Form F-45014 "Application for Radioactive Material License Authorizing the Use of Self Shielded Irradiators" - Wisconsin

What Is Form F-45014?

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 February 1, 2005;
  • 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-45014 by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form F-45014 "Application for Radioactive Material License Authorizing the Use of Self Shielded Irradiators" - Wisconsin

Download PDF

Fill PDF online

Rate (4.6 / 5) 25 votes
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Bureau of Environmental Health
F-45014 (Rev. 02/05)
Radiation Protection Section
(608) 267-4797
APPLICATION FOR RADIOACTIVE MATERIAL LICENSE
AUTHORIZING THE USE OF SELF SHIELDED IRRADIATORS
The Wisconsin Department Of Health Services is requesting disclosure of information 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 if this is an initial application or an application for renewal of a license. Refer to WISREG “Guidance for Self Shielded
Irradiators.” Use supplementary sheets where necessary. Retain one copy and submit original of the entire application ot the State of Wisconsin,
Department of Health Services (DHS), 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
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):
(
)
-
x
(
)
-
x
LOCATION OF RADIOACTIVE MATERIAL
Item 4 Addresses Where Licensed Material Will Be Used or Possessed (Do not use Post Office Box):
Telephone Number (Include area code)
Address
(
)
-
x
,
-
Telephone Number (Include area code)
Address
(
)
-
x
,
-
Telephone Number (Include area code)
Address
(
)
-
x
,
-
RADIATION SAFETY OFFICER
Item 5. Radiation Safety Officer (RSO) (Check one box and attach evidence of training and experience)
-
x
(
)
Name:
Telephone Number (Include area code):
Before obtaining radioactive material, the proposed RSO will have successfully completed training as described in Appendix G of
WISREG ‘Guidance For Self Shielded Irradiators’. Before being named as the RSO, future RSOs will have successfully completed
training as described in Appendix G of WISREG ‘Guidance For Self Shielded Irradiators.’
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 training as described in Appendix G of WISREG ‘Guidance For Self
Shielded Irradiators.’
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
Bureau of Environmental Health
F-45014 (Rev. 02/05)
Radiation Protection Section
(608) 267-4797
APPLICATION FOR RADIOACTIVE MATERIAL LICENSE
AUTHORIZING THE USE OF SELF SHIELDED IRRADIATORS
The Wisconsin Department Of Health Services is requesting disclosure of information 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 if this is an initial application or an application for renewal of a license. Refer to WISREG “Guidance for Self Shielded
Irradiators.” Use supplementary sheets where necessary. Retain one copy and submit original of the entire application ot the State of Wisconsin,
Department of Health Services (DHS), 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
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):
(
)
-
x
(
)
-
x
LOCATION OF RADIOACTIVE MATERIAL
Item 4 Addresses Where Licensed Material Will Be Used or Possessed (Do not use Post Office Box):
Telephone Number (Include area code)
Address
(
)
-
x
,
-
Telephone Number (Include area code)
Address
(
)
-
x
,
-
Telephone Number (Include area code)
Address
(
)
-
x
,
-
RADIATION SAFETY OFFICER
Item 5. Radiation Safety Officer (RSO) (Check one box and attach evidence of training and experience)
-
x
(
)
Name:
Telephone Number (Include area code):
Before obtaining radioactive material, the proposed RSO will have successfully completed training as described in Appendix G of
WISREG ‘Guidance For Self Shielded Irradiators’. Before being named as the RSO, future RSOs will have successfully completed
training as described in Appendix G of WISREG ‘Guidance For Self Shielded Irradiators.’
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 training as described in Appendix G of WISREG ‘Guidance For Self
Shielded Irradiators.’
F-45014 (Rev. 02/05)
Page 2 of 4
AUTHORIZED USERS
Item 6 Authorized Users (Check one box)
Before using radioactive material, authorized users will have received training as described in Appendix G in WISREG ‘Guidance for
Self Shielded Irradiators.’
OR
A description of the training and experience for proposed authorized users is attached.
RADIOACTIVE MATERIAL
Item 7 Radioactive Material (Attach additional pages if necessary)
ELEMENT AND MASS NUMBER
CHEMICAL AND PHYSICAL FORM
Cobalt-60
Strontium-90
SEALED SOURCE
Cesium-137
Other Isotope (please specify):
SEALED SOURCE MANUFACTURER OR DISTRIBUTOR AND
DEVICE MANUFACTURER OR DISTRIBUTOR AND MODEL
MODEL NUMBER:
NUMBER:
MAXIMUM QUANTITY (Not to exceed either the maximum activity
SEALED SOURCE AND DEVICE REGISTRATION SHEET
per source or device as specified in the Sealed Source and Device
NUMBER:
Registration Certificate)
INTENDED USE:
FACILITIES AND EQUIPMENT
Item 8 Facilities And Equipment (Check all that apply)
Diagrams of radioactive material area(s) of use are attached.
AND EITHER
We will ensure that each area where a self-shielded irradiator is located corresponds to the ‘Conditions of Normal Use’ and
‘Limitations and/or Other Considerations of Use’ on the applicable irradiator’s Sealed Source and Device Registration Certificate;
the floor beneath the self shielded irradiator is secured to prevent unauthorized access or removal; and each area where a self
shielded irradiator is located is equipped with an automatically operated fire detection and control system (sprinkler, chemical, or
gas) or the location of the area and other controls ensure a low-level radiation risk attributable to fires.
OR
We will submit alternative information; be sure to include justification for placing an irradiator in an area that does not correspond
to the ‘Conditions of Normal Use’ and the ‘Limitations and/or Other Considerations of Use.’
F-45014 (Rev. 02/05)
Page 3 of 4
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 DHS for review. This matter will be examined during
inspection.
Item 9.2 Radiation Monitoring Instruments (Check one box)
We will use instruments that meet the radiation monitoring instrument specifications published in Appendix K of WISREG
“Guidance for Self Shielded Irradiators.” Additionally, each survey meter will have been calibrated by the manufacturer or other
person authorized by DHS, the NRC or an Agreement State to perform survey meter calibrations no more than 12 months before
the date the meter is used.
OR
We will use instruments that meet the radiation monitoring instrument specifications published in Appendix K of WISREG
“Guidance for Self Shielded Irradiators.” Additionally, we will implement the model survey meter calibration program published in
Appendix K of WISREG “Guidance for Self Shielded Irradiators” and we ensure that each survey meter will have been calibrated
no more than 12 months before the date the meter is used.
OR
We will have access to survey equipment and/or procedures for ensuring that interlocks function, as required, to return
moving self shielded irradiator sources to the shielded position and/or determining source shielding integrity after an incident
involving the self shielded irradiator.
Item 9.3 Material Receipt And Accountability (Check 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.
Item 9.4 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 9.5 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 one box)
We will develop, implement, maintain and distribute operating procedures that will meet the Criteria in the section titled
‘Operating and Emergency Procedures’ in WISREG “Guidance for Self Shielded Irradiators.” (Procedures are attached)
OR
We will submit alternative procedures. (Procedures are attached)
Item 9.7 Leak Tests (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 supplier’s instructions.
List 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 leak testing and sample analysis and will follow the model procedures in Appendix P of WISREG
“Guidance for Self Shielded Irradiators.” (Procedures are attached)
OR
We will submit alternative procedures. (Procedures are attached)
F-45014 (Rev. 02/05)
Page 4 of 4
Item 9.8 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 self shielded irradiators according to each
manufacturer’s (or distributor’s) written recommendations and instructions.
OR
Alternative procedures are attached.
NON-ROUTINE MAINTENANCE:
We will have the self shielded irradiator manufacturer (or distributor) or other person authorized by DHS, the NRC or an
Agreement State perform the non-routine maintenance.
OR
We will provide procedures that address the information listed in Appendix I of WISREG “Guidance for Self Shielded Irradiators”
supporting a request for authorization to perform this work. (Procedures attached)
Item 9.9 Transportation (Check one box)
We choose to transfer possession of radioactive material to an irradiator manufacturer, distributor or service licensee with a DHS,
NRC or Agreement State license who then acts as the shipper.
OR
Before offering a Type B package for shipment we will be registered with the NRC as user of the package and obtain DHS approval of
our QA program.
DISPOSAL, TRANSFER AND LICENSE TERMINATION
Item 10 Disposal, Transfer and License Termination
Item 10.1 Disposal And Transfer ( Check Box)
We will return the source to the manufacturer for disposal or transfer the device to a specific licensee authorized to receive
radioactive material.
Item 10.2 Termination Of Activities (Check box)
We will notify DHS, in writing, within 30 days of the decision to permanently cease radioactive material use per s. DHS 157.13(10)(d)
SPECIFIC LICENSE FEE
Item 11 License Fees (Refer to Wisconsin Administrative Code DHS 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 12
I hereby certify that this application was prepared in conformance with Wisconsin Administrative Code 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.
:
Date signed
SIGNATURE - Applicant Or Authorized Individual
Print Name and Title of above signatory
Page of 4