ML20128M166
| ML20128M166 | |
| Person / Time | |
|---|---|
| Issue date: | 09/16/1996 |
| From: | NRC |
| To: | |
| Shared Package | |
| ML20128M155 | List: |
| References | |
| SSD, NUDOCS 9610160015 | |
| Download: ML20128M166 (4) | |
Text
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I REGISTRY OF RADIOACTIVE SEALED SOURCES AND DEVICES SAFETY EVALUATION OF DEVICE (CORRECTED PAGE 1 - September 16, 1996)
NO.: NR-104-D-101-S DATE: April 28, 1995 PAGE 1 OF 8 DEVICE TYPE:
TransmissionfLine Source Housing",
MODEL:
STEP MANUFACTURER / DISTRIBUTOR:
Picker International (Formerly Ohio Imaging)
Nuclear Medicine Division 595 Minor Road Highland Heights, OH 44143 SEALED SOURCE MODEL DESIGNATION:
Isotope Products Laboratories:
Model 3409 ISOTOPE:
MAXIMUM ACTIVITY:
Cobalt-57 29 mci (1.07 Gbq)
Isotope Product Code HEGL-0021
~
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Gadolinium-153 86 mci ( 3. 2 Gbq)
Isotope Product Code HEGL-0022 Technetium-99m (1) 23 mci (0.85 GBq)
LEAK TEST FRI;OUENCY:
6 Months PRINCIPAL USE: (B) Medical Radiography i
I j
(1) Not a sealed source; user fabricated source at site.
9610160015 960919 PDR RC SSD PDR
PAGE1 NRC FORM 567 l,U,S fUCIAAR RE!OUMIOSYCOMMISSION i/)
14 la b /U ca n) e REQUEST FOR A SEALED SOURCE OR DEVICE EVALUATION INSTRUCTIONS: Send this request AND a copy of all related letters /applicahons and drawings to: The Sealed Source Safety Section, ATTN: Chief, OWFN Mail Stop 6 H3. Change the Ucense Tracidng System rnilestone to 19 and assign to reviewer code B-5.
NOTE: Retain a copy of this request with the application and background files.
WEoVEsTE p g
REGION / LOCATION:
y /MO 4N l1 U ll Ill IV V
HQ U LFDCB TELEPHONE NUMBER DATE TYPE OF ACTION REQUESTED (Check as appropriate)
APPUCANT'S NAME SOURCE REVIEW AMENDMENT OF REGISTRATION SHEET MAIL CONTROL NUMBER (S)
DEVICE REVIEW NUMBER (S) 1
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9 -/C /- d LETTER /APPUCATON DATE UCENSE NUMBER (S)
CUSTOM REVIEW COMMENTS F) i
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hNW gg f.ffQ 0N WW3 FOR SSSS USE ONLY juCA d n
t DATEMECEffED
' UATE ASSIGNED DATE TO FEES TYPE OF ACTION (Indicate the' number of each type)
/
/
l COMMERCIAL DISTRIBUTION (FORMAL) l USE BY A SINGLE APPLICANT (CUSTOM)
SOURCE (9C)
DEVICE (9A)
SOURCE (90)
DEVICE (98)
NEW NEW
~
AMENDMENT AMENDMENT NEW NEW MdIEENDMENT AMENDMENT t,
j NO SAFETY EVALUATION REQUIRED
] LICENSING ACTION REQUIRED IF KNOWN NO NO FEES REQUIRED
] OTHER (Spec #y)
TOTAL NUMBER OF NOTES REVIEW HOURS NUMBER OF DEFICIENCY LETTERS NUMBER OF DEFICIENCY CALLS FOR BILLING PURPOSES ONLY
] NEW REGISTRATION -
] PRODUCT INACTIVE -
NAME CHANGE ADDRESS CHANGE ADD TO BILLING REMOVE FROM BILLING FOR FEE USE ONLY TYPE OF FEE FEE CATEGORY
~
k'Mby9 9A 9B 9C U 9D
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CMOUNT RECEIVED v '
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CHECM NUMBER MATANN UPDATED f \\ A _ g(@
hi
~ AS REQUIRED
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$ pg
] MATSYS UPDATED DATE OF CHECK LOD e l r, [ _,
c AS REQUIRED
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DATE RETUR4 DATE mt i
NRr.eORM r,ar esa M!N N w
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PAGE1 NRC FORM 567
,, U, S. NUCLEAR REGULATORY COMMISSION j
J pos) i REQUEST FOR A SEALED SOURCE OR DEVICE EVALUATION INSTRUCTIONS: Send this request AND a copy of all related letters / applications and drawings to: The Sealed Source Safety Sectxm, ATTN: Chief, j
OWFN Mall Stop 6 H3. Change the License Tracking System milestone to 19 and assign to reviewer code I-5.
NOTE: Retain a copy of this request with the application and background files.
r g
REGION / LOCATION:
1 REQUESTE 7/g M* _
/fMd
]I ll U lil IV V U HQ U LFDCB TELEPHONE NUMBER DATE TYPE OF ACTION REQUESTED (Check as appropriate)
APPLCANT'S NAME SOURCE REVIEW AMENDMENT OF j
REGISTRATION SHEET I)
MAIL CONTROL NUMBENS)
DEVICE 'tEVIEW o
LETTER /APPLCATION DATE LCENSE NUMBER (S)
CUSTOM REVIEW
~
) 40 /~d I
COMMENTS f
h M..,s Nf
/
FOR SSSS USE ONLY 5
/ a 7
M R NUMBERS NUMBER ASSIGN k
j gp L
DATERECEIVED /
DATE AS$1GNED DATE TO FEES
/
$b lY9N Yh2f$b I
TYPE OF ACTION (Indicate theinumber of each type)
/
/
I l COMMERCIAL DISTRIBUTION (FORMAL) l USE BY A SINGLE APPLICANT (CUSTOM)
SOURCE (9C)
DEVICE (9A)
SOURCE (9D)
DEVICE (98)
NEW NEW NEW NEW dENDMENT
] AMENDMENT
] AMENDMENT
{
AMENDMENT y
j NO SAFETY EVALUATION REQUIRED j LICENSING ACTION REQUIRED IF KNOWN NO f
NO FEES REQUIRED
) OTHER (Specsty)
~
TOTAL NUMBER OF NOTES REVIEW HOURS NUMBER OF DEFICIENCY LETTERS NUMBER OF DEFICIENCY CALLS i
FOR BILLING PURPOSES ONLY NAME CHANGE ADDRESS CHAN'GE
] NEW REGISTRATION -
] PRODUCT INACTIVE -
ADD TO BILLING REMOVE FROM BILLING FOR FEE USE ONLY t
s TYPE OF FEE FEE CATEGORY
~
U 90 f
( fM.- b9 9A
' U 9B 9C
~
AMoVNT RECElvED hf]
- AS REQUIRED V'
CHECK NUMBER MATANN UPDATED f
k(
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7 DATE OF CHECK
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/.5 h,pg
] MATSYS UPDATED r
/3 1CM-J/
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AS REQUIRED DQ+,, cHy5 K EfATERETURM7/W,/ e6 APPROvg m DATE 7
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i i
h NRC FORM $67 (6-93) k.
OfuGMATOftS COPY
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NUCLEAR REGULATORY COMMISSION FY 96 Annual Materials Fee Invoice Period 10/1/1995 - 9/30/1996 10 CFR 171.16 Invoice Date License Anniversary Month Invoice Number
==
=============
==
06/11/1996 April AM3193-96 g/
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PICKER - 2;;IC I M ^. C I N C-l20 C L c}* l-N W 0* #
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l ATTENTION:
RADIATION SAFETY OFFICER h
f30'O MTirc unan S 9 7 /19 A, efa.
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Mark THIS COPY with any billing address changes License / Approval /
Registration /
Code Annual Fee Certificate Number AA905 Category (s)
Fee Amount
======
=
=
===
NR0104D101S ANN 9A 6,700.00 TOTAL:
6,700.00 TOTAL INVOICE:
6,700.00 Make Checks Payable To:
===========
U.S.
Nuclear Regulatory Commission
<=== This PO Box address is License Fee & Accounts Receivable Branch
<=== for receipt of payments 1
F' O Box 954514
<=== only.
St. Louis, MO 63195-4514 For terms and conditions see attached.
Questions:
call 301/415-7554.
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W W
PA YME N T C0 PY
- MM**%%%%%*MM%%%%%*%*K*%%%K%%%%M
> To ensure accurate credit, return this copy of the <
===> invoice with your payment.
Processing may be
<===
===> delayed if the invoice is not included.
<===
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