Free Applicaiton for a Radioactive Material License for Academic, Research and Development and Other Licenses of Limited Scope, F-450 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-45016 (Rev. 07/08)

STATE OF WISCONSIN Bureau of Environmental Health Radiation Protection Section (608) 267-4797

APPLICATION FOR A RADIOACTIVE MATERIAL LICENSE FOR ACADEMIC, RESEARCH AND DEVELOPMENT AND OTHER LICENSES OF LIMITED SCOPE
The Wisconsin Department of Health Services is requesting disclosure of information for obtaining a radioactive material license. Failure to provide any information may result in denial or delay of a radioactive material license. Instructions ­ Complete all items if this is an initial application or an application for renewal of a license. Refer to WISREG `Guidance for Academic, Research and Development and other Licenses of Limited Scope'. Use supplementary sheets where necessary. Retain one copy and submit original of the entire application to the State of Wisconsin, Department of Health Services (DHS), P.O. Box 2659, Madison WI 53701-2659.

APPLICATION TYPE
Item 1 Type Of Application (Check one box ) New License Renewal License Number Amendment License Number Item 3 Person To Contact Regarding Application:

CONTACT INFORMATION
Item 2 Name And Mailing Address Of Applicant:

Applicant's Telephone Number (Include area code):

Contact's Telephone Number (Include area code):

( ) LOCATION OF RADIOACTIVE MATERIAL
Address

(

)

Item 4 Address(es) Where Radioactive Material Will Be Used Or Possessed (Do not use Post Office Box) Telephone Number (Include area code)

(

)

Address

Telephone Number (Include area code)

(

)

Address

Telephone Number (Include area code)

(

)

Is radioactive material used at locations for field studies or other off-site locations?

Yes

No

If yes, please attach an additional sheet(s) with the locations (addresses) and a list of activities to be conducted at each location.

RADIATION SAFETY OFFICER
Item 5 Radiation Safety Officer (RSO) (Check boxes) The name of the proposed RSO and other potential designees who will be responsible for ensuring that the licensee's radiation safety program is implemented in accordance with approved procedures. NAME AND We will provide information demonstrating that the proposed RSO is qualified by training and experience. TELEPHONE NUMBER ( (Include area code)

)

F-45016 (Rev. 07/08)

Page 2 of 5

AUTHORIZED USERS AND TRAINING
Item 6 Authorized Users (Check both boxes) We will attach a list of each proposed authorized user with the types and quantities of licensed material to be used. AND Information is attached demonstrating that each proposed authorized user is qualified by training and experience to use the requested licensed material. Item 7 Training For Individuals Working In Or Frequenting Restricted Areas (Occupationally exposed individuals and ancillary personnel) (Check box) A description of the radiation safety training program, including topics covered, groups of workers, assessment of training, qualifications of instructors and the method and frequency of training is attached.

RADIOACTIVE MATERIAL
Item 8 Radioactive Material (Attach additional pages if necessary) UNSEALED SOURCES Radioisotope

Chemical/Physical Form

Maximum Possession Limit

Proposed Use

SEALED SOURCES Radioisotope

Chemical/Physical Form

SEALED SOURCE

SEALED SOURCE

SEALED SOURCE

SEALED SOURCE

Sealed Source Manufacturer or Distributor and Model Number Device Manufacturer or Distributor and Model Number Sealed Source Device Registration Sheet Number

Maximum Possession Limit

Proposed Use

F-45016 (Rev. 07/08)

Page 3 of 5

FACILITIES AND EQUIPMENT
Item 9 Facilities And Equipment (Check all that apply) A description is provided of the facilities and equipment at each location where radioactive material will be used. Diagrams should be drawn to a specified scale, or dimensions should be indicated. For facilities where it is anticipated that more than one laboratory or room may be used, a generic laboratory or room diagram may be submitted. (Diagrams are attached) NOTE: See Appendix K of WISREG `Guidance for Academic, Research and Development and Other Licenses of Limited Scope'. AND/OR For animal use, a description is provided of the facilities and equipment at each location where radioactive material will be used. Diagrams should be drawn to a specified scale, or dimensions should be indicated. For facilities where it is anticipated that more than one laboratory or room may be used, a generic laboratory or room diagram may be submitted. (Diagrams are attached) NOTE: See Appendices K and H of WISREG `Guidance For Academic, Research and Development and Other Licenses Of Limited Scope'. AND IF APPLICABLE A description showing the locations of shielding, the proximity of radiation sources to unrestricted areas, and other items related to radiation safety is provided. AND/OR For radioactive materials that may become airborne, diagrams contain schematic descriptions of the ventilation systems, with pertinent airflow rates, pressures, filtration equipment, and monitoring systems. (Diagrams are attached)

RADIATION SAFETY PROGRAM
Item 10.1 Audit Program The applicant is not required to submit its audit program to DHFS for review during the licensing phase. This matter will be examined during an inspection. Item 10.2 Radiation Monitoring Instruments (Check one box) We will use instruments that meet the radiation monitoring instruments specifications published in Appendix M of WISREG `Guidance for Academic, Research and Development and Other Licenses of Limited Scope'. We reserve the right to upgrade our survey instruments as necessary. OR We will use instruments that meet the radiation monitoring instrument specifications published in Appendix M of WISREG `Guidance for Academic, Research and Development and Other License of Limited Scope'. Additionally we will implement the survey meter calibration program published in Appendix M of WISREG `Guidance for Academic Research and Development and Other License of Limited Scope'. We reserve the right to upgrade our survey instruments as necessary. OR We will provide a description of alternative equipment and/or procedures for ensuring that appropriate radiation monitoring equipment will be used during licensed activities and that proper calibration and calibration frequency of survey equipment will be performed. We reserve the right to upgrade our survey instruments as necessary. (Procedures are attached) Item 10.3 Material Receipt And Accountability (Check all that apply) UNSEALED SOURCES We will submit procedure(s) for ensuring radioactive material accountability. SEALED SOURCES We will perform physical inventories at intervals not to exceed 6 months, to account for all sealed sources and devices received and possessed under the license. OR We will submit a description of the frequency and procedures for ensuring that no sealed sources have been lost, stolen or misplaced. (Description is attached)

F-45016 (Rev. 07/08)

Page 4 of 5

Item 10.4 Occupational Dose (Check one box) We will maintain, for inspection by DHFS, documentation demonstrating that unmonitored individuals are not likely to receive, in one year, a radiation dose in excess of 10 percent of the allowable limits in s. HFS 157.22. OR We will provide dosimetry processed and evaluated by a NVLAP-approved processor that is exchanged at a frequency recommended by the processor. Item 10.5 Public Dose No response is required in this license application, however the licensee's evaluation of public dose will be examined during an inspection. Item 10.6 Safe Use of Radionuclides and Emergency Procedures (Check all that apply) We will develop, implement and maintain safe use of radionuclides and emergency procedures that will meet the criteria in the section titled `Safe Use of Radionuclides and Emergency Procedures' in WISREG `Guidance for Academic, Research and Development and Other Licenses of Limited Scope'. (Procedures are attached) AND/OR For Gas Chromatographs, we will submit the information requested in Appendix D of WISREG `Guidance for Academic, Research and Development and Other Licenses of Limited Scope'. (Information is attached) AND/OR For use of radionuclides in animals, we will develop, implement and maintain safe use of radionuclides and emergency procedures that will meet the criteria in the section titled `Safe Use of Radionuclides and Emergency Procedures' in WISREG Guidance for Academic, Research and Development and Other Licenses of Limited Scope'. (Procedures are attached) Note: See Appendix H `Considerations for Lab Animals and Veterinary Medical Use' of WISREG `Guidance for Academic, Research and Development and Other Licenses of Limited Scope' for additional information. Item 10.7 Surveys (Check all that apply) We will survey our facility and maintain contamination levels in accordance with the survey frequencies and contamination levels published in Appendix Q of WISREG `Guidance for Academic, Research and Development and Other Licenses of Limited Scope'. IF SEALED SOURCES ARE USED Leak tests will be performed by an organization authorized by DHFS, the NRC or an Agreement State to provide leak testing services to other licensees; or by using a leak test kit supplied by an organization licensed by DHFS, the NRC or an Agreement State to provide leak test kits to other licensees according to kit supplier's instructions. List the name and license number of organization authorized to perform or analyze leak test (Specify whether DHFS, NRC, or other Agreement State): Organization Name License Number

Note: An alternate organization may be used to perform or analyze leak test, without amending the license, provided the organization is specifically authorized by DHFS, NRC or an Agreement State. OR We will perform our own leak testing and sample analysis. We will follow the procedures published in Appendix R of WISREG `Guidance for Academic, Research and Development and Other Licenses of Limited Scope'. OR We will submit alternative procedures. (Procedures are attached) Item 10.8 Transportation No response is needed from applicant in this license application; transportation issues will be reviewed during inspections. Item 10.9 Minimization of Contamination No response is required if applicant meets the criteria in the following sections: `Unsealed and/or Sealed Sources', `Facilities and Equipment', Safe use of Radioisotopes and Emergency Procedures', `Surveys', and `Waste Management'. Item 10.10 Termination Of Activities No response is required from the applicant during the application process. Refer to section titled `Termination of Activities' in WISREG `Guidance for Academic Research and Development and Other License of Limited Scope'.

F-45016 (Rev. 07/08)

Page 5 of 5

WASTE MANAGEMENT Item 11 Waste Management (Check all that apply) We will follow the model waste procedures published in Appendix T of WISREG "Guidance for Academic Research and Development and Other Licenses of Limited Scope." OR We will follow: Decay-In-Storage or Disposal of Liquids Into Sanitary Sewerage waste procedures that are published in Appendix T of WISREG `Guidance for Academic Research and Development and Other Licenses of Limited Scope'. OR We will develop, implement and maintain procedures for waste collection, storage and disposal by any of the authorized methods described in Item 11 `Waste Management' of WISREG `Guidance for Academic Research and Development and Other Licenses of Limited Scope'. We will contact DHFS for guidance to obtain approval of any method(s) of waste disposal other than those discussed in Item11 `Waste Management' of WISREG `Guidance for Academic Research and Development and Other Licenses of Limited Scope'. (Procedures are attached) OR If access to a radioactive waste burial site is unavailable, we will request authorization for extended interim storage of waste. We will refer to NRC IN 90-09 `Extended Interim Storage of Low-Level Radioactive Waste by Fuel Cycle and Materials Licenses', dated February 1990, for guidance and submit the required information with this applications. NOTE: Applicants do not need to provide information to DHFS if they plan to dispose of LLW via transfer to another authorized recipient or to dispose of liquid scintillation media or animals containing low levels of H-3 or C-14 as authorized by s. HFS 157.30(5). IF SEALED SOURCES ARE USED We will return sealed sources/devices to the manufacturer, distributor or an organization licensed by DHFS, the NRC or another Agreement State.

SPECIFIC LICENSE FEE
Item 12 License Fees (Refer to Wisconsin Administration Code s. HFS 157.10) Category: License fee enclosed: Yes No Amount Enclosed

CERTIFICATION (To be signed by an individual authorized to make binding commitments on behalf of the applicant.)
Item 13 I hereby certify that this application was prepared in conformance with Wisconsin Administrative Code Chapter HFS 157 "Radiation Protection" and that all information contained herein, including any supplements attached hereto, is true and correct to the best of my knowledge and belief. SIGNATURE - Applicant Or Authorized Individual Date signed

Print Name and Title of above signatory