"Application for Radioactive Material License Authorizing the Use of Sealed Sources in Xrf Devices" - Maryland

Application for Radioactive Material License Authorizing the Use of Sealed Sources in Xrf Devices is a legal document that was released by the Maryland Department of the Environment - a government authority operating within Maryland.

Form Details:

  • The latest edition currently provided by the Maryland Department of the Environment;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Maryland Department of the Environment.

ADVERTISEMENT
ADVERTISEMENT

Download "Application for Radioactive Material License Authorizing the Use of Sealed Sources in Xrf Devices" - Maryland

Download PDF

Fill PDF online

Rate (4.5 / 5) 30 votes
Maryland
Department of the
Environment
APPLICATION FOR RADIOACTIVE MATERIAL LICENSE AUTHORIZING
THE USE OF SEALED SOURCES IN XRF DEVICES
Maryland Department of Environment (MDE) 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 COMAR26.12.01.01 "Regulations for the Control of Ionizing Radiation." for additional
information. Use supplementary sheets if necessary. Retain a copy and submit the original of the entire application to: MDE,
Radiological Health Program, 1800 Washington Boulevard, Suite 750, Baltimore, Maryland 21230.
APPLICATION TYPE
Item 1 Type of Application (Check one box)
A. New License
B. Renewal
License Number MD -
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)
(
) -
(
) -
Federal Tax ID Number:
Privacy Act Notice: This Notice is provided pursuant to the Federal Privacy Act of 1974, 5
U.S.C. § 552a. Disclosure of your Social Security or Federal Tax Identification on this form
is mandatory pursuant to the provisions of § 1-203 (2003) of Environment Article, Annotated
Code of Maryland, which requires MDE to verify that an applicant for a permit or license has
paid all undisputed taxes and unemployment insurance. Social Security and Federal Tax
Identification Nos. will not be used for any purposes other than those described in this Notice.
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)
Telephone Number (Include area code)
Stored
(
) -
And used at temporary jobsites for testing for lead paint in situ
Are portable XRFs stored at temporary jobsites?:
Yes
No
If yes, check the following boxes:
We will store the device at the temporary job site in a locked room, trailer or other secure location utilizing two
independent barriers 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.
Page 1 of 3
Maryland
Department of the
Environment
APPLICATION FOR RADIOACTIVE MATERIAL LICENSE AUTHORIZING
THE USE OF SEALED SOURCES IN XRF DEVICES
Maryland Department of Environment (MDE) 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 COMAR26.12.01.01 "Regulations for the Control of Ionizing Radiation." for additional
information. Use supplementary sheets if necessary. Retain a copy and submit the original of the entire application to: MDE,
Radiological Health Program, 1800 Washington Boulevard, Suite 750, Baltimore, Maryland 21230.
APPLICATION TYPE
Item 1 Type of Application (Check one box)
A. New License
B. Renewal
License Number MD -
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)
(
) -
(
) -
Federal Tax ID Number:
Privacy Act Notice: This Notice is provided pursuant to the Federal Privacy Act of 1974, 5
U.S.C. § 552a. Disclosure of your Social Security or Federal Tax Identification on this form
is mandatory pursuant to the provisions of § 1-203 (2003) of Environment Article, Annotated
Code of Maryland, which requires MDE to verify that an applicant for a permit or license has
paid all undisputed taxes and unemployment insurance. Social Security and Federal Tax
Identification Nos. will not be used for any purposes other than those described in this Notice.
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)
Telephone Number (Include area code)
Stored
(
) -
And used at temporary jobsites for testing for lead paint in situ
Are portable XRFs stored at temporary jobsites?:
Yes
No
If yes, check the following boxes:
We will store the device at the temporary job site in a locked room, trailer or other secure location utilizing two
independent barriers 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.
Page 1 of 3
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)
(
) -
Provide manufacturers’ certificates of training for XRF use and Hazmat demonstrating the RSO has successfully
completed the required training/ courses described in the Criteria section titled “Individual(s) Responsible for
Radiation Safety Program and Their Training and Experience-Radiation Safety Officer” in COMAR26.12.01.01
"Regulations for the Control of Ionizing Radiation."
Or
Alternative information demonstrating that the proposed RSO is qualified by training and experience is attached.
Commit to the RSO having responsibility to stop unsafe conditions
Attach organization chart showing RSO reporting chain with management
Sign and attached Attachment A Duties and Responsibilities of the Radiation Safety Officer for XRF License
AUTHORIZED USERS
Item 6 Training for individuals working in or frequenting restricted areas (Check one box)
Provide manufacturers certificates of training for XRF use and Hazmat for authorized users. Commit to provide the
same training to new users before use and to conduct annual user training and Hazmat training every three years to
all users
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: Certificates and other documentation and training shall be available for inspection. Annual refresher
training and Hazmat training apply to all authorized users.
RADIOACTIVE MATERIAL
Item 7 Radioactive Material (Attach additional pages if necessary)
Element and mass number
Chemical and physical form
SEALED SOURCE
Source manufacturer and model number
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. With the diagram submit written description on how
you maintain two independent physical barrier (locks, doors, safes etc) while XRF is in storage (Section D.803
COMAR 26.12.01.01)
RADIATION SAFETY PROGRAM
Item 9.1 Audit Program (Check box)
Attach a copy of you annual audit program that meets the scope of Appendix E Portable Gauge Audit Checklist in
NUREG 1556 Vol 1 . Commit to conduct the audit annually.
Item 9.2 Termination Of Activities (Check box)
We will notify RHP/MDE, in writing, within 30 days of the decision to permanently cease radioactive material use.
(Section D.1301 COMAR 26.12.01.01)
Item 9.3 Instruments
N/A for XRFs
Page 2 of 3
Item 9.4 Material Receipt And Accountability (Check 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.
Item 9.5 Occupational Dosimetry N/A for XRFs
Item 9.6 Public Dose No response is required in this license application
Item 9.7 Operating And Emergency Procedures (Check box)
We will implement and maintain the operating and emergency procedures for XRF Devices and provide copies
of these procedures to all gauge or XRF users and at each job site. (Sign and attach Attachments B and C)
Item 9.8 Leak Tests (Check one box)
Leak tests will be performed, at intervals not to exceed 6 months, in accordance with Section D.401 of
COMAR26.12.01.01 "Regulations for the Control of Ionizing Radiation." by an organization authorized by MDE, 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 MDE, 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 MDE,
NRC, or another Agreement State)
Organization Name_________________________________________________________________________
License Number _____________________ Issuing Agency ________________________________________
Or
We will perform leak testing and sample analysis and will with a procedure that follow the model procedures in
Appendix R-1 of NUREG 1556, Volume 7. (attach procedure and qualifications of person(s) doing the tests)
Item 9.9 Maintenance (Check one box for routine cleaning and lubrication and one box for non-routine maintenance)
Routine cleaning and lubrication:
We will implement and maintain procedures for routine maintenance of our XRF(s) according to each manufacturer’s
recommendations and instructions.
Or
Alternative procedures are attached.
AND
Non-routine maintenance:
We will send the XRF(s) to the manufacturer or other person authorized by MDE, the NRC or another Agreement
State to perform non-routine maintenance or repair operations that require the removal of the source from the XRF(s).
Item 9.10 Transportation (Check box)
Provide a description on how XRF will be transported that provides blocking and bracing of the gauge and how it is
secured by two independent physical barrier (locked case is portable and must be secure to the vehicle). Commit to
following the transportation regulations in Section T of COMAR 26.10.01.01.
Item 9.11 Waste Management - Gauge or XRF Disposal And Transfer (Check box)
We will transfer the XRF to the manufacturer for disposal or transfer the device to a specific licensee, authorized to
receive radioactive material.
SPECIFIC LICENSE FEE – Invoice will be sent after receipt and acceptance of application. Fee must be
paid before license review can be completed.
CERTIFICATION
(To be signed by an individual authorized to make binding commitments on behalf of the applicant.)
Item 11
The applicant understands that all statements and representations made in this application are binding upon the applicant.
The application and any official executing this certificate on behalf the applicant named in item 2, certify that this application is
prepared in conformity with Maryland regulations for control of ionizing radiation and that all information contained herein is
true and correct to the best of our knowledge and belief.
SIGNATURE - Applicant Or Authorized Individual
Date signed
Print Name and Title of above signatory
Page 3 of 3
ATTACHMENT A
DUTIES AND RESPONSIBILITIES OF THE
RADIATION SAFETY OFFICER FOR XRF LICENSE
1.
Licensed activities that the RSO considers unsafe are stopped.
2.
Possession, use, storage and maintenance of sources and gauges are consistent with the
limitations in the in the license, the Sealed Source and Device registration certificate(s), and the
manufacturer’s recommendations and instructions.
3.
Individuals who use the XRF(s) are properly trained.
4.
Radiation exposures are kept as low as reasonable achievable (ALARA).
5.
XRFs are properly secured.
6.
Proper authorities are notified in the case of accident, damage to, or malfunctions of XRF(s), fire,
loss, or theft.
7.
Unusual occurrences involving the XRF (e.g., malfunctions, accident, damage, theft) are
investigated, causes(s) are determined, and appropriate corrective action(s) are identified, and
corrective action taken.
8.
Audits are performed at least annually and documented, and corrective actions
are taken.
9.
When the licensee identifies violation(s) of regulations or license conditions or program
weaknesses, corrective action(s) are developed, implemented, and documented.
10.
Licensed material is transported in accordance with all applicable NRC and U.S.
Department of Transportation requirements.
11.
Licensed material is disposed of properly.
12.
All required records are maintained.
13.
An up-to-date license is maintained, and amendment and renewal requests are
submitted in a timely manner.
14.
Documents are posted as required by 10 CFR 19.11, “Posting of notices to workers,”
(10 CFR Part 19, license documents, operating procedures, NRC Form 3, “Notice to
Employees,”), and 10 CFR 21.6, “Posting Requirements,” (10 CFR Part 21 Section 206
of the Energy Reorganization Act of 1974, procedures adopted under Part 21), or a
noted is posted indicating where these documents can be examined.
APPROVED BY: _________________________________
DATE ___________________________
(Applicant)
Page 1 of 1
ATTACHMENT B
RADIATION SAFETY PROGRAM
FOR XRF LICENSE
The following radiation protection program will be followed at all times. A copy of these procedures shall be
maintained in the licensee’s radioactive materials license file, and another copy in the shipping case of each
XRF gauge at all times.
Only certified operators shall use, or supervise the use of, XRF gauges.
1.
2.
The licensee shall not open a source containing radioactive material.
3.
No one shall be permitted to touch or directly handle the unshielded source.
4.
The operator shall never unnecessarily be exposed to the unshielded source.
The XRF gauge source shall be locked in the closed, safe, off, or stored position when not in
5.
use and during routine maintenance.
Security of the XRF gauge shall be maintained at all times. The gauge shall be returned to the carrying case
.
when not in use. XRF gauges shall never be left unattended, except when in storage in the licensed storage
facility in the designated locked storage area or in a locked vehicle out of sight so as to minimize the attractive
nuisance value.
Only licensed operators shall have or carry keys to the XRF gauges or to their locked storage areas. The
6.
Radiation Safety Officer shall maintain control of all keys.
If the operator detects any malfunction in the shutter or other part of the XRF gauge, the operator shall
7.
immediately notify the Radiation Safety Officer.
8.
The licensed operators shall keep the Radiation Safety Officer informed of the location of the radioactive sources
at all times. A utilization log shall be maintained at the secondary and/or primary storage location (not carried with
the gauge into the field) including, but not limited to, the following information:
a.
Device manufacturer
b.
Model number,
c.
Serial number,
d.
User,
e.
Date(s) of use, and
f.
Location(s) of use.
9.
The company shall maintain on file indefinitely the training certificates.
The XRF gauges shall be securely restrained with two methods, independent of each other, within the
10.
transportation vehicle and away from the passenger compartment to prevent theft or loss in an accident and to
keep personnel exposure to a minimum.
The Radiation Safety Officer shall maintain a current copy of the following along with the XRF
11.
gauge license:
Code of Maryland Regulations (COMAR) 26.12.01.01 “Regulations for the Control of Ionizing Radiation” An
updated copy of Attachment ‘B’ “Emergency Procedure” shall also be carried with each nuclear gauge.
(continue)
Page 1 of 2
Page of 7