R-61 Status of Radiation Machines

Hazardous Materials and Waste Management Division

Radiation Control Program

X-Ray Certification

Status of Radiation Machines (R-61)

Owner and Facility Information

Facility Registration # *

Application date *

Legal Business Name *

Doing Business As

Phone Number *

Email Address *

Confirm Email *

Facility Address *

City *

State *

Zip *

Mailing Address Same as Facility Address *

Yes

Mailing Address *

Mailing City *

Mailing State *

Mailing Zip *

Are you closing your X-ray Facility? *

Yes

Are you selling your X-ray facility? *

Yes

Name of New Facility Owner *

X-Ray Machine Information

Blue Certification Label Number *

Expiration date on Blue Label

Room Number

X-Ray Machine Mfg *

X-Ray Machine Model *

X-Ray Machine Serial Number *

Definitions of Status Type

Disabled in Storage (Inactive)

The machine must be disabled by a Colorado-registered service company. Attach a work order (or equivalent) from the service company that states when the machine was disabled. The machine will be designated as "inactive" and will be exempt from certification evaluations required under Part 2, Section 2.5.1 as long as the machine is in storage. You must pay the facility registration fee required in Part 12 of the Regulations. To restore the machine back to "active," a Colorado-registered service company must install the machine and a Colorado-registered qualified inspector must certify the machine's performance.

Transferred, sold or traded in

Provide the name and address of the person or company who took possession of the machine. If a broker is being used to transfer the machine, you must provide contact information for the broker.

Disposed/discarded

The machine must be made physically inoperable by dismantling the electrical circuitry such that the machine is not capable of producing radiation. You must provide information on the method of disposal and the name and address of the recycling company. Note that x-ray machines are considered electronic waste and cannot be disposed of in a landfill.

Status Type *

Disabled in storage (Inactive); still in possession

Transferred, sold, or traded in; not in possession

Disposed/discarded; not in possession

You must attach a signed document from a Colorado-registered Service Company stating that the radiation machine has been disabled such that the machine is not capable of producing radiation.

Attach your service company work order or equivalent here

Machine Recipient Name *

Address *

Phone

Are there other active machines at your facility? *

Yes

Number of x-ray machines still in use. *

Do you need to report the status of additional x-ray machines for your facility? *

Yes