Free Application for Radioactive Material License authorizing the Use of Sealed Sources in Portable Gauges or XRF Devices, DPH 45006 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 45006 (02/06)

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 PORTABLE GAUGES OR XRF DEVICES
Department of Health and Family Services (DHFS) is requesting disclosure of information. Completion of this form is required to obtain a Radioactive Material License. Failure to provide all requested information may result in denial or delay of a Radioactive Material License. Instructions ­ Complete all items. Refer to WISREG `Guidance for Portable Gauges or XRF Devices' for additional information. Use supplementary sheets if necessary. Retain a copy and submit the original of the entire application to: DHFS, Radiation Protection Section, P.O. Box 2659, Madison, WI 53701-2659.

APPLICATION TYPE
Item 1 Type of Application (Check one box) New License Renewal License Number

CONTACT INFORMATION
Item 2 Applicant - Name and Mailing Address Item 3 Contact Person ­ Name

Applicant - Telephone Number (Include area code)

Contact Person - Telephone Number (Include area code)

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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/Stored Used Stored Used/Stored Used Stored Used/Stored Are portable gauge devices and/or portable XRFs used at temporary jobsites?: Are portable gauge devices stored at temporary jobsites?: If yes, check the following boxes: Yes No Yes No Telephone Number (Include area code)

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We will perform and maintain documentation of radiation surveys to ensure that radiation levels are less than 2 mR in any one hour and 100 mR/yr at all temporary job site storage locations. We will store the device at the temporary job site in a locked room, trailer or other secure location to prevent unauthorized removal of the device. We will minimize exposures for occupational and non-occupational workers when selecting storage location. We will limit storage at a temporary job site to 180 days per calendar year.

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RADIATION SAFETY OFFICER
Item 5 Radiation Safety Officer (RSO) (Attach evidence of training and experience and check one box) Name ­ Radiation Safety Officer Telephone Number (Include area code)

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Before obtaining radioactive material, the proposed RSO will have successfully completed one of the training courses described in the Criteria section titled "Individual(s) Responsible for Radiation Safety Program and Their Training and ExperienceRadiation Safety Officer" in WISREG `Guidance for Portable Gauge Devices or Portable XRFs. Or Alternative information demonstrating that the proposed RSO is qualified by training and experience is attached.

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 the Criteria section titled "Training for Individuals Working In or Frequenting Restricted Areas" in WISREG `Guidance for Portable Gauge Devices or Portable XRFs.' NOTE: If using an 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 attached. NOTE: These individuals will be listed on the license as authorized users. An amendment request is required to add new authorized users.

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

Device manufacturer and model number

Intended Use

FACILITIES AND EQUIPMENT
Item 8 Facilities And Equipment (Check box and attach diagram.) Diagrams of radioactive material storage area(s) are attached.

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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 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)) Item 9.3 Instruments (Check one box) We will possess and use a radiation survey meter that meets the Criteria in the section titled "Instruments" in WISREG `Guidance for Portable Gauges or XRF Devices.' Or We will submit an alternative procedure for determining source integrity after an incident involving the portable gauge(s). (Procedures are attached) Or Not Applicable [XRF Device(s)] Item 9.4 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 gauge has been lost, stolen or misplaced. (Procedures are attached) Item 9.5 Occupational Dosimetry (Check one box) We will provide dosimetry processed and evaluated by a NVLAP-approved processor that is exchanged at a frequency recommended by the processor. (Note: Individuals operating portable moisture or density measuring devices must be monitored for occupational exposure to radiation per s. HFS 157.25(2)(a)6) Or 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(1). (See Appendix I in WISREG `Guidance for Portable Gauges or XRF Devices.') Item 9.6 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 9.7 Operating And Emergency Procedures (Check one box) We will implement and maintain the operating and emergency procedures in Appendix H of WISREG `Guidance for Portable Gauges or XRF Devices' and provide copies of these procedures to all gauge or XRF users and at each job site. Or Operating and emergency procedures will be developed, implemented, maintained and provided to all gauge or XRF users at each job site and will meet criteria in the section titled "Radiation Safety Program ­ Operating and Emergency Procedures" in WISREG `Guidance for Portable Gauges or XRF Devices.' (Procedures are attached)

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Item 9.8 Leak Tests (Check one box) Leak tests will be performed by an organization authorized by DHFS, the NRC or another 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 another 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 another Agreement State) Organization Name__ ____ License Number ____

Issuing Agency ___ 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, the NRC, or another Agreement State. Or We will perform leak testing and sample analysis and will follow the model procedures in Appendix K of WISREG `Guidance for Portable Gauges or XRF Devices.' (Procedures are attached) Or We will submit alternative procedures. (Procedures are attached) Item 9.9 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 gauge(s) or XRF(s) according to each manufacturer's recommendations and instructions. Or Alternative procedures are attached. Non-routine maintenance: We will send the gauge(s) or XRF(s) to the manufacturer or other person authorized by DHFS, the NRC or another Agreement State to perform non-routine maintenance or repair operations that require the removal of the source or source rod from the gauge(s) or XRF(s). Or We will provide the information listed in Appendix G of WISREG `Guidance for Portable Gauges or XRF Devices' to support a request to perform this work "in house." Item 9.10 Transportation No response is needed during the license process; this issue will be reviewed during inspection. Item 9.11 Waste Management - Gauge or XRF Disposal And Transfer (Check box) We will transfer the gauge or XRF to the manufacturer for disposal or transfer the device to a specific licensee, authorized to receive radioactive material.

SPECIFIC LICENSE FEE
Item 10 License Fees (Refer to Wisconsin Administrative Code HFS 157.10) Category: Application Fee Enclosed (For new applications): 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 Date signed

Print Name and Title of above signatory