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Application for Amend to License 48-03220-03,Designating a Ho As

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Application for Amend to License 48-03220-03,Designating a Ho As * . _ , . seRC perm U.S. NUCLEA;) EEGULt.TO'iY COMMISSION e ^*'"'4oss''sEso 'd 0"'' is.as) * * * " * ' " * * * " " APPLICATION FOR MATERIALS LICENSE - TELETHERAPY 1 INSTRUCTIONS - Complete ttoms 1 through 22 if this is an init.ai application or en apphcation for renewal of a license. Use supplemental sheets where necessary. Item 22 must be completed on all appliutions and signed. Retam one copy. Submit original and one copy of entire apphcation to: Direcior, Omco of Nuclear Materiste Safety and Safeguards, U.S. Nucteet Regulatory Commission, Washington, D C. 20555. Upon approval of this application, the applicant wilt receive a Matensis License. An NRC Materials License is issued in accordance w*t i the general requirements contained in Title 10. Code of Federal Regulations, Part 30, and the Licensee is subject to Title 10, Code of Federal Regulations. Parts 19,20,21, and 35 and the license fee provision of Title 10, Code of Federal Regulations, Port 170. The license fee category should be stated in item 22 and the sopropnete fee enclosed. 1.b. STREET ADDRESSIE81. ACTUAL LOCATION OF TELETMCRAPy SOURCE rNCLL/ DING t .e. N AME AND MAlk. LNG ADDRE SS OF APPLICANT isneraturson. farm, sisase, physican, etc.J BUILDING suAME. ROOM NUMBER, ETC. INCLUDE ZIP CODE St. Vincent Hospital Radiation Therapy SAME AS 1a 835 South VanBuren Green Bay,. WI 54307-3508 TELENONE | AREA CODE 414 INUuBE a 433-8184 3. THIS IS AN APPLICATION, FOR. (Check sproprefe from) 2. PERSON TO CONT ACT REGARD!NG T Hl3 APPLICATION _ Anthony Ho * ' * '' C ' " 5' T .. "Auf NOMENT TO48-03220-03 LICENSE NO. O * "'"'**' or ''eENsf NO. TELEPHONE | AREA CODE t gjy NUMBER 433-3081 4 INDIVIDUAL USER 5 (Nene indersovets who . anti use or directly supervme use of redsoectase 6. RADIATION $AF ETY OF F ICER IFtSOI f/ltame of person ansernered es rednerson aefery effJeer. metsref Coorotete $atspiements A and 0 9er each mdoveduel.1 of other then erudowntunt user. comoJefe resume el trenning and experience er in Suwonnent AJ Anthony Ho 6. $E ALE D I;OJRCES r0 BE USED IN TE LETHERAPy UNIT 6 (Arrech suspiementer papes rf necessaryl BYPROBJCT MATERIAL NAM 5 OF SOURCE | SOU8tCE MAxlMUM ACTivlTY NUMBER OF SOURCE $ Ilse ne tt and tissa ko.) M ANUF ACTURE R MOC'EL NUMBER PER SOURCE A. B. C. 7 TELETHER APY UNIT 5 (Arreca suopamenres peess. se necessery> MODEL NUMBER M NAME 05 MANUF ACTURER tincluan descr, prion. et untt er custom medel ; A. B. C. a usE tArteen suooiemontery pegen. or necamera A B C e4UMAN U$E ONLY HUMAN AND OTHER USE (Specify on separam sheer) 6 PkRSONNE L MONtTORING DEvlCES TYPE SUPPLIER (Check and/or comrete as appropostel | (Service Company) EXCHANGE FREoVENCY (11 FILM BADGE - WHOLE BODY (2) THL'RMOLUMINESCENT DO51 METE R ITLDI- WHOLE BODY (3) OTHE R isoectlyl - " 8707210515 070324 REG 3 LIC30 48-03220-03 PDR I I ; _ q INFO [tMATION REQUl3ED FOR ITEMS 10 THROUGH 21 w For items 10 through 21 check the appropriate boxtes) and submit a detaued description of a41 the reauested information Beg n each item on a separate sheet identh the item nu mber and the date of the appi. cation m the lower right corner of each page if you mdicate that an append m to the te'etheispy licensmg guide will be lohowed. do not submit the pago but so,ci ,yf the revis.on number ano date of the telerenred guide Regulatory Guide 10 Rev Date 10 MEDICAL ISOTOPE COMMirTE E 15 BE AM STOPS Names and specialties attached and / check one) Description of stops used to estnet tseam orientation attached 1 a Duties as in Append +s A. or 16. SHIE LDING EVALUATION b E quwalent dut+s attached E varvation of proposed shieldir:0 attached ^ i 1 11 TR AINING AND EXPERIENCE 17. OFERATING AND EMEFfGENCY PROCEDURES ! | 1 a. Supplements A & D attached for each indmdua: user, ant 4. Description of operatmg proceduees attachet and , j 1 X b Supplement A attghed for RSO. b Copy of emergency protevores attachert 12 INST RUMENT ATION rchecA one/ 18 |NSTRUCTION OF FE RSONNEL / deck orrel . | ' a Append:= C form attached or a Trammo program and schedvic m Appendix H followed. or (* List manuf aclu *et s name and mode: number b DesCr tpfion of mstruClion program for UMployees attached. 13 CALIBR ATION OF INST RUMENTS fcr es onel 19. LE AK TESTS OF SE ALED SOURCES a ANwnd:n D Part 2 procedures fohowed for mstrumentation tabbration. or Description of leak test procedures attached - b Dest.nption of sources. cahbration frequency ar.d eauwa;ent procedures 20 OU ALIFIED E XPERT /Use only .-f the er,dmictus' fads to meet 70 CFR 35 24 Bt?ht hed reqwrements ) 14 F ACillTIES AND EQUIPMENT apent c3 wa@ canons d W emm do wm em teMWan cahbration, attached a Descript.on and drawmg af tacmt es attached and 21. ALAR A PROGRAM (chsck onel t Descr:pt.on of p.tient v cwmg. and communicatmg systems attarbrd. anc AL AR A Piogram as m A.ppendix 1, or c Description of area saf egsa os attached Eau.vatent AL ARA Prog'am attached. | t | 22. CE RTIF IC AT E (The trem must tse completed by the appinant) The apphtant and any (,ftcia: esecutmg this cer'.sf ote on behatt o' the apphcant named m item la certifies that this appbcation is prepared in coMormity with T+tle 10. Code of Federa! Regulat 0% Paris 30 and 35. and that all information contamed herern, mcladmg supplements attac9d hereto, ts true and correc' to the best of our knowleflge and behef /,9 b Af L0- 't Pff _i, f faturc ' s Lect ME f if. 54t OUtHLD fVT OH . ( 5 0161/ Ger sectos 170 3 * TO CF M 9 70i * / / (f', Qwt 116 or bro " Joseph J. Neidenbach a l LiLi h St 8 t t C A f t GOM v N 7 tit t 7A Administrator '21 L ICI N5t F i t t r4CW5E D c OATt ' s 230.00 October 14, 1986 W APNI A'G. 18 U.S C, Section 1901; Act of June 25,1948,62 Stat. 749, makes et a criminal offense to make a mHtully f alse statement or repeewntation to any department or agency of the United States as to any matter withm its iurisdictson. -- _ .. w. _ _ _ _ _ _ _ . _ . _ . ._ .. _...___ _ _ _ _ _________ ___ .. NRCfor uppiament A * U.S. NUCLE AR REGULATORY COMM!SSION (2 62) " " " * * | TRAINING AND' EXPERIENCE ' PROPOSED AUTHORIZED USER OR RADIATION SAFETY OFFICER i Nwi o, PHoposi D Aumoma D e cH Hio, A r vN sA, t v , m ,co, 2 sT A u oH ri-'t um . A WmcH ua Nsto ru PHACT ILE M[ D+CIN' r H phriec dol Anthony Ho 3. CE RATIFICATION set c. A t t i soAH3 CAT E LOH y YONTH AND * E AH ClHil''f D Eligible for certification by Radiation Therapy Physics Taken Part 1 on the American Board of and October, 1986 Radiology i Diagnostic Radiological Physics 4. TR AINING RECEIVt.D IN D AstC R RADIOISOTOPE HANOLING TECHNIOUES (To tw comsnered by institut,an provedmg treor'mg) ~ TvPLANDLfN01HOF TH AIN>ND F it LD DI THa MNG LOC A flON AND DAT E ISl Of T H AINING L E C T UH6 'L AllOH AT OH V g gg , couHst,H~ a [ A . ., n , , N a ,~,,,,,,, H ADinTION PHYSICS AND INST RUME NT ATION R ADI ADON FROHCh0N 1 PLEASE SEE ATTACHED C.V. , MATHEMATICS PERT A!NING TO THE USE, ME ASUREME NT, AND SHtELLING Of h ADICACTivE SOURCES _ R ADIATION BIOLOGY V 6 E XVE RIENCE WITH R ADIOACTIVE M ATE t?| ALS* (Actual use of ra&osserwes or eu merent esperience) M A A %M AMAN T 4 04 AN v 5 N at APs'ac A tigN W a [ '* ( l k i't M E NCf W A 5 (, A + Nil Dv4 ATION OF E A PE Fit ( NC E T YPE OF USE Cs-137 300 mci St. Peter's Hospital, 2 years Brachytherapy Albany, N.Y. / Co-60 Teletherapy University of Wisconsin Hosp. Source Madison, WI 5 years Calibration, Spot Check and Other Experience n . .. 4, . - ,, o .,u,,c.,m.m.,,,,,,,._,.e o m, ,a,,.,n,,,,,..,,_,, n..,- , , . f m,-, . - , , , . m,.<,, ...m ,+,_,..m a P..,,,_,,,,,,,_,,,,,,,,,,.,,,,,,,. ,,,,,,m,,,,,,,, IP'FNf'3PV U fl 5 g ,, f, y t tip, yp g t for r ama , e t i , *#M LIIU # 'd i <dd@'ii fi $dWt Qud *f y CD'O ' O' efid F871P'g@fw'W Pf ut PdnJret ' " ' * " ~ < " " " - " - 3 c...m,_,....,_,,,-, 6 I (( HT IF Y THAY It!{ f N8 OHY ra T ivN D64! $| NT !. D At104 [ 35 f H g.L ,.ND CO6 4((1 T O 7,. g [i [ $ T (,; pp g g Ny g [ 9;,9 A N 9 gi g ( ,) y g,g g, p r p,p,,, gjpp,,,,g, j ,e MM T v Pil. f M PHiNT[O N AV6 DATL Bhudatt Paliwal, Ph.D. 10/14/86 NAVt OF IN5 fit UT oON University of Wisconsin, Radiation Oncology MAeNc,AD = s 600 HiCJhland Ave., K4/B100 _c't v |sme + um. H ADm Au.s i m n H.ust,a Nsi Nu,m H Madison WI p53792 48-09843-18 W ARNING.18 U.S C. Section 1001. Act of June 25,1948, 62 Stat. 749. makes et a crimmal offense to make a milfully fotse4 statementP0984P3i or representation to any departmt,nt Or agency Of the Unfted Statfl at (O any matter withan sta }urisdictaon.
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