type of service provided. Record the type of radiation-producing machine, the manufacturer s name, model number and control panel serial number, or major x-ray system components involved in the transaction. Have the technician who performed the service print, sign and date form. The completed form may be submitted by either: ra-epbrpvendor@pa.gov Fax: or by US Postal Service: Commonwealth of Pennsylvania Department of Environmental Protection Bureau of Radiation Protection P.O. Box 8469 Harrisburg, PA