Free Application for Radioactive Material License Authorizing the Use of Sealed Sources, F-45017 - Wisconsin

DEPARTMENT OF HEALTHSERVICES Division of Public Health F-45017 (Rev. 07/08)

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

APPLICATION FOR RADIOACTIVE MATERIAL LICENSE AUTHORIZING THE USE OF SEALED SOURCES
The Wisconsin Department of Health Services is requesting disclosure of all information on this application for the purpose of 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. Refer to WISREG " Guidance for The Use of Sealed Sources" for additional information. Use supplementary sheets if necessary. Retain a copy and submit the original of the entire application to the Department of Health Services, 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 this 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

(

)

Item 4 List all address(es) where radioactive material(s) will be used or possessed. (Attach additional pages if necessary) Address (Do not use Post Office box) Used Stored Used and Stored Telephone Number (Include area code)

(

)

Used Stored Used and Stored

(

)

Used Stored Used and Stored

(

)

Are sealed sources used at temporary jobsites?:

Yes

No

RADIATION SAFETY OFFICER
Item 5 Radiation Safety Officer (RSO) (Check both 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. TELEPHONE NUMBER: ( (Include area code) Information demonstrating that the proposed RSO is qualified by training and experience is attached. NAME:

)

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AUTHORIZED USERS
Item 6 Authorized Users (check all that apply) 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. NOTE: If requesting authorization to perform non-routine maintenance, submit outline of the instruction and training for individuals performing non-routine maintenance.

RADIOACTIVE MATERIAL
Item 7 Radioactive Material (Attach additional pages if necessary) Element and mass number Source manufacturer and model number Chemical and physical form SEALED SOURCE Maximum activity per source

Sealed source and device registration sheet number

Device manufacturer and model number

Intended use

FACILITIES AND EQUIPMENT
Item 8 Facilities And Equipment (Check boxes and attach diagram.) Diagrams of radioactive material storage area(s) are attached. And We will lock or secure the room or storage area when the authorized user is not physically present.

RADIATION SAFETY PROGRAM
Item 9 Radiation Safety Program Item 9.1 Audit Program The applicant is not required to submit its audit program to the department for review during the licensing phase. This matter will be examined during an inspection. Item 9.2 Radiation Monitoring Instruments (Check all that apply) We will have access to a survey meter that meets the Criteria in the section titled "Radiation Monitoring Instruments" in WISREG "Guidance for Uses of Sealed Sources". (Description attached) OR We will possess a survey meter that meets the Criteria in the section titled "Radiation Monitoring Instruments" in WISREG "Guidance for Uses of Sealed Sources." AND ONE OF THE FOLLOWING Each survey meter will be calibrated by an organization licensed by DHFS, the NRC or an Agreement State to perform survey meter calibrations. OR We will implement the model survey meter calibration program published in Appendix E in WISREG "Guidance for Uses of Sealed Sources." OR We will submit alternative calibration procedures for DHFS review. (Procedures are attached)

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Item 9.3 Material Receipt And Accountability (Check one box) We will conduct 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. (Procedures are attached) Item 9.4 Occupational Dosimetry (Check one) 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 9.5 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 9.6 Operating And Emergency Procedures (Check box) Operating and emergency procedures will be developed, implemented, and maintained, and will meet criteria in the section titled `Operating and Emergency Procedures' in WISREG " Guidance for Uses of Sealed Sources." (Procedures are attached) Item 9.7 Leak Tests (Check one box) 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 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 leak testing and sample analysis and will follow the procedures in Appendix J of WISREG "Guidance for Uses of Sealed Sources." (Procedures are attached) OR We will submit alternative procedures. (Procedures are attached) Item 9.8 Maintenance and Repair (Check one box) We will send the device to the manufacturer or other person authorized by DHFS, the NRC or an Agreement State to perform maintenance or repair operations. OR We will implement and maintain procedures for maintenance of devices containing sealed sources according to each manufacturer's recommendations and instructions. OR We will develop, implement and maintain procedures for maintenance of devices containing sealed sources. (Procedures are attached) OR We will only possess sealed sources not in devices. No maintenance or repair is required.

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Item 9.9 Transportation No response is needed during the license process; this issue will be reviewed during inspection. Item 9.10 Waste Management (Check box) We will transfer the sealed source or device containing the sealed source to the manufacturer or a specifically licensed recipient for disposal. Item 9.11 Termination Of Activities (Check box) We will notify DHFS, in writing, within 30 days of the decision to permanently cease radioactive material use. s. HFS 157.13 (10)(d)

SPECIFIC LICENSE FEE
Item 10 License Fees (Refer to Wisconsin Administrative Code 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 11 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 Print Name and Title of above signatory Date signed