ML16293A278

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Radiological Survey and Dose Assessment Report for the Western New York Nuclear Service Center and Off-Site Areas in Follow Up to Aerial Gamma Radiation Survey Conducted in 2014, Rev. 0, Reference 16
ML16293A278
Person / Time
Site: West Valley Demonstration Project, P00M-032
Issue date: 08/22/2016
From:
MJW Technical Services
To:
Office of Nuclear Material Safety and Safeguards, State of NY, Energy Research & Development Authority, Office of Nuclear Reactor Regulation
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Download: ML16293A278 (17)


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Reference 16-MJWTS Radioactive Materials License -C3181

Reference 16 - MJWTS Radioactive Material License and Reciprocity Approval

-1*1'1*' 'if i(f;.. ~

~EWYORK 5TATfOF Department l

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5 Qt OPPORTUNtTY.

of Health *

Andrew M. Cuomo Howard A. Zucl<er, M.D., J.D~ Sally Dreslin, M.s,, R.N.

Governor :Commissioner Executive Deputy Commissioner September 15, 2015 JAMES P GRIFFIN MJW TECHNICAL.SVCS./MJW CORPORATION, INC 243 ,ROOT.STREET, SUITE 100 O~EAN NY 147{)0 RE: *Tiniely Renewal for License Nm:n~er C31.81

Dear Radiation Safety Officer:

Thi.s letter acknowledges receipt of your applica:tiori for renewal of New York State Department of Health Radioac,tive Mater~a:ls *Lfoense Number C318L The appllcatiqn has been deemed "timely", allowing License Number C3181 to remain active until iss:Uaiic!'!

of the renewal *from this office~

As~ reminder, PH Nun1ber 20:15-0295 has been assigned t6 your renewal a$ a tracking number. Please refer to this number in any correspondence cir telephone calls .

regarding your renewal.

For inquiries regarding renewal status, call the Radioactive Materials ~ection at (S 18) 4:02-7590 and a secretary can assist ,Y.OU; For inquines that ~re technical in nature, please cair the same phone number, and a secretary can direct you to the Radioiogica) Health Specialist :assigl':\ed to your renewal. You may also e-mail inquiries to befp@Jl.ealth.ny.gov All written cor-respondence should be addressed to:

New York State Department of Health Buteau oi Bnvttonm~ntal Radiation Protection Radioactive Materials Section Empire State Plw~, Corning Tqwer,. 12th floor Albany! NY 12237 Sincerely, Robert E. Dansereau, Assistant Director I Bureau of Environmental Radiatio:µ Prot~ction Empire State Plaza, Corning Tower. Albany NY 12237 I health.ny.gov

  • ANDREW M. CUO?t/10 HOWARD A.. ZUCKER, M.O.; J.D. SALLY DRESLIN, M.S., R.N.

Governor Commissioner

  • Executive Deputy-Commissioner AUG 0 5 Z015 MJW Technical Services, Inc.

243 Root Street Otean.* New York_ 14790 Attention: ~am es P. -Griffin Ha.\:liaticm ~E!fety Offic~r

'RE: NYS Dept. of Health Radioactive M;at~rials License N9. *c3t&1 OH No. 15:-498

Dear Mr. GritT_in:

Enclosed is Amendm~nt No. 9 fo NewYork State Departm~nt orHe~lth Radioaptive Materials license No. C3181, whi~h ma~es changes to Conditfon Nos. 6, 7\ .8, 9 *and 12. The purpose of these ch_~nge~ is to add ~larlfying t13njiindlC)gy concerning yoµr _alit,hoMz~tion to conquct decommi~si6ning and decontamination wor.k,-at .t~nworaryjobsites in New York, SJate.

If I may be-of ass.istaiic~, pJease.cqhtact ~hi$ offic~ at ~5-18) 492-.7590 or; NevJ York State Department of Health B1.1re~u of Environmental R<;idiatioh Rrptectron 8adipactiv~ Materials S~ction .

ESP, Corning Tower - Room* 1245 Albany, Ne\v York *12237 Sincer~ty, Michael G. Harmon Associate Radiological *Health SpeciaUst-bJS/MGH Enclosur~: Amendrrierit*No.- $

-~--------~----~-----'--'----'--------..,..---*------*--,.**~---

Errip1re State Plaza. Corn mg ToWer-All;)any. NY 12237 \ heallli l')y.g:ov

NEW YORK STATE DEPARTMENT OF HEALTH RADIOACTIVE MATERIALS LICENSE Pursuant to the Public Health Law. Part 16 of the New York State Sanitary Code, Industrial Code Rule 38, and in reliance on statements and representations heretofore made by the licensee designated below, a license is hereby issued authorizing radioactive material{s) for the purpose(s), and at the p!ace(s) designated below. The license is subject to all applicable rules, regulations, and orders now or hereafter in effect of all appropriate regulatory agencies and to any conditions specified below.

1. NAME OF LICENSEE 3. LICENSE NUMBER FEIN 20-2450867 C3181 MJW Technical Services, Inc. 4. EXPIRATION DATE Phone (716)631-8291 October 14,2015
2. ADDRESS OF LICENSEE 5a. REFERENCE b. AMENDMENT NO.

243 Root Street DH 15-498 9 Olean_ New York 14760

6. Radioactive Materials 7. Chemical and/or 8. Maximum quantity licensee telements in mass number) physical form may possess at any one time
  • A An:v isotope with atomic A.* Sealed sources A. I curie number 3 tlu*ough 95 B. Cesium 137 B. Sealed source B. 300 curies
c. Americium 241 c. Sealed source c. 14 microcuries D. Any isotope with atomic D. Solid or liquid as D. 25 millicL1ries number 1 through 92 contamination I

(See Condition 9.B.)

E. Any isotope with atomic E. Solid or liquid as E. 2.5 millicuries number greater than 92 contamination (See Condition 9.B.)

F.. Custom gamma source F. Sealed source F. See Condition g_c.

{See Condition 9.C.)

G. Any isotope with atomic

  • G. Sealed sources G. 25 millicuries number I through 92 (See Condition 9.0.)

,* °'I:~: 'I (1111. ".

Page 1of11

NEW YORK STATE DEPARTMENT OF HEALTH RADIOACTIVE MATERIALS LICENSE

3. ;License Number C3181 5a. Reference DH 15~498 b 7 Amendment No. 2
6. Radioactive Materials 7. Chemical and/or 8. Maximum quantity licensee

{elements in mass number) physical form may possess at any one time H. Any isotope with atomic H. Sealed sources H. 2.5 millicuries number greater than 92 (See Condition 9.0.)

I. Cesium 137 I. Sealed sources I. 10 curies J. Americium 241 / J. Seaied sources J. 2,500 millicurics Beryllium K. Any radioactive material K. Any, as potentially K. *Any, as found at client subject to licensing under contaminated materials sites Part 16 of the New York State Sanitary CoQe or .

Article 175 of the New York City Health Code

9. Authorized use.

A. Conditions 6.A.. 6.B.. and 6.C.:

For use as calibration sources to calibrate commercially available radiological instrumentation.

B. Conditioris 6.D. and 6.E.:

For possession incident to the decontamination of too ls, equipment, and other contaminated items.

  • C. Condition 6.F.:

Ninety-liter solid cylindrical polyacrylate matrix containing the following:

Co-57 2.35 E-02 ~LCi Co 2.0 E-01 µCi Sr-85 3.93 E-04 µCi Y~88 7.97 E-03 µCi Cd-109 1.99 µCi SnM 113 2.0 E-02 µCi Cs-137 1.51 E-01 µCi Cc-139 7.0 E-03 ~tCi l-Ig-203 6.4 E-05 µCi Am-241 4.03 E-01 µCi For use as a calibration/reference source.

Page 2of11

NEW YORK STATE DEPARTMENT OF HEALTH RADIOACTIVE MATERIALS UCENSE

3. License Number C3181 Sa. Reference DH l 5-498 b. Amendment No. 2
9. D. Conditions 6.G. and 6.H.:

The licensee is authorized to isolate, retrieve and secure radioactive material from unauthorized locations and to store these temporarily, pending disposal. Such material shall be stored for not longer than 12 months.

E. Conditions 6.1. and 6.J.:

l. The licensee is authorized to service. repair, and perform leak tests on: Campbell Pacific Nuclear MC series. Humboldt Scientific model 5001 series, Instro Tek model 3500 and Troxler models 3411, 3430, 3440, 3450, 3451, and 4640B portable moisture/density gauges which have been manufactured and distributed in accordance with a specific license issued by an Agreement State or the United States Nuclear Regulatory C01runission.
2. No single source may exceed the maximum activity specified for that nuclide in the Sealed Source and Device Registration Certificate for any device in which the source is to be used.
f. Condition 6.K.:

Possession incident to performing site characterization, decontamination, decommissioning and final status surveys at temporary jobsites anywhere within the State of New York, where the Department of Health exercises jurisdiction for regulating the use of radioactive material.

10. A. The Radiation Safety Officer (RSO) for this License is James P. Griffin.

B. Licensed material shall be used by, or under the supervision of, James P. Griffin. by persons with the training and experience described in Condition 14 of the License.

C. For the purpose of use under Condition Number 9.E. Licensed material shall be used by, or under the supervision of, James P. Griffin (Radiation Safety Otlicer), by licensee personnel trained by the device manufacturer or by other persons specifically licensed by an Agreement State or the United States Nuclear Regulatory Commission to conduct such training. The licensee shall maintain a complete and accurate record of the qualifications of ea.ch person permitted to use radiation sources under this license.

11. Except as specifically provided otherwise in this License, the licensee shall conduct its program in accordance with the statements, representation and procedures contained in the documents.

including any enclosures, listed below. The Department's Regulations shall govern. unless the statements, representation and procedures in the licensee's application and correspondence are more restrictive than the Regulations.

Page 3of11

NEW YORK STATE DEPARTMENT OF HEALTH RADIOACTIVE MATERIALS LICENSE

3. License Number C3181 Sa. Reference DH 15-498 b. Amendment No. 2
11. A. License Application dated April 29. 2005, signed by David Dooley, Ph.D., with attachments.

B. Letters dated June 22, 2005 and July 29, 2005. signed by David Dooley, Ph.D., with attachments.

c. Letters dated October l 1, 2007, November 27, 2007, and December 11, 2007, signed by David Dooley, Ph.D., with attachments.

D. Letter dated January 14, 2008, signed by James Griffin.

E. Letter dated Febmary 11, 2008, signed by James Griffin:

F. Letters dated March 14 and 24, 2008. signed by William Schaper, with attachments.

G. License Renewal Request dated July 22. 2008, signed by Moira S. Dooley, President. with attachments.

  • H. License Renewal Request dated June 7, 2011, signed by David Dooley, Ph.D .. with attachment.
12. A. Licensed material authorized under Conditions 6.A. and 6.F. shall be stored and used at the address indicated in Condition 2.

B. Licensed material authorized under Conditions 6.G. throllgh 6.H. shall be stored at the address indicated in Condition 2.

C. Licensed material authorized under Conditions 6.I. and 6.J. may also be used at clients*

temporary job sites and facilities anywhere within the State of New York, where the Department of Health exercises jurisdiction.

D Overnight storage is authorized for licensed materials under Conditions 6.I. and 6.J. and shall be in accordance with statements referenced in Condition 11 herein. providing that such storage may not be in a residence, or in an attached garage except \vithin a vehicle.

Any vehicle used for storage shall be driven only for purposes associated with use or transport of the contained radioactive material, by a person qualified to use the material.

and no passengers shall be carried unless they are also involved in work under this license.

Vehicular storage shall only be allowed if no other storage is possible and shall not exceed five {5) consecutive nights unless authorization to exceed this limit is obtained from the Department.

.E. Under no circumstances shall radioactive material authorized by this*license be transferred to the custody of any person or firm other than the licensee, or be used or stored by another person or firm or its employees~ unless that person or firm possesses a valid license to possess and use such radioactive material.

Page 4of11

NEW YORK STATE DEPARTMENT OF HEALTH RADIOACTIVE MATERIALS LICENSE

3. License Number C3181 Sa. Reference DH 15-498 b. Amendment No . .2
12. F. Materials authorized in Condition 6.K. shall be used at client sites within Nevi' York State where the Ne\Y York State Department of Health or the New York City Department of Health ancl Mental Hygiene exercises jurisdiction for regulating the use of radioactive material. PosscssiQn of authorized material at a client site shall be limited to material originating from the site.
13. Sealed sources containing radioactive materials shall not be opened by the licensee.
14. The licensee shalJ instruct persons before they engage in work under the license, in accordance

\Vrth 10 NYCRR 16.13(c) of Part 16 or 38.27(c) of Code Rule 38. and shall provide annual refresher training. Such instruction shall include the licensee's operating and emergency procedures, and other information contained in documents incorporated in Condition I 1.

15. The licensee shall have available appropriate survey meters tbat shall be maintained operational and shall be calibrated before initial use and at subsequent intervals not exceeding twelve months by a person specifically authorized by tbc U.S. Nudear Regulatory Commission or an Agreement State to perform such services. Records of all calibrations shall be kept a minimum of three years.

A. The licensee shall suhmit to the Department a detailed description ofany proposed changes to the facilities and equipment. described in the license application and supporting documents, before making any such changes. This shall include. but not be limited to.

changes iri use, floor plans. ventilation systems and usage of areas contiguous to areas

\vhere radioactive materials are used and stored.

B. Plans of focilitie.s, which the licensee intends to dedicate to operations involving the use of radioactive material, shall be submitted to the Dcpar1ment for review and approval prior to any such use.

16. The licensee shall submit complete decontamination proct:dutes to the Department for approval ninety (90) days prior to the termination of authorized operation~ involving radioactive material in controlled areas and/or vacating installations pursuant to 12 NYCRR 38, section 38.23.
17. The licensee shall maintain records of information important to safe and effective decommissioning al the address indicated in Condition 2, and al other locations as the licensee chooses. The rc~ords shall be maintained until this license is knninated by the Department and shall include:

A. Records of spills or other unusual occurrences involving the spread of contamination in and around the facility. equipment, or site:

Page 5 of 11

NEW YORK STATE DEPARTMENT OF HEALTH RADIOACTIVE MATERIALS LICENSE

3. License NumberC3181 Sa. Reference DH 15-498 b. Amendment No. 2.
17. B. As-built drawings and modifications of structures and equipment in restricted areas where radioactive materials are used and.Jar stored, and locations of possible inaccessible contamination, such as buried pipes which may be suqject to contamination.
18. The licensee shall submit full information on any proposed changes of ownership. or control of licensed premises, at least 90 days prior to the proposed action.
19. The licensee shall not accept receipt of items for decontamination without a specific written agreement with the originator,.that all residual radioactive contamination, and all radioactive waste generated as a result of decontamination activities, shall remain the property of the originator. who shall also agree to accept its return.
20. The licensee shall conduct, or have conducted, a periodic inventory of al1 devices possessed under this license. Such inventory shall be conducted. at intervals not to exceed six months and shall be documented in a record containing the identity of each device (make. model and serial number).

the radionuclide and activity in the source, its location, whether it is in active use, date of last leak test of the device, and the identity of the person who performed the inventory.

21. The licensee shall submit full information on any proposed changes of ownership or control of licensed premises, at least 90 days prior to the proposed action.
22. In addition to the possession limits in Condition 8, the licensee shall fu11her restrict the possession of licensed material to quantities below the minimum limit specified in Section 38. 7of12 NYC RR 38 for establishing decommissioning financial assurance.
23. A. Personnel who handle radioactive materials shall have at least 40 hours4.62963e-4 days <br />0.0111 hours <br />6.613757e-5 weeks <br />1.522e-5 months <br /> of on-the~job training in the use of those radioactive materials authorized in the License, or shall receive such training at the licensee's facility under the supervision of an authorized user.

B. Alt personnel who perform work under the license. will be instructed in applicable regulations, license conditions, and the licensee's operating and emergency procedures.

C. Records of training received pursuant to paragraphs A and B of this Condition shall be maintained for a period of three (3) years and shall include:

i) the name of the individual who conducted the training:

ii) the name of the individual who received the training; iii) the dates and duration of the training; and iv) a list of topics covered.

Page 6of11

NEW YORK STATE DEPARTMENT OF HEALTH RADIOACTIVE MATERIALS LICENSE

3. License Number C3181 Sa. Reference DH 15-498 b.Amendment No. 2
24. Each portable nuclear gauge shall have a lock or outer locked container designed to prevem unauthorized or accidental removal of the sealed source from its shielded position. The gauge or its container must be locked when in transport storage or when not under the direct surveillance.

of an authorized user.

25. A minimum of two independent physical controls that form tangible barriers shall be used to secure each portable gauge from unauthorized removal, whenever the gauge is not under the control and constant surveillance of an authorized user.
26. (IC-I) In order to ensure the safe handling, use, and control of licensed material iri use and in storage, each licensee shall control access at all times to radioactive mate1ial quantities of concern and devices containing such radioactive material (devices), and limit access to such radioactive material and devices to only approved individuals who require access to perfonn their duties.

A. The licensee shall allow only trustworthy and reliable individuals, approved in \\lliting by the licensee, to have unescorted access to radioactive material quantities of concern and devices. The licensee shall approve for unescorted access only those individuals with job duties that require access to such radioactive material and devices. Personnel who require access to such radioactive material and devices to perfom1 a job duty. but who are not approved by the licensee for unescorted access, must be escorted by an approved individual.

B. For individuals employed by the licensee for three years or' less, and for non-licensee personnel, such as physicians, physicists, housekeeping personnel. and security personnel under contract, trustworthiness and reliability shall be determined, at a minimum, by verifying employment history, education, and personal references. The licensee shall also, to the extent possible;, obtain independent information to corroborate that provided by the employee (i.e., seeking references not supplied by the individual). For individuals employed by the licensee for longer than three years, trustworthiness and reliability shall be determined, at a minimum, by a review of the employee's employment history with the licensee.

C. Service providers shall be escorted unless determined to be trustworthy and reliable by an NRC-required background investigation as an employee of a manufacturing and

  • distribution (M&D) license*e. Written verification attesting to or certifying the person *s trustworthiness and reliability shall be obtained from the manufacturing and distribution licensee providing the service.
  • D. The licensee shall document the basis for concluding that there is reasonable assurance that an individual granted unescorted access is trustworthy and reliable, and does not constitute an unreasonable risk for unauthorized use of radioactive material quantities of concern.

The licensee shall maintain a list of persons approved for tmescorted access to such radioactive material and devices by the J.icensee.

Page 7of11

NEW YORK STATE DEPARTMENT OF HEALTH RADIOACTIVE MATERIALS LICENSE

3. License Number C3181 Sa. Reference DH 15-498 b. Amendment No. 2
27. {IC-2)
  • In order to ensure the safe handling, use, and control of licensed material in use and in storage, each licensee shall have a documented program to monitor and immediately detect, assess.

and respond to unauthorized access to radioactive material quantities of concern and devices.

Enhanced monitoring shall be provided during periods of source delivery or shipment, where the delivery or shipment exceeds 2,700 curies of Cesium 137.

A. The licensee shall respond immediately to any actual or attempted theft, sabotage, or diversion of such radioactive material or of the devices. The response sha11 include requesting assistance from a Local Law Enforcement Agency (LLEA).

B. The licensee shall have a* pre_-arranged plan with LLEA for assistance in response to an actual or attempted theft, sabotage. or diversion of such .radioactive material or of the devices which is consistent in scope and timing with realistic potential vulnerability of the sources containing such radioactive material. The pre-arranged plan shall be updated when changes to the facllity design or operation affect the potential vulnerability of the sources.

Pre-arranged LLEA coordination is not required for temporary jop sites.

C. The licensee shall have a dependable means to transmit information between. and among, the various components used to detect and identify an unauthorized intrusion, to inform the assessor, and to summon the appropriate responder.

D. After initiating appropriate response to any actual or attempted theft, sabotage, or diversion of radioactive material or of the devices, the licensee shall, as promptly as possible, notify the Department at 518-402-7550 during business hours, or the New York State Warning Point at all other times at 518-292-2200.

E. The licensee shall maintain documentation describing each instance of unauthorized access and any necessary corrective actions to prevent future instances of unauthorized access.

28. A. (IC-3) In order 10 ensure the safe handling, use, and control of licensed material in transportation for domestic highway and rail shipments by a carrier other than the licensee, for quantities that equal or exceed 27 curies but are foss than 2, 700 curies of Cesium 137.

per consignment, the licensee shall:

1. Use carriers whicl1:
a. Use package tracking systems,
b. Implement methods to assure trustworthiness and reliability of drivers,
c. Maintain constant control and/or surveillance during transit, and Page 8of11

NEW YORK STATE DEPARTMENT OF HEALTH RADIOACTIVE MATERIALS UCENSE

3. License Number C3181 Sa. Reference DH 15-498 b. Amendment No. 2
28. A. l. d. Have the capability for immediate communication to summon appropriate response or assistance.

The licensee shall verif}' and document that the caiTier employs the measures listed above.

2. Contact the recipient to coordinate the expected arrival time of the shipment;
3. Confim1 receipt of the shipment; and
4. Initiate an investigation to determine the location of the licensed material if the shipment does not arrive on or about the expected arrival time. When, through the course of the investigation, it is detennined the shipment has become lost, stolen, or missing, the licensee shall immediately notify the Department at 518-402-7550 during business hours or the New York State Warning Point at all other times at 518-292-2200. If. after 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of investigating, the location of the material still cannot be determined, the radioactive material shall be deemed missing and the licensee shall immediately notify the Department at 518-402-7550 during business hours or the New York State Warning Point at all* other times at 518-292-2200.

B. For domestic highway and rail shipments, prior to shipping licensed radioactive material that exceeds 2,700 curies of Cesium 137 per consignment. the licensee shall:

1. Notify the NRC (Director, Office ofNuclear Material Safety and Safeguards, U.S.

Nuclear Regulatory Commission, Washington, DC 20555) in \.vriting. at least 90 days prior to the anticipated date of shipment. The NRC will issue the Order to implement the Additional Security Measures (ASMs) for the transportation of Radioactive Material Quantities of Concern (RAM QC). The licensee shall not ship this material untiJ the AS Ms for the transportation of RAM QC are implemented or the licensee is notified otherwise, in Vl-'Titing, by NRC.

2. Once the licensee has implemented the AS Ms for the transportation of RAM QC, the notification requirements of Condition 28.B.1. shall not apply to future shipments oflicensed radioactive material that exceeds 2.700 curies of Cesium 137.

The licensee shall implement the ASMs for the transportation of RAM QC.

C. If a licensee employs an M&D licensee to take possession of the licensed radioactive material and ship it under its M&D license, the requirements of Condition 28.A. and Condition 28.B. above shall not apply.

D. If the licensee is to receive radioactive material greater than or equal to 27 curies of Cesium 13 7 per consignment, the licensee shall coordinate with the originating licensee to:

1. Establish an expected time of delivery: and Page 9of11

NEW YORK STATE DEPARTMENT OF HEALTH RADIOACTIVE MATERIALS LICENSE

3. License Number C3181 Sa. Reference DH 15-498 b. Amendment No. 2.
28. D. 2. Confirm receipt of transferred radioactive material. If the maietial is not received at the expected time of delivery, notify the originating licensee and assist in any investigation.
29. (1CM4) In order to ensure the safe handling, use, and control of licensed material in use and in storage, each licensee that possesses mobile or pol1able devices containing radioactive material in quantities greater than or equal to 27 curies of Cesium 137 shall:

A. For portable devices, have two independent physical controls that fonn tangible barriers to secure the material from unauthorized removal when the device is not under direct control and constant surveillance by the licensee.

B. For mobile devices:

1. That are only moved outside of the facility {e.g., on a trailer), have two independent physical controls that form tangible barriers to secure the material from unauthorized removal when the device is not under direct control and constant surveillance by the licensee. *
2. That are only moved inside a facility, have a physical control that fom1S a tangible barrier to secure the material from unauthorized movement or removal when the device is not under direct control and constant surveillance by the lice11see.

C. For devices in or on a vehicle or trailer, licensees shall also utilize a method to disable the vehicle or trailer when not under direct control and constant surveillance by the licensee.

30. (lC-5) The licensee shall retain documentation required by these increased controls for three years after they are no longer effective:

A. The licensee shall retain documentation regarding the trustworthiness and reliability of individual employees for three years after the individual's employment ends.

B. Each time the llcensee revises the list of approved persons required by Condition. 26.D .. or the documented program required by Condition 27, the licensee shall retain the previous documentation for three years after the revision.

C The licensee shall retain documentation on each radioactive material carrier for three years after the licensee discontinues use of that particular carrier.

D. The licensee shall retain documentation on shipment coordination, notifications, and investigations for three years after the shipment or investigation is completed.

E. After the license is te1111inated or amended to reduce possession limits below the quantities of concern., the licensee shall retain all documentation required by these increased controls for three years.

Page 10of11

NEW YORK STATE DEPARTMENT OF HEALTH RADIOACTIVE MATERIALS LICENSE

3. License Numbe1* C3181 Sa. Reference DH 15-498 b. Amendment No. 2.
31. (IC-6) Detailed information generated by the licensee that describes the physical protection of radioactive material quantities of concern, is sensitive infonnation and shall be protected from unauthorized disclosure.

A. The licensee shaH control access to ils physical protection information to those persons who have an established need to know the infotmation, and are considered to be trustworthy and reliable.

B. The licensee shall develop, maintain and implement policies and procedures for contro.lling access to, and for proper handling and protection against unauthorized disclosure of, its physical protection information for radioactive material covered by these requirement<;.

The policies and procedures shall include the following:

1. General performance requirement that each person who produces, receives, or acquires the licensee's sensitive information, protect the information from unauthorized disclosure,
2. Protection of sensitive information during use, storage. and transit.
3. Preparntion, identification or marking. and transmission.
4. Access controls,
5. Destruction of documents,
6. Use of automatic data processing systems, and
7. Removal from the licensee's sensitive information category.

J2. Radioactive material listed in License Condition 6.B. is subject to National Source Tracking requirements contained in LICENSE ADDENDUM - National Source Tracking Requirements.

dated 11/17/08.

  • FOR THE NEW YORK STATE DEfART!vtENT OF HEALTH Date: AUG 0 5 Z015 By ,L__jc, *_~~*

A-J* / '/:.."' . - -

  • _ _ _ _ __

Daniel J. S msori, CI-IP, Chief DJS/MGH:ks Radioaethe Materials Section Bureau of Environmental Rauiation Protection Page 11 of 11

Sep 25 15 09:42a p:2 NRCFORM241 /, u.s. !iUCLEAR REGULATORY COMMISSION .APPROlfEO BYOMB: NO. 3.1 Gi>-0013 EXPIRES: 111iJ1121>1?'

(11-2o)41

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3. ADDl'!ESS OF LI~E!iSce tr.!a>1"9116d~ o1tther locaUoi> de,.,'.ilceiiseom~y ~ !<><8.'udl . l 243 RootStn:d: #100 James Grifl'in, CHP, RSO Olean, NY 1<1760 Is. ~~;:;;;;;4
  • S. OMcoNuml!f!I' f'ACS!~ ,f*:wr.1e_E!<

116372530 . 16 7163725307 7 S~'t\ILAOC~ESS jgriffin@mjwcorp,com alternate .contact Louis Henry lhenry@mjwcorp.com 7l6 631 &~91'

e. .\Cilllli!ES r.o II!' COtlDUCHD UNOER THE GENSRAl LIC:B>SE GIVEN IN 10 CPR 1!i:).:!O D W::.U. LOGGING 0 LEAKTESTlr-JG ANDi'OR CALIBRATIONS 0 TYPE OF SERVlCE D PORTABLE GAUGES g) orHER )Speci&t -7 eoncduct erivironiltenlRl radiation sirn:.:y.r,

. REGIST~.:a 115 'L'SER OF PACKl\Gll'IG (CERT;r;C/\1es OFCOl<IPLANCE NU"15Efi5)

D ~DIOGR.;PHY

~

9. ct.!a.1' NAM~. ADDRESS, CIT't'icOUNTY, slATE, zn>"cobf. 10. AC"ruAI. PHYSICAL llOORESS OF' .WORK U:X:...TION (Slreot *n4 Nr;m!Jeiiu ollm'loc1ilion: PirNde GPS a:iii..i~ ~ /rrl~.i.J l\'YSERDA :WestVaUcy Site*'

- 10282

.... Rock '-

Springs

. . . Rd. .

West Valley'i\Ty. 14171 as 9030-B, Route 219 w~ll as offoi1e locations ~s des~ribed.inf!,t1achm_cnt 1 West \ljiliey~l'.\"Y 14.17.i 11 . CLlfNT TELEPHONE NUMBER O.ie ..

7169429,960 I ii.o:'* c.;,

71635'.H943*

i:

Ol!fc&

~VORKWCATIOl<ITElEPHO~E 'Ut.IEER none I~*c*~none H. l';UMEIER. OF 17.- l.OCATICN t<>. DATES SCHEDULEiD '<\ORK .DAYS

15. ADO 16. DELETE

~EFERENCE NL°MBER F"'<O.~'. TO *1 v.G:l<E..US NUr.i\J;;R rolie ASSIGNE!i8"NRC l0il2/15 I nno Ill "" o.*c 30 UST ADDITIO<NAL WORK SITES ON SEPARATE SHeET(S) TO INCLUDE ALl!INFORMATIO'N CONTAINED IN ITEMS 1o.~17 ABOVE.

30 Oct/No~-. 3() .rio dBys Sept.

27027

18. uar flAO Ci\CTI\IE !.lllTERIAL, VMCH 'J'~U. !Ill PCSSESSEO. USEO, INSTl.u.EC. SERIJlCED. OR TESTED I O~i~~oiilMSaui~e*

{ln<JIJde ~P~*a o(li;ic .ild11**/llio/or,.,;;....,;;.,, nioiotiot*st:;;.'cd$ou*..,es. DI :1er1die 1o be usod.J ** 11.1cao1~.

E~\'ir6nme~tal sampl~s; TypicaJ\y soil ,~Ith total aciivity'les5 than -.5 nCitgm byptoiliict. material

\p. AGREE.lllBlT STATS SPECIFIC LICENSE WH CHP.lf"l<CRIZSS ;14E UNCEFISIGNEDTO CCNDUCT

,ACTilllTIES, ~*.t;1CH./llllt*iH£SAME. E>:Cl!PT FOR 1.Qc;,;,TION ~ l.13S,'...s SPl?C!PleD It! ITELI 111. ';ieovi;.

1onee0pyMl(let~~~Gcoii1$1lm:isl~yllle.WtfstNRf;JFoi:ri~l.J * * '

  • I Ll:;_ENSf NUMBER C318,I Sl'!\TC

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.I EXPIAA10~ '-'l'E Timely R~i;".1-'al

.:W. CERTlFlc;ATION (MUST BE COl'l!PlETEC BY APPLICANT)

I, THE UND~RSIGNED, HEREBY CERTll'Y '!HAT:

An lnfonnation In ihls mpart is !!'Illa end'c1>mp1'!1e *

b. I NV& t<1ad and ~de.,.&iiod the tM pro111ii1~11 ef g~nera! license 10 C~ .t&0.20 n)Jlllti!ed ail the bti;tnicllons Qfl!ll* io*rnr, <ind I undel3t.!nd fhall mri mq!l~ <<o .cilmpl)t wl~ lllNi~ prcvtsltimi;;.,; tD 'ail b;iprodu~ aoun:e, aT speci~I nu~leai' rriaterlal which I posses.s .itnd u,Q*rn 1>oli-Agm11meot Sl_acila tit cfhs~ wilt~ und.81' !he goooral OctJris& !or which thl6 rep.Drt I.a filed with 'lhe. u. s. Nticloar R&galll!Dry eammls$ion, c.. I und<>mla.1141 that a~ivltiee, lnoludi119 l!)!!>rage, conducied In no.n-Agreemnn_t S!iit..a under g&nernl l~en3e 1Q Ci;l'I 161),211 are *1.lm&d lo Ill tolfi.1 Dlf 180 l!llJS In ca.ler..:iar yoat. With the owceptton ot )'<Dile conductD<f in '!fl'-elioffl water*, willch Is authorlzed fer an 1.ml!mil&d !J'!.riod of limo ln lhll Cl)lelldar:ye~r. *
d. I undnrolen,d that I may bo 1"8pel:ta~ tri HRC ~tit& eboY<ll Dsted -ri. site lccatlonii arid a\ ll'te Ll~en&OO ho ma offiC.,, mtdmos l'or' activ!Uas porfin111ad In non*Asroem*ntStateti orcil'lsha~ wabl'te~ *

... I undliriitand t~t 'comluCt of &ny a'cilvflla& not dllGcribtd abovo, lno1udlng oondu~l af.actlvltles <<1 dat~ or locailona

~boli& mwiflloutNR.C authorization, m.Y subjoct m<> t.o erifOrtinrntirn_actron;incl~dlnlJ civil ore!;lminal P.,nall:ia*.

dilfel"1nt fr'um tbose dascrlbed APl'RQ\15!? av MO OR ~"'"'"'~CM:;.m REPRESeNT...TlVEl?!WM NBIM *"!"Tilio; r~ ~ L* rTE TOTAL USAGE* D.a.1S TO DATE James!> C3!Tf~CHP RSQ

~~

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9-.?r-;s 0

~mG: ~ft.it *~*Drm~bh'ltil1 e.f!ttlf&:::itli may ':'t ~~too clvUt:'i£ta1<rintlnal.~ull~;r.:.~a.1t~ n:~!~ th:.? Wtuni&'ion!I t* tt11 :.i!RC.b.t.c~~ Qn:1~ecurit.11:in11!1tii&1cir.!Qi ,.,.~Id.$~ rei*u..a...e. !!ac:U!M! '1o~r'il!\.a'hct

. ._ l Jr.-. - - c,,.,..,,,..~

.,Crl~ ~Ullll!I ft"llU!J!lll'\l!:~f.llM.U~n\Orl'll!n~~ft~.t~l'lment~~

  • ~) SIGNATURE VC.~'O'JO Url~dBfAtou u
  • llnftMndr'IMt?'lfl,t~~~rb:lal~rt*

~

l°J\TE' lOTAt. ~SAGE,**. o~vs TQ CATE' FORNRC - _ //. J /tJjl/;.e11;" 30 USE ONLY D NON*P~BUC D SENsmvi:_sECURIT~ RELATED: MO J.4 Nor..PabTiea~ llO~MSMl..d

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URC FORI.' 241' i l 1-2014)

Nov091501:14p p.2 NRC FORM 241

('1-2014)

~

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U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 31SD*0013 EXPIRES: 1013112017.

Es~maltd bcrden per res~cru;e lo <Omfly \\il1 tt;. maid2b;y col'edi<r. r~quost: 3~ mi,.tss. This nolii:albn Is roqt.t:rej.so that NRC may 'theduto '0$poctl*in or111c actMios to e11Su1e lhal Hiey ars i:ondudod In accord2!lco wtth 'cquirements for protection of llte publ c hed\jj and salet)'. Ssr.j corrmenls regar~ing burden eslimota to the FOIA. Pri;acy, ar.d ln'crmatipn Cala::llor.; Sraw.:h t.T-S FSJ) L. S. Nucl&ar Regulalor;* Com11lss~n. Washington, DC 20555-0lOI. or by lnl<met **mail to REPORT OF PROPOSED ACTIVITIES IN lnfo:x:ll~c~.ResoJrco@nrc-00v, an<! lo the D..st Olfrc~r. O'!ice of lnb<m~Z!ld Reg~lato')' Affairs NON-AGREEMENT STATES, AREAS OF EXCLUSIVE NEOB-10202, (3'50-0013j, Olfce cl Msil!IJ*rnenl arj Budget, \Vas * <>'\DC 20503. fa me~** ~d 1<l irnpcso ao irlormaticri oclledion doos "ol dlsp'BJ' a currenlly */illid *Jl.lB ccn~ol FEDERAL JURISDICTION, OR OFFSHORE WATERS ~umbet. U,o NRC mll)I no~ conduc\ or sponsor, and a p;rso~ Is nol requfred :c re~Dlld ta. th*

(Please read the instructions before completing this form) !r.forinaUcn c:illa.;o:t

1. NA \IE OF LICENSEE {Per.son or ffrm pmposing (o conrtuct fhe Ediliilies aesciib8:1 below) 2. TYFE Of REPORT MJW Technical Services D INITIAL 0 CHANGE
3. ADJRESS OF LICENSEE (.'.la!l.ng addl1:S.S or offlor loc*fian whcro !/C<:r.*oo may be lxo/cd) 4. LICENSEE CONTACT AND TITLE James Griffin CHP, RSO 243 Root Street #I 00 Olean, NY 1476(} 5. Office Numbc' (716) 372-5300 Is.. ;;~~;;~~~74 r FACSIMl..E t<Ul.1BER (716) 372-5307
7. EMAIL ADDRESS j gri ffin~mjwcorp .com Alternate contact - Louis Henry, lhenry@mjwcorp.com (17 631 &291

!  :' r

6. ACTIVITIES TO 3E COl\DUCTED UNDER THE GENERA-llCENSEGl,'EN IN 10CFR15020 D WELL LOGGING D LEAK TESTING AND/OR CALIBRATIONS 0 TYPE OF SERVICE

[{] ~ Conduct environmi'~tal radia1ion surveys D PORTABLE GAUGES OTHER (Specify)

~EGISiERED AS USER OF PACKAG'NG (CERTIFl'.:ATES ::JF COV.PUANCE NUMBERS!

D RADIOGRAPHY

~ *-

9. CLIENT KAME, All DRESS, crTYICOUl\TI. STATO:, ZI::> CD)E 10. ACTUA~ PHYSICAL ADDRESS Of IM'.lRK LOC<\TION (Streoc and Nurrtber or other loc;ati::Jr. Provfdo GPS coordinates if k.no\Vn,,

West Valley Site - 102&2 Rock Springs Read, West Valley, NY l4Jil as NYSERDA well as off site locations as described in Attachment 1.

9030-B, Route 219 12 ',"\IOFIK LOCA710N TE ..EFHOt;E NUlllBER West Valley, :NY 14171

11. CLIENT TC::LEPHONE NUVIBER 0 I
~6) 942-9960 I~~;~~ 353-1943 Cffir.
e t.1.'llrf<Celr None "None
14. NUMBER OF 17. LOCATION
13. DATES SCHEDULED 15. ADD 16. DELETE WORKDAYS REFERENCE NUMBER FROM TO \l\!:EKEN:JS NUMBER TO BE ASSIGNED BY 'lRC 30 30 Nov./Dec. !3days

~ltJ,;77 11/11/2015 12/12/2015 0 ,."' D *a LIST ADDITIONAL WORK SITES ON SEPARATE SHEET(S) TO INCLUDE ALL INFORMATION CONTAINED IN l1EMS 10-17 ABOVE.

1&. LIST RAC:IOACTIVE MATERiA*., \'1iHICH l'l~LL BE POSS::SSED, \JSED, INSTALLED. SERVICED, OR T:;STED I D1WiceTyp&ISealOO Sourc2S Nol applicable (ltlr:Jutje tte;cdptfon of type a.-,d q11~n~ifyol rsd;°oa~ive ms!eri;:l, se11IFJd sou.rr.e~, crd~ces lo be used.)

I Modelho. Not ~pplicable Envjronment:al samples; typically soil with activity less than -.5 nCilgm byproduct material .,

1e. A'.3REEMENT STATE S.PECIFIC LICENSE 'MilCH AL. THORIZES THE UNDERSIGNED TO CONDUCT ACTIVITIES WHICH AP.ETHE SA!o:E. EXCEPT FO'l LOCATION OF VSE. AS SPECIFIED ;h l7EM 10. ASOVE.

(O.,e ccpy el tr.a $pecl5c lk:ens& must aacornp1my 1.~~ fn~isl NRC Fann 241.)

I LICENSE '.>JLIMBER C3l81 STATE NY

/J1L t..$3o3J1..3 l/fl fEXPIRATION DATE Timely Renewal

20. CERTIFICATION (MUST BE COMPLETED eY APPUcANn I, THE UNDERSIGNED, HER.EBY CERTIFY l'HAT:
a. All i11formatian in this report. is true and complete.
b. l have read and undenitand the provision cf the general licensa 10 CFR I 50.ZC reprinted on the Instructions of this form: and I understand that I am required to complif with these provisions as to all byprod.uet, source, or special nuclear material which I possess and use In non-Agreement Slates or offshore v.aters under the geJleral licmseforwnich this report Is filed with the U.S. Nuclear Regulatory Commission.
c. I understand tllet activities, Including storage, conducted in non*Agreemont States under gen oral l!cen:se 10 CFR 150.~0 are llrnlted lo a tolill of 180 days in calendar year, With the 11xc:eption cl work condue\ad In off-shore waters, which is au1horized for an unllmlte<l period of time in th& calendar year.
d. I understand that I may be lnspe1>ted by NRC at the above listed wor1< site locations and at the Licensee home office address for activities performed In non-Agreement States or offsllcre waters.
e. I understand that conduct of any activities not described above, in~ll.lding conduct of activities on dates 01 location$ diffe1errt frcm tllose described above or without NRC authorization, may subject me to enfon:emont ac:tlcn, lncludlng civil or criminal pE>nallles.

TOTAL USAGE* DAYS -o DATE 5MJ APPROVED 6'1RSO0."l MANAGEMENT REPRESENTATIVE (Prin:ed Name and TiUe) DATE JarnesP. Grifin, CHP, RSO * /L ___...-'

_-cr'J'/ .,.. -- ~-

IN

/lf~/f' 19 WARNl?IG: Fa.ls*sta~cnt:li in thr.:ls IOCl'1ifkz!5.c, may oo sut:Jec.1 to clvlhndlor'Crllrim11P':!natifos;, ~9ultdJDt11 n:quire- tha\$\.ltlm~t: Im- NRC bG- t<llTIJ>lii'.:I,} ond att\ltlde In .a!lmalcri011I ~1pe1;b. ,s U.S.C.. Sedloh 1cn1 maku 1

11 a.crimion.;;i,I ofl'anH la male a \vmt.my tllllwstatallten1 Q.f' n'!p~soentati~11~_:ny d.epoi-Jtrnen\ ar Ola FORNRC

\:>>lS ,.,.. ~*-,...*------ ,~,~}I~~

1' o(tliD Unl~tl St.areso u lo>anvm 1 w:rh!n lt:s:juris<<ldiCfl,

...... 1--o. t?r:~~l~ *, . ~i?

D~TE *~

r1/1 4 t:-G()'

~om USAGE DAYS TC OATE 19 USE ONLY D NON-PUBUC o. SENSITIVE_S';CURITY RELArEc.'Mc 3.~0l>-f'ubllc a.3 A::JAMS M.~

(3J 11/9/I~

NRC FORM 241 (1 "*2014)

p.2 Dec 07 15 09:55a NRCFORM241 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BYOMB: NO. 315D-OD13 EXPIRES: 1013112017 (1Vi014) EslJMale( b<>"den per rasper.., to comply 'lli!h Iii* macdmcry co\'s<:1lcn r~quesc 30 rninulos. Tnis ootlfieat'"' is r~qulrea so tna: NRC mav ""hedu/e irsp*don 011110 aol~lt!es to ensure th.t they.,,,

condtI:ted In accord'""" with requ~emen~ ror prcleclon of the ~ullllc hoallh and safety. Se11d comroo.*ts r<J9..-1lng burdsn (l!;umaie ltJ the FOIA, Pi'/at*f, aoo lnfarrr.~)ion Co:~cfo.1s Branch {T-5 FSlJ, U.S. Nucloar Re;iulatorf Comrr:lsskr\, VfashinglO<l. DC 20!55*0001, or ty ln!Errol e-ill*~ 1)

REPORT OF PROPOSED ACTIVITIES IN l."ioco:lee!S.Rescurce@nrc.go*, aoo lo Ille )&st Olfcar, Olfice or lnlorme!jon <ncl Regulate~ Affair<.

NON-AGREEMENT STATES, AREAS OF EXCLUSIVE NEOS.10202. (3150-0003), Ctr1tHf Ma'legoment *nd 9udi;e~ Wa!hiii'itton, DC 205C3. Ha mears csed tv im>cse an ilfonnaUon 001;,:lkm coos not di*pi!f)' " ct.rrll!11ly val!d 0M9 oco\*ol FEDERAL JURISDICTION, OR OFFSHORE WATERS num~er, Ito NRC may *ol CtJndJcl or sp~nsor and a per*on Is na: reclllred 10 *~sp~nd ID, the (Please read the Instructions before completing this form) 1r1~orma:iQ1 co~ecUMl.

1. NAME OF' Ll::ENSEE (Pe;so* or firm proposing to ccnduct fnc scfiv:Yes closcribed below) 2. TYPE OF REPO'lT MJW Technical Services D INrTIAL 0 CHANGE
3. ADORE.SS OF Lt::Ef\SEE {Malin; nddress 01 ~l'tet Jcc..aJ.i0t1 where litcnsee m9y bs foca!ed) 4. LICElllSEE ::;oNTACT AN071Tc::

James Griffin CHP, RSO 243 Root Street# 100 Olean, 1'.TY 14760 S. Olf.ce NLJm~e1 158. Vhrk :::e11 No'11bor 6 F~.CSIWLE Ni.JMB<:R (716) 372-5300 (716)353-0374 1 (716) 372-5307

7. E:.1AIL ADDRESS jgriffin@mjwcorp.com Alternate contact - Louis Henry, lhenry@mjwcorp.com ,,717 631 8291

! f.

B. ACrlVITIES TC BE CONDUCTED UNDER -HE GENERAL JCEl\SE GIVEN IN 10 CFR 150.20 D WELL LOGGING D LEAK TESTING AND/OR CALIBRATIONS p TYPE OF SERVICE _ _ _ _ _ _ _ _ _ __

~

D PORTABLE GAUGES [{] OTHER (Specify) Conduct environmJntal radiation surveys D RADIOGRAPHY -+ REGISTC:~ED AS USE!'l OF PACKAGING (CERTIFICATES OFC014PLIAU'.:E NUMBERS)

10. kCTUAL FHYSICAl ADDRESS OF V..ORK LOCATION

/Slreer alJC' NIJ'llbGf'O< olhor local/On. Proride GPS ooo.*:Jina!es If known.)

West Valley Site- 10282 Rock Springs Road, West Valley, NY 14171 as 1'-YSERDA well as off site locations as described in Attachment L 9030-B, Route 219 1f. CLIENT TELEPHONE NUMBER , 12 WORK LOCATION iELEPHCNE tlU.\!SER West Valley, :NY 14171 Office J WOii' CeM . Office 114-tlri< Celi (716) 942-9960 I (716) 353-1943 None None 14, NUM3ER OF 17. LOCATION

13. DATES SCHEDULED 15. ADD 1. DELETE WORKDAYS REFERENCE NUMBER LISTAorimONAL WORKSITE.S ON SEPARATESHEET(S) TD INCLUDE ALL INFORMATION CONTAINED IN ITEMS 10-17 ABOVE.

1S. UST RADIOACTJVE MATERIAL, lf"1-11CH '/\'ILL BE POSSESSED, ;JSED, JNSrALLED, S"R'*lCEO, OR TESrED j DeuiceTy~eJSealooSourC<Js Nm applicable (Include <tesr:ripffon or I'/;>~ and quontiry ol raaioacfive rnaleria/, sealed sources, at de*icas hl t.e used.)

I Meda No. Not applicable Environmental samples; typically soil with activity less than -.S nCi/gm byproduct material I

19, AGREEME1'fl STATE SPECIF JC LICENSE li\HICH At, THORIZES THE UNDERSIGNEC* TO CONDUCT LICENSE N\JIJBER STATE IEXPIRATIO.'l DATE ACTIVITIES 'M-!ICH ARE THE SAME, EXCEPT FO.'l LOCATION OF USE. AS SPECIFIED IN 17EM 10. A!lOVE

{O:ie a:;pyof l~e sp~lfc license musi w;ompaoy ti>* /nit/Bl NRC Ferm 241.J C3181 NY j Timely Renewal

20. CERTJFICA.T!ON (MUST BE COMPLETED BY APPLrCANT)

I, THE UNDER51GNEO, HEREBY CERTIFY THAT:

a. At! Information in this report is true and complete.
b. I ha11e read and understand the *prolllsion of the general licen8e 10 CFR 1S0.20 reprinted on the instructions of this form; and I underatand Chat I am required lo comply with these provisions as lo arr byp reduct, &ource, er special nuclear material which I possess and use In non-Agreement States or I offshore waters under the 9ef1eral license forwhich this report is filed with the lJ. S. ~uclear Regulatory Commission.
c. I understand that activities, Including storage, conducted in non*Agreem.,nt States under general ticense 10 CFR 150.20 are limited to a totar of 1BD da,,s in calendar year. With the exception of work conducled In off-Ghorewatcrs, which is authorized for an unllmil.ed perioi:I of time in the calendar year.

d, I underntand that I may be inspected by NRC at the above listed work site locallons and ~t the Licensee home office address for actil1itiM performed In non-Agre1iment Stales or offshore waters.

e. I understand that conduct of any activities not deserJboo abo1te, including conduct of activities on dates ot lo.cations different from those de:.crii:l!XI above or without NRC authorization, m.y subject me to enforcement action, ir>cludlng clvU or criminal penalties.

A?PROVED SY RSO OR MAN.~GE:\'IENT R='P'lESENTATl\/E (Printed Nnm~ a,ij T1Uo) SIG~ ~ It, J/ DATE TOTAL USA3E *DAYS TO DATE JamesP.Grifin,CHP,RSO *~ ~£a__ / ~"fi'* /~/t//;5 40

~t~~~1 t'Cotm~~;e~W'"*! ISIGHAY'~E /? /7 . . ,, o~rE

.Jl..1

./ / rarAI..us ...o::-oAYsrooAre FORMm:' ,-~*"" If'. ( ~ .. t?-/t(ul, Ill USE ONLY ~' * '"'

  • 0 NON-PUBLIC 0 SENSllVE_s::cURINRELATEC,MD3.4Nan-Publica.3 AD...MSMLli ~ 1?f?/ottJ/S NRC FORM 241 (11-2014)

...- - - * - - - - - - - - - - - - - - - - - - - * * - - - ..* - - - -