Form F-45009 "Application for Radioactive Material License Authorizing the Use of Sealed Sources in Fixed Gauge Devices" - Wisconsin

What Is Form F-45009?

This is a legal form that was released by the Wisconsin Department of Health Services - a government authority operating within Wisconsin. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2012;
  • The latest edition provided by the Wisconsin Department of Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form F-45009 by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

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Download Form F-45009 "Application for Radioactive Material License Authorizing the Use of Sealed Sources in Fixed Gauge Devices" - Wisconsin

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Bureau of Environmental and Occupational Health
F-45009 (05/12)
Radiation Protection Section
(608) 267-4797
APPLICATION FOR RADIOACTIVE MATERIAL LICENSE
AUTHORIZING THE USE OF SEALED SOURCES IN FIXED GAUGE DEVICES
Department of Health 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 Services (DHS), Post Office 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. 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’.
Or
Alternative information demonstrating that the proposed RSO is qualified by training and experience is attached.
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Bureau of Environmental and Occupational Health
F-45009 (05/12)
Radiation Protection Section
(608) 267-4797
APPLICATION FOR RADIOACTIVE MATERIAL LICENSE
AUTHORIZING THE USE OF SEALED SOURCES IN FIXED GAUGE DEVICES
Department of Health 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 Services (DHS), Post Office 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. 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’.
Or
Alternative information demonstrating that the proposed RSO is qualified by training and experience is attached.
F-45009 (05/12)
Page 2 of 4
AUTHORIZED USERS
Item 6. Training For Individuals Working In Or Frequenting Restricted Areas (Check one box)
Routine Maintenance
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
Krypton-85
Americium-241
Cesium-137
Strontium-90
Radium-226
Other Isotope (Please specify):
List name of Sealed Source Manufacturer or Distributor and
List Name of Device Manufacturer or Distributor and Model Number
Model Number
Maximum Quantity (Not to exceed either the maximum activity
Sealed Source And Device Registration Sheet Number
per source or device as specified in the Sealed Source and
Device Registration Certificate)
Intended use
FACILITIES AND EQUIPMENT
Item 8. 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 9 Radiation Safety Program
Item 9.1 Audit Program
The applicant is not required to, and should not, submit its audit program to the DHS for review during the licensing phase. This matter
will be examined during an inspection.
Item 9.2 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.
F-45009 (05/12)
Page 3 of 4
Item 9.3 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 DHS, 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 DHS review. (Procedures are attached)
Item 9.4 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 9.5 Occupational Dose (Check one box)
We will maintain, for inspection by DHS, 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. DHS 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 9.6 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 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 9.8 Leak Test (Check one box)
Leak tests will be performed by an organization authorized by DHS, 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 DHS, 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 DHS, 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 DHS, 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)
F-45009 (05/12)
Page 4 of 4
Item 9.9 Maintenance (Check one box each for Routine Cleaning and Lubrication and 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
Radiation surveys required by s. DHS 157.25(1) will be performed by a person specifically authorized by DHS, the NRC or an
Agreement State.
Or
We will perform non-routine maintenance in-house and will provide the information listed in Appendix N of WISREG “Guidance for
Fixed Gauge Devices” to perform this work. (Information is attached)
Item 9.10 Fixed Gauge Disposal And Transfer (Check 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 9.11 Transportation
No response is needed from applicants during the licensing process; this issue will be reviewed during inspection.
Item 9.12 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 10. License Fees (Refer to Wisconsin Administration Code s. DHS 157.10)
Category
License fee enclosed (for new applications only)
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 DHS 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
OPTIONAL: CORRESPONDENCE AUTHORITY
I have delegated correspondence authority for matters pertaining to our Radioactive Materials License to
.
The designee named here has approval to submit amendment requests concerning this Radioactive Materials License. I understand that
license renewal applications must be signed by a member of upper management.
SIGNATURE - Applicant Or Authorized Individual
Date signed
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