(A) The manufacturer's name, serial number, model number, the radioisotope, and the radioisotope's activity (as indicated on the device's label). For devices used in a fixed location, the physical address of each location where a device is used and the total number of devices at each location shall be submitted. For portable devices, the physical address of each primary place of storage and the total number of devices stored at each location shall be submitted. If renewing registration and there has been no change in the previously indicated devices, indicate that no change has occurred;

(B) Name, title, and telephone number, if different than the number specified in subsection (a)(1), of the individual appointed pursuant to section 30192.1(d)(15);

(C) Name and license number of the distributor from whom the device was obtained; and

(D) Signature and date of signature of the individual identified in subsection (a)(2)(B), attesting to the following statement:

“I [insert name as it appears in response to subsection (a)(2)(B)] attest that I am aware of the requirements of the general license specified in section 30192.1 of title 17, California Code of Regulations, and that the information provided concerning the device or product has been verified through a physical inventory and checking of label information.”

(A) A statement that the registrant has, pursuant to section 30192.6(c)(3), developed, implemented, and will continue to maintain procedures designed to establish physical control over the depleted uranium described in section 30192.6(a), and designed also so as to prevent transfer of such depleted uranium in any form, including metal scrap, to persons not authorized to receive the depleted uranium; and

(B) The name, title, and telephone number, if different than the number specified in subsection (a)(1), of the individual appointed pursuant to section 30192.6(c)(4);