ARRA-4I https://arra.az.gov Phone (602) 255-4845
June 2017 4814 S. 40 xray@azrra.gov
th
St. Phoenix, AZ. 85040.
ARIZONA RADIATION REGULATORY AGENCY
ARRA-4I is an attachment to the ARRA-4 for the registration of any x-ray system used in industry. This form may also be used for a
specimen x-ray system utilized in a medical or hospital setting.
(Complete 1 ARRA-4I for EACH x-ray unit for which you are applying for registration. Or you may print the completed form, sign by hand, scan and submit as an email
attachment. The completed form may also be submitted via fax or mail.)
1.
Facility Name:
Street Address:
City and Zip:
2.
Registration Number for current registrants: I
- or
NEW Applicant
3.
Your Name and Title:
Date: Email:
4.
Machine Type (check applicable type of x-ray):
Check the box that best describes your type of x-ray system.
Industrial Radiography is the use of x-rays to visualize a component for
verifying integrity, locating defects, or to view the contents of a package
or container. Also included is a specifically designed unit for the viewing
of a specimen in a medical setting. Rules regulating industrial radiography
are found in A.A.C. R12-1 Article 11.
An analytical x-ray system uses x-rays to determine the
elemental composition or examine the microstructure of
materials. Rules regulating analytical x-ray operations are
found in A.A.C. R-12 Article 8.
Check the box that best describes your type of
industrial Radiography Unit.
Check the box that best describes your type
of analytical X-Ray system.
Baggage and package inspection system. (A.A.C. R-12-1-
1142)
Enclosed beam analytical system (A.A.C. R-12-
1-803)
Security Screening Of Inmates.
Certified or certifiable cabinet x-ray system (A.A.C. R-
12-1-1140)
Shielded room x-ray system. (A.A.C. R-12-1-1140)
Open beam analytical system. (A.A.C. R-12-1-
804)
Open beam Radiography performed at a location other
than a permanent installation.
Open beam radiography performed at a permanent
installation.
5.
Machine Subtype:
Stationary Mobile Portable Handheld Transportable
6.
Equipment Information:
New Unit: Replacement Unit:
Unit Removed:
Manufacturer name: Model Name:
Num
ber of tubes: Location of unit:
Replaced or deleted unit make and model Name:
To whom and where was the unit transferred?
For temporary locations, please provide a copy of your operating and emergency procedures which contain the information required by
A.A.C. R-12-1-1128. Please provide the specific instruction including any restrictions provided to the radiographers.
SHI
ELDING INFORMATION (for shielded room only) Submit as an attachment to this form.
INSTRUCTION: Please provide a drawing of the facility, including construction material, and your calculations of the shielding needed to assure
compliance with A.A.C. R-12-1-408 and A.A.C. R-12-1-416.
