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Application for Amend to License 13-13144-012,Authorizing MJ

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Application for Amend to License 13-13144-012,Authorizing MJ __-_ _ '' -' 's . - ' . h - ST. ANTHONY HOSPITAL , 301 West Horner Street. Michigan City, Indiana 46360 (219) 879 8511 .A August 12, 1987 |r- c-&| g,, p . i [/ 48 #W- U. S. Nuclear Regulatory Commission | Radioisotopes Licensing Section /d M[[[ | 799 Roosevelt Road Region Ill ------ v -- Glen Ellyn, Illinois 60137 Re: Amendment to NRC Radioactive Materials License #13-13144-02 Gentlemen: We request amendment to our Nuclear Regulatory Commission radioactive materials license #13-13144-02 for the following: 1. Indicate Marco John DiBiase, M.D., as Radiation Safety Officer, replacing R. S. Plank, M.D. However, Dr. Plank will remain on the license as an authorized user. For training and experience of Dr. DiBiase, please reference NRC radioactive materials license #13-13144-02. 2. Addition of Drs. Theodore Leonas, D.F.M., and Mann Spitler, D.P.M., for use of I-125 with the Lixiscope. For training and experience of Drs. Leonas and Spitler, please reference the attached training certificates and curriculum vitaes. 3. Increase Alan C. William, M.D., coverage to include Group VI. 4. Add 1501 North Wabash, Medical Arts Building, as an additional site fcr the use of the Lixiscope- 5. Revision of Item 10 to our NRC radioactive materials license. Please see attached. We trust the above information is sufficient to grant our request for amendment and look forward to receipt of that document. Enclosed is our check for $120 to cover the amendment processing fee. Sincerely, ? /{IA AhbA , I l G E B- 'YED 919r/- ! Kevin Leahy 1 inn Administrator UCIOllyg7 *d** CONTR0l. N0 84281 Enclosures gg7 gg B9022704B9 BB0301 " Celebrating Eight Decades of Service" REG 3 LIC30 13-13144-02 PNV _ _ _ _ _ _ _ - _ _ _ _ _ - ' ~* , . - - . , ; , - . - REF: NRC 313M - ITEM 10 CALIBRATION OF INSTRUMENTS .SURVEYMETER(SJ The survey meter (s) will be calibrated at least annually, and after repairs, by i any firm that is approved by the NRC for .such cal tbrations. Instruments wi H be I calibrated on at least two (2) points on each scale range. Currently, our calibration service firm is Stan A. Huber Consultants, Inc., of New Lenox, Illinois, whose radiation sources and procedures are on file with the NRC under License #12-17503-01. The licensee shall perform operational constancy checks on survey instruments ; ' before each day's use to ensure proper functioning of the devices. For any infrequently used meters, these reference source operational checkt shall be taken at least quarterly, per NRC Regulatory Guide 10.8 (October 1980) Appendix D, Section 1. Item B, as well as after repairs and battery changes to assure constancy within +20% of expected readings. DOSE CALIBRATOR (S) We shall follow the calibration methods and frequencies for dose calibrator (s) as defined in the NRC Regulatory Guide 10.8, dated October 1980, Appendix D, Section 2, " Methods for Calibration of Dose Calibrator". For the linearity test, we will test the dose calibrator over the range of its use between the highest dosage that will be administered to a patient and 100 uCi. For the accuracy test, Stan A. Huber Consultants, Inc., of New Lenox, Illinois, or other licensed calibration firms, will use the following sources t under the authority of their NRC license: Model NES-356, 200 microcuries of Cs-137 (high energy) 1 Model NES-352,1 millicurie of Co-57 (low energy) (Or other NRC approved Co-57 calibration sources of greater millicurie ! activity.) Model NES-358, 250 microcuries of Ba-133 (medium energy) (The minimum activities used for dose calibrator accuracy checks are 100 uCi each for Cs-137 and Ba-133, and 1 mci for Co-57.) We use a NEN Model NES-356, Cs-137 standard, 100 - 300 uC1, or any approved similar standard for our day-of-use dose calibrator constancy checks. Records of all tests and checks will be maintained. i We request use of the "Calicheck" (Calcorp) system or "Lineator" (Atomic Products) system as an alternate method of performing dose calibrator quarterly linearity checks. The product certifications for these devices are on file with the NRC. CONTROL N0.8 4 2 8 1 - _ - - _ - _ _ - - - _ - - - - - - - - - - - - - - - - - - - - - 3 _ - _ _ _ _ _ _ ' . - . THEODORE LEONAS, JR., D.P.M. i Foot Physician and Surgeon 1501 Wabash, Suite 101 , Michigan City, IN. 46360 | 219 - 872-5540 , September 15, 1987 1 | t | l Marco J. DiBiase, M.D. I Department of Radiology 301 W. Homer Street Michigan City, Indiana 46360 RE: Curriculum Vitae To Whom It May Concern: Personal Background: Theodore Leonas Jr., Age: 31. Native of Chicago Heights, Illinois. Educational Background: College: Roosevelt University, Chicago Illinois. 9.S. in Biology, 1976 Professional School: Illinois College of Podiatric Medicine, Chicago, Illinois. Doctor of Podiatric Medicine, 1980. The above consisted of a 4 year curriculum with the first 2 years being comprised of the basic medical sciences in the last 2 years consisting of clerkships through the various clinical sciences. 1 Included in the basic sciences were anatomy, biochemistry, pathology, | microbiology, radiology, clinical diagnosis and biomechanics. The { clinical clerkships consisted of rotations in the various clinical . sciences including radiology. | Professional Practice: Engaged in private practice since 1980. Currently main- tains offices in the St. Anthony Medical Arts Building, 1501 Wabash, Michigan City, Indiana. Have full surgical privilegos at St. Anthony Hospital and Memorial Hospital, both located in Michigan City, Indiana. ; _ _ _ _ _ _ _ _ _ _ _ _ _) - - . ~ ,.m- , , . - . ~ . ,' % -~ _y '' ,f _y-~'',, -x ,r~_,- f~' , $ip@, .,. ,,y*y@#?%gysiq @7N 4,.$9ti _APXT M_. M Y &q"'%,@ X M M; 3 ApV gy g %q (3gy _ _ _ _ _ _ -4 p CERTIFICATE OF TRAINING $.c$e:. M> 9,[y g RADIATION SAFETY ) } >iff., ho, This is to certify that Theo Leonas Jr. nPM ] pp. < -e.3 ' , ,5, pn 9 ; P ang,& , has completed the LIXIm Radiation Safety Training Course on file with $i k; ' f y y$p# the U.S. Nuclear Regulatory Commission. ] Julv 30.1987 l / t This training was completed on: h* 4<h"*'k%e- < & m(ui,hy * This training course was developed by Lixi,Inc. and S.A. Huber Con- I (d * $4 j dh ^ // , sultants Inc. for the purpose of providing the necessary training in j .. ( \ , radiation safety and experience for LIXIm scope users. The training H gf 'g {$ : ' was given as approved by the NRC under License Nos. 12-17503-01 gejgk) 4%,,hgy ; hn #? and 12-18215-01. q' a f y? . )st"n"um"%y h/:T This also certifies that the trainee has personally operated a working hb 4 LIXIm scope, under supervision,in the aforementioned course. "(' / 7 g, h A copy of this certificate is to be provided to the NRC or Agreement h. ,hpT r State as proof that the trainee has the necessary experience to make a g ;,dj<j specific application for a Byproduct Material License to possess and , p",f'ji j' y,,,""4tg" ) I y **y' t j use a LIXIm scope. | m. ?% %.5s 'h $f. t ) Weer i This document was prepared in conformity with Title 10, Code of I Federal Regulations, and all information contained herein is true and d@ N @? O M re #g (kIf @p'>; correct h% toa the best of our knowledge and belief. ' a 4 d. ? '%g%vs / $.4...$e>s ,, ( Certified by: LIXI. Inc. : sg u , Q gl.p.e. y . Randy Foster, DAr::::. p') / s" P | Instructor: / ?,WJ 1 ,,/ &n # ' | y b-f '7 4 i,. Q[%?"'"%( **'Ti Signature: { AA F( ('"'"ufM Under License No: 12-1821601 [ 88 41 | D[1%!h,, fetu Date: Auqust 10. 1987 I us.ey : L ',Weje j 3 |9a< %qg,|"!!'. { Ns.s4 ~%& * j k - . - . - . t g' L' , . , _ . - - . , , . - | x}y'",'f. y g.w ,- m.r;.m. y m y yg;3--- q a- _4ggt# 6 :%y: y' ,4F . m" !b d# W %y.un v $ f | e, g yp 4 4 y,p p , g , 4Pi I | lh,,,a,w($;;&(v...4$3hmeh ,e m % *$ r o eww.se[ Abs @mkk, '*$I'%ayw%$pw h.m h E-_ - _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , | - | . 1 * ,~, , y -. ~ ,. .v n .,-, n , ,m , k ., ,-Q - | & h h h f $ h f | k h & , h b h, , ,0 4 h }) ' . '' . ,, k! ( 'j { .[ . .f / .$. k. w.~ a .:agaz.x . + . ~ . ..+ , ...v.n.w w.,uw .ce== ,.n.=w.. n.g.,gy..u... CERTIFICATE OF TRAINING Nady $[,- ' '} RADIATION SAFETY ag 4 ge Mann snitine iti npM | k[//n,,,, . j f This is to certify that 3,gj '.p.? k | g;| ?m,Q f d | has completed the LIXIm Radiation Safety Training Course on file with f the U.S. Nuclear Regulatory Commission. fg { . }74 ! This training was completed on: July 30.1987 h y q8 f"$"% - ' ~'%ug. (g{hy""%gg This training e[ boy course was> developed by Lixi,Inc. and S.A. Huber Con- j F/ ' sultants Inc. for the purpose of providing the necessary training in t. j y.p g| ( .. jp$t radiation safety and experience for LIXIm scope users. The training 4 g3 . was given as approved by the NRC under License Nos. 12-17503-01 ,,* 4;:' s (h:*?,nn g :. , , and 12-18215-01. 31s k "P;j" ; ;2 h | . %y . } (' p$:.ge ,,r++;g.a) ~ . 5 L This also certifies that the trainee has personally operated a working j j l . LIXIm scope, under supervision,in the aforementioned course. [ @h" 4 . : . ! A copy of this certificate is to be provided to the NRC or Agreement dh }>^{g , , Qg(, ' (iff.;h.,,;p[eA State as proof that the trainee has the necessary experience to make a .
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