Fillable Radiation-Producing Machine Registration Application (The State of New Jersey)

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Radiation-Producing Machine Registration Application (The State of New Jersey)

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New Jersey Department of Environmental Protection
Bureau of X-ray Compliance
Radiation-Producing Machine Registration Application
BXC-001 (Revised 3/7/2013)
Facility ID ______________________ Registration Number_________________
The Bureau issues the numbers for new facilities and all registrations.
2. BILLING/MAILING ADDRESS (If different from item 1)
Ma
iling address____________________________________________ PO Box______ Suite #_________
City_____________________________ ST____ Zip Code+4_______________ County______________
3. OWNER or RESPONSIBLE PARTY
Owner Name ________________________ ____ _______________________________ ___________
First MI Last
Title (MD,DDS,DVM, etc)
Mandatory Information: Business Type Check One:
Sole Proprietor LLC LLP INC.
Non-Profit, INC. PA PC Other
Pho
ne Number ________________________ Fax Number _______________________
Business E-mail__________________________________________________________________________
1. FACILITY INFORMATION (Please print/type all information).
F
acility Name_________________________________________________________________________
Facility Owner/Contact__________________________________________________________________
Physical Address________________________________________________ Suite # ___________
City_____________________________ ST_____ Zip Code+4______________ County__________
4. MOBILE/MOTOR VEHICLE/TRAILER FACILITIES (only for equipment permanently mounted in vehicle)
Vehicle Information: Year_______ Make_____________________ Model________________________
State:_______ Plate #_______________ Vin #_______________________________________
Please enclose a copy of your vehicle registration.
5. REGULATORY REQUIREMENTS
1. The New Jersey Administrative Code (N.J.A.C.) 7:28-3.1(b) requires all owners of x-ray equipment to register
equipment within 30 days of acquisition.
2. Please see N.J.A.C. 7:28 et seq. for regulations regarding radiation safety surveys of the environs (www.xray.nj.gov
);
Rules and Regulations
Registration information continued on page 2.
New Facility Existing Facility-New Machine Amended Registration We’ve moved
IMPORTANT: Both pages MUST BE COMPLETED when registering or modifying a machine registration
Mail completed forms to BXC, PO Box 420, Mail Code 25-01,Trenton, New Jersey 08625-0420
or Submit PDF forms to BXC@dep.nj.gov
Phone: 609-984-5463 Fax: 609-984-5811 Website: www.xray.nj.gov
Registration information continued on page 2
Page 1 of 2
New Jersey Department of Environmental Protection
Bureau of X-ray Compliance
Registration Application Information Continued---
Facility ID ______________________ Registration Number_________________
Page 2 of 2
6. MACHINE INFORMATION
Machine Category _______ ____ Fee schedule location: http://www.state.nj.us/dep/rpp/reg/fees.htm
Date Acquired____________________ Manufacturer______________________________________
Model Name_______________________________ Model No. __________________________
Serial No.__________________________ Tube Insert Serial No. _______________________
Date Manufactured __________________ Location (Room ID) if applicable _______________________
Max kVp _________ Max mA____________ Max MeV_______ (therapy and industrial units only)
7. IMAGE RECEPTOR (Must check one)
DR - Digital Radiography CR/PSP- Computed Radiography/ Photo Stimulable Phosphor
Film – Automatic processing Film – Manual processing No film (Industrial x-ray units)
IMPORTANT Do NOT send check with registration application.
You will receive an invoice after the equipment has been registered.
8. SIGNATURE
_____________________________________________________ ____________________________________
Print Name (Owner or Responsible Party) Title
_________________________________________________ ____________________________________
Signature (Owner or Responsible Party) Date
For Bureau Use Only
Date Received _______________________ Date Returned_
_______________________
Phone: 609-984-5463 Fax: 609-984-5811 Website: www.xray.nj.gov
All registration forms are now two pages. Please complete both pages, sign and send to BXC.
BXC-001 (Revised 3/7/2013)
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Radiation-Producing Machine Registration Application (The State of New Jersey)

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Completed 6 November 2020

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