Free Application for Radioactive Material License Authorizing the Use of Sealed Sources in Fixed Guage Devices, DPH 45009 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 45009 (05/03)

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

APPLICATION FOR RADIOACTIVE MATERIAL LICENSE AUTHORIZING THE USE OF SEALED SOURCES IN FIXED GAUGE DEVICES
Department of Health and Family Services is requesting disclosure of information. 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 Fixed Gauge Devices." Use supplementary sheets where necessary. Retain one copy and submit original of the entire application to the State of Wisconsin, Department of Health and Family Services (DHFS), Post Office Box 2659, Madison,WI 53701-2659.

APPLICATION TYPE
Item 1. Type Of Application (Check one box) New License Renewal License Number Amendment License Number

CONTACT INFORMATION
Item 2. Name And Mailing Address Of Applicant: Item 3. Person To Contact Regarding Application:

Applicant's Telephone Number (Include Area Code):

Contact's Telephone Number (Include Area Code):

LOCATION OF RADIOACTIVE MATERIAL
Item 4. Address(es) Where Radioactive Material Will Be Used Or Possessed (Do not use Post Office Box) Address Telephone Number (Include Area Code)

Address

Telephone Number (Include Area Code)

Address

Telephone Number (Include Area Code)

RADIATION SAFETY OFFICER
Item 5. Radiation Safety Officer (RSO) (Check one box and attach evidence of training and experience) Name:_______________________________________ Telephone Number (Include area code):________________________________ Before obtaining radioactive material, the proposed RSO will have successfully completed one of the training courses described in Criteria in the section titled "Radiation Safety Officer" in WISREG `Guidance For Fixed Gauge Devices'. Before being named as the RSO, future RSOs will have successfully completed one of the training courses described in Criteria in the section titled `Radiation Safety Officer" in WISREG "Guidance For Fixed Gauge Devices'. Or Alternative information demonstrating that the proposed RSO is qualified by training and experience is attached. Before being named as the RSO, future RSOs will have successfully completed one of the training courses described in Criteria in the section titled `Radiation Safety Officer' in WISREG "Guidance For Fixed Gauge Devices'.

DPH 45009 (05/03)

Page 2 of 4

AUTHORIZED USERS
Item 6. Training For Individuals Working In Or Frequenting Restricted Areas (Check one box) Before using radioactive material, authorized users will have successfully completed one of the training courses described in Criteria in the section titled " Training for Individuals Working In or Frequenting Restricted Areas" in WISREG " Guidance For Fixed Gauge Devices." NOTE: IF USING IN-HOUSE TRAINING PROGRAM SUBMIT, COPY OF COURSE CONTENT, SAMPLE COURSE EXAMINATION AND COURSE INSTRUCTOR QUALIFICATIONS. Or Documentation of the training and experience for the proposed gauge user(s) is/are attached.

RADIOACTIVE MATERIALS
Item 7. Radioactive Material (Attach additional pages if necessary) Element And Mass Number Cobalt-60 Cesium-137 Other Isotope (Please specify) Krypton-85 Strontium-90 Americium-241 Ra-226

Item 8. Chemical And Physical Form
List name of Sealed Source Manufacturer or Distributor and Model Number List Name of Device Manufacturer or Distributor and Model Number

Maximum quantity (Not to exceed either the maximum activity per source or device as specified in the Sealed Source and Device Registration Certificate)

Sealed Source And Device Registration Sheet Number

Intended use

FACILITIES AND EQUIPMENT
Item 9. Facilities And Equipment (Check boxes and attach diagram) Diagrams of radioactive material area(s) of use are attached. AND The fixed gauge is secured to prevent unauthorized removal or access and these security features will not impact the safety or integrity of the source or device.

RADIATION SAFETY PROGRAM
Item 10 Radiation Safety Program Item 10.1 Audit Program The applicant is not required to, and should not, submit its audit program to the DHFS for review during the Licensing phase. This matter will be examined during an inspection. Item 10.2 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 Fixed Gauge Devices" for further information.

DPH 45009 (05/03)

Page 3 of 4

Item 10.3 Survey Instruments (Check all that apply) We will have access to a survey meter that meets the Criteria in the section titled "Survey Instruments" in WISREG "Guidance for Fixed Gauge Devices." (Description attached) Or We will possess a survey meter that meets the Criteria in the section titled "Survey Instruments" in WISREG "Guidance for Fixed Gauge Devices." 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 I in WISREG "Guidance for Fixed Gauge Devices." Or We will submit alternative calibration procedures for DHFS review. (Procedures are attached) Item 10.4 Material Receipt And Accountability (Check one box) Physical inventories will be conducted 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 gauge has been lost, stolen or misplaced. (Procedures are attached) Item 10.5 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 10.6 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 10.7 Operating And Emergency Procedures (Check one box) We will implement and maintain the operating and emergency procedures in Appendix L of WISREG "Guidance for Fixed Gauge Devices" and provide copies of these procedures to all gauge users. Or We will develop, implement and maintain operating and emergency procedures that will meet criteria in the section titled "Operating and Emergency Procedures" in WISREG " Guidance for Fixed Gauge Devices." (Procedures are attached) Item 10.8 Leak Test (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 suppliers' 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 model procedures in Appendix M of WISREG "Guidance for Fixed Gauge Devices." Or We will submit alternative procedures. (Procedures are attached)

DPH 45009 (05/03)

Page 4 of 4

Item 10.9 Maintenance (Check one box for routine cleaning and lubrication and one for non-routine maintenance) ROUTINE CLEANING AND LUBRICATION: We will implement and maintain procedures for routine maintenance of our gauges according to each manufacturer's recommendations and instructions. Or Alternative procedures are attached. NON-ROUTINE MAINTENANCE: We will utilize the manufacturer or another person specifically licensed to perform non-routine maintenance or repair operations that require the removal of the source from the device. Radiation surveys required by s. HFS 157.25(1) will be performed by a person specifically authorized by DHFS, the NRC or an Agreement State. Or We have provided the information listed in Appendix N of WISREG "Guidance for Fixed Gauge Devices" to support a request to perform this work "in house." (Procedures are attached) Item 10.10 Fixed Gauge Disposal And Transfer (Check one box) We will return the gauge to the manufacturer for disposal or transfer the device to a specific licensee authorized to receive radioactive material. Item 10.11 Transportation No response is needed from applicants during the licensing process; this issue will be reviewed during inspection. Item 10.12 Fixed Gauges used at Temporary Job Sites (Check one box) We will submit procedures for the use of fixed gauges at temporary job sites. (Procedures are attached) Or No temporary job sites used.

SPECIFIC LICENSE FEE
Item 11. License Fees (Refer to Wisconsin Administration Code s. HFS 157.10) Category: License fee enclosed Yes Item 12 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 No Amount Enclosed________________________

CERTIFICATION (To be signed by an individual authorized to make binding commitments on behalf of the applicant.)

Print Name and Title of above signatory