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Matls Licensing Package for Amend 12 to License 48-16117-01 for St

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Matls Licensing Package for Amend 12 to License 48-16117-01 for St _ _---____ -___ _ - _ _ _ _ _ _ _ _ - - _ _ _ _ _ _ - _ _ _ _ - _ _ - - - - _ _ - - - - _ _ - - - - - _ _ _ _ _ - - - - - - - - - - - - - - - - - - - - - - - - - - . u.S. NUCLEAR REGULATORY Commission g g MATERIALS LICENSE Pursuant to the Atomic Energy Act of 1954, as amended, the Energy Reorganization Act of 1974 (Public Law 93-438), and Title 10 Code of Fed:ral Regulations, Chapter I, Parts 30,31,32,33,34,35,36,39,40, and 70, and in reliance on statements and representations heretofore made by the licensee, a license is hereby issued authorizing the licensee to receive, acquire, possess, and transfer byproduct, source, and special nuclear material designated below; to use such material for the purpose (s) and at the place (s) designated below; to deliver or transfer such material to persons authorized to receive it in accordance with the regulations of the applicable Part(s). This license , sh:ll be deemed to contain the conditions specified in Section 183 of the Atomic Energy Act of 1954, as amended, and is subject to all I applicable rules, regulations, and orders of the Nuclear Regulatory Commission now or hereafter in effect and to any conditions specif'e d c. Ucensee In accordance with the letter dated May 19,1998, and fax transmittal dated June 2,1998 1. St. Joseph's Community Hospital 3. Ucense number 48-16117-01 is amended in of West Bend, Inc. Its entirety as follows: 2. 551 S. Silverbrook Drive g R le. gpiration date January 31,2002 W st Bend, WI 53095 Y- b 5. Dock"et 1(o 30-10451 Q Reference { v v 6. Byproduct, source, and/or special @ 7. Chemical and/or physical form ' , 0. ximum amount that licensee may nuclear material 7 ess at any one time under this O g a, 4 li nse A. Any byproduct materi I Nh adiopharpiaceu ~ ! A. ks needed identified in 10 CFR 100 Tidentified in 10 CFR 35.100 0 ' c,:n ( ( A u.4 ._7 - B. Any byproduct materW BCAny. ceutical B. s needed identified in 10 CFR 3g200 : # Tident FR 35.200 3|* O ' f %g N' ?, C. Any byproduct ma'erial S Afu1yfac i talTlaceuticalG C.[As needed (not to exceed 1 identified in 10 CFR 35. : identifit .11) CFR 35.300 o, curie of I-131) ,; ~, .;.3y y D. Any byproduct material h D. P packaged Mts ' 9) O.D As needed identified in 10 CFR 31.11 4 Q' 4 Q a v h 9. Authorized Use: A. Medical use described in 10 CFR 35.100. B. Medical use described in 10 CFR 35.200. C. Medical use described in 10 CFR 35.300. D. In vitro studies. CONDITIONS 10. Licensed material shall be used only at the licensee's facilities located at 551 S. Silverbrook Drive, West Bend, Wisconsin,1700 W. Paradise, West Bend, Wisconsin, and 205 Valley Avenue, West Bend, Wisconsin. t g y j ,ng , , " 7' 9807080191 980604 ( .I b '\/ PDR ADOCK 03010451 d b W'' II C PDR _ 's NRC FORM 374A u.s. NUCLEAR RE!uLAToRY Commission PAGE 2 of 2 PAGES Ucense Number 48-16117-01 MATERIALS LICENSE Docket or Reference Number SUPPLEMENTARY SHEET 030-10451 Amendment No.12 11. Radiation Safety Officer: Robert L. Meredith, M.L. 12. Licensed material listed in item 6 above is only authorized for use by, or under the supervision of, the ! following individuals for the materials and uses indicated: Authorized Users Material and Use j Robert L Meredith, M.D. 10 CFR 35.100,35.200,35.300 and 31.11 Patrick M. Gardner, M.D. g R idfft 35.19,35.200,35.300 and 31.11 William J. Pier, M.D. O 10 CFR 35.100,3h,35.300 and 31.11 D G John G. Fink, M.D. Y 10 CFR 35.100,35.200,3$.300 (excluding 1-131 for g k, m, thyroid carcinoma)'and 31.14 13. The licensee is auth ek to trans m'Eiirlal oni rdance Oh the provisions of 10 CFR Part 71, " Packaging an transportation"of' R$dioactivd Mdtsrisf.st O , /k 4"44 ,,MM E 14. Except as specifically provided se in- the lice 6see shall cogduct its program in accordance with the sta$pment rocedures contained Irf'the documents, including " any enclosures, listed below, ex'q' 'lM i the medicil use rgBlation safety procedures as provided in 10 CFR 35.31RThe b asion'*9egulations shall govem unless the . m statements, representation, and . Econsee's application (Ad correspondence are more ' restrictive than the regulatio(s f5) " A. Application dated July 24,1"999, B. Letters received October 17,1991 d ru 2 996 with enclosures); C. Letters dated December 18,1991, January 16,1992, and June 19,1996; and D. Close-out survey results dated August 13,1996. ' FOR THE U.S. NUCLEAR REGULATORY COMMISSION JUN 0 41998 Dats By Vw 0$ 1 - - a Jam 4pf R. Mullau'er, M.(.S. Nuclear Materials Licensing Branch Region lli _ _ _ _ _ _ _ - _ _.. ) ' f e - : (FOR LFMS USE) ) : , INFORMATION FROM LTS BETWEEN: : ____________________ License Fee Management Branch ARM Progran Code: 02120 ) and Status Code: 0 Regional Licensing Sections : Fee Category: 7C * Exp. Date: 20020131 * Fee Comments: ) : Decon Fin Assur~ Req 8T~R~~~~~~~~~~~~ :::::::::::::::::::::::::::::::::::::: ) LICENSE FEE TRANSMITTAL I A. REGION $ j - 1. APPLICATION ATTACHED ) | Applicant / Licensee ST. JOSEPH'S COMM. HOSP.0F WEST BEND | Received Date 980528 1 Docket No: 3010451 '' Control No.: 303999 0 3 e ) License No.: 48-16117-01 .;; Action Type Amendment V6 Q gg, 2. FEE ATTACHED 8 , ) Anount d k Check No.: ' ~2,, : 3. COMMENTS Si D.knede :::NOZ''f~~~~_~::::,~~ , ) 'B. LICENSE FEE MANAGEMENT BRANCH (Check Whe flestone 03 is entered /__/) 1. Fee Category and Anount: ,, __,,_____y,___f_______,,______________ ' 2. Correct Fee Paid. ./pplicationnaybeprocessedfor: Amendnent V Rcnewd ~~~~~~~~~~~~~' License ::~~,, :~~ _~::~: 3. OTHER _ _ _ , , _ _ _ _ , _ _ _ _ , , _ _ _ , , _ , , , , , , , _ _ _ _ , , , , , , , _ _ _ ___ _______________ __ ___ ___ oate ::::::_. _ ff::::::::::::::::::: ~ tse wie H 27.L__ _ _ _ _ ' nanient.. checkNo.J _2. __ ___ _ ___- __ _. _ - ! Amount __ cd____ _-__.' Fee Category _,._7_d_____ . _ _ Typo of Fee ____AG2.b_ _ -- -- ) - Date Check Rec'd _ _____ . Daseysy._____._ _ g _ _ _ _ _ _ _;| ______________ _ - __ - _ - , - _ __ __ .. ____ _ _ - _ _ - _ _ _ - _ _ _ ___-__ _ ____-__ - - aii ' M $1 JOSEPH'S ' COMMUNITY HOSPITAL . OF WESTIHND y Yoca Tausno Praimafur IJfEIDNG ntAIDL i [|ig May 19,1998 .. gp|a Op: U.S. Nuclear Regulatoly Commission O* 801 Warrenville Road Lisle, Illinois 60532 1 | Subject: By-Product Material License #48-16117-01 P , Dear Sir or Madam: ?.+ #! We request that you amend our by-product material license to show the following i changes: M 1. Please delete Roland Brown, M.D. as the Radiation Safety Officer. ypj 7l 2. Please add Robert L. Meredith, M.D. as the new Radiation Safety Officer. kk 'd 3. Please add Patrick M. Gardner, M.D. and Robert L. Meredith, M.D. as authorized users of by-product on our licence. Copies of training and preceptor statements are enclosed for your review. [Qm 4. We request these individuals be added for all materials that we are currently authorized for. W:q d 5. Enclosed please find our check for $460.00 to cover the appropriate amendment I#** g( . Should you have any questions or require additional information regarding this 3 matter, we authorize Mr. Ronald D. Edwards, Radiation Physicist, Radiation $f Protection Services, Ltd.,800 W. 5* Ave. Suite 103E, Naperville Illinois 60563 d (630) 309-6493 to answer any questions or provide any additional information you ] may require. p g Sincerely, Aadutd 7t&' ($) Barbara L. Knutzen RECEIVED vi Director of Professional and Support Services , MAY 2 81998 , " * d"" h REGION III Enclosures: 1. Training and Preceptor Statements M1 2. Check for Amendment Fees MAY 2 8 R8 BOARD OF DIRECrORS Wmm W. Kieckhafer, Ih/mau.umwn h nusR.Bei Rohen D. Gilmon, M D Barbra T. Manm Rnden J. khnald Gregory T. Burns Rohen J. Swiner. Er Acadms Mx!wel F. Bk=xk,rn Amirew J Gurnm Mark A. Nrhen Rita B Scpenky Emwnw thw Rxhard A.14rwn. Tmuner Paul S. Christemen TmL! J. Hamner. M D. George L Preami Arty. ILine A. Shanchnmk Gre5or, T. Burns, hwirr Charles 5. Gnger, M.11 Allen C. IGepke Jean M Rngic Sbmn S. Zryler 551 S. Silverbrmk Drive, Wen Bend. WI 53095 3898 (414) 334-5533 Fax (414) 334-8484 ]Q - - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ * ' ' - . , 0 0 .. t - . .. Date April 23,1998 | Ms. Michelle Uecker ' Nuclear Medicine Supervisor St. Joseph Community Hospital 551 Silverbook Dr West Bend, WI 53095 . ! Dear Ms. Uecker: This letter is to verify that Robert L. Meredith MD. is in the process of completing his residency and will complete his residency by June 30,1998. Dr. Meredith has completed greater than the required amount of(500) five hundred hours of clinical and gmater than (500) hours of work experience, as well as two hundred (200) hours of didactic training. I have completed and returned the preceptor forms to you along with this letter. If you have further questions or concerns regarding Dr. Memdith's training, feel free to contact me by phone at (608) 263-5306 or by fax at (608) 262-0907.
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