State of California ­ Health and Human Services Agency California Department of Public Health Radiologic Health Branch RADIATION MACHINE REGISTRATION FOR NEW REGISTRANTS Click here for instructions. A: REGISTRANT INFORMATION Registrant (name of facility, business, or practice) Business Phone Number Type of Facility, Business, or Practice (e.g. dental, medical, veterinary, etc.) Mammography Provider State Zip Code Physical Address (street number and name) City Mailing Address (street number and name) City State Zip Code B: MACHINE INFORMATION List all radiation machines that you possess. Manufacturer Model Type Code (see instructions) Number of X-ray Tubes, Waveguides, or Electron Guns Room Name or Number Acquired Date (mm/dd/yyyy) Form FDA 2579 Additional Information FOR RADIOLOGIC HEALTH BRANCH USE ONLY Manufacturer Model Type Code (see instructions) Number of X-ray Tubes, Waveguides, or Electron Guns Room Name or Number Acquired Date (mm/dd/yyyy) Form FDA 2579 Additional Information FOR RADIOLOGIC HEALTH BRANCH USE ONLY RH 2261N (11/14) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com State of California ­ Health and Human Services Agency California Department of Public Health Radiologic Health Branch C: FACILITY CONTACT INFORMATION. Enter the individual that a Radiologic Health Branch representative may contact regarding any information provided on this form. Name Phone Number E-mail Address D: SIGNATURE OF AUTHORIZED REPRESENTATIVE. I declare under penalty of perjury under the laws of the State of California that the information submitted on this form and on any attachments is true and correct. I agree to abide by all laws and regulations that pertain to the operation and registration of the radiation machine(s) for which I am applying including but not limited to those laws and regulations governing the establishment, implementation, and maintenance of a radiation protection program. Name Title/Position Signature Date E: RECORDKEEPING/SUBMISSION. Submit all pages. Keep a copy for your records. Do not submit multiple copies of the same completed form. No payment is required at this time. Mail the original with supporting documents to: ATTN: Registration and Certification Support Unit California Department of Public Health Radiologic Health Branch MS 7610 P.O. Box 997414 Sacramento, CA 95899-7414 For more information, please visit our website at http://cdph.ca.gov/rhb or call (916) 327-5106. FOR RADIOLOGIC HEALTH BRANCH USE ONLY RH 2261N (11/14) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com