INSTRUCTIONS

• Contact Person
• Department
• Phone #
• Work Address
• Radiation Safety Authorized User – Printed or Typed
• CHARGE Authorized Signature
• Date – When the CHARGE Authorized Signature signed this form
• UMMS COST CENTER

• Quantity for each line that is needed – How many?
• Amount for each line that is needed
• Get this information from the memo Radiation Safety sends you.
• Parts – You can write a description in the space next to it.
• Other – You can write a description in the space next to it.

BRING TO EHS – RADIATION SAFETY DEPARTMENT

• Survey Instrument
• University of Maryland Baltimore Environmental Health and Safety Inter-Departmental Billing form (single sheet)
• REMINDER – Make a COPY of the UMB/EHS INTER-DEPARTMENTAL Billing form BEFORE bringing your Survey Instrument over to be calibrated.