ML20134G774

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Forwards Rept of Proposed Activities in Agreement States. NRC Has Granted Recognition of Agreement State License for Activities to Be Performed within State Boundaries
ML20134G774
Person / Time
Issue date: 01/10/1997
From: Dan Collins
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To: Ball J, Bruchmann G, Dornsife W, Foldesi L, Lipoti J, Mccarthy K, Keith Miller, Nauth D, Owen R
CONNECTICUT, STATE OF, INDIANA, STATE OF, MICHIGAN, STATE OF, MINNESOTA, STATE OF, MISSOURI, STATE OF, NEW JERSEY, STATE OF, OHIO, STATE OF, OKLAHOMA, STATE OF, PENNSYLVANIA, COMMONWEALTH OF, VIRGINIA, COMMONWEALTH OF
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ML20134G305 List:
References
NUDOCS 9702110031
Download: ML20134G774 (22)
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Text

.

January 10, 1997 t State'of Minnesota Section of Radiation Control  :

ATTN: Ms. Judith A. Ball 1 Manager Division of Environmental Health Minnesota Department of Health 121 East Seventh Place. Suite 220 Minneapolis, Minnesota 55164-0975 l

SUBJECT:

NOTIFICATION OF RECIPROCITY RECOGNITION - CALENDAR YEAR 1997 Gentlemen:

The enclosures to this letter are a Report of Proposed Activities in Non-Agreement States (NRC Form 241) and an Agreement State License. This notice is provided to you as a courtesy.

This office has granted recognition of an Agreement State license for activities to be performed within your boundaries. This recognition is authorized under Title 10, Code of Federal Regulations. Part 150, Section 20 (10 CFR 150.20). We have reviewed this license. The license is valid for the activities and devices described and for the time frame requested. The license does not limit the licensee to a particular location.

Further notifications of activities by this licensee within your boundaries may be made. We shall notify you should this happen. Should you have any questions concerning this matter, please call me at (404) 331-5624. Our fax numbers are-(404) 331-7437/5559.

Sincerely, David J. Collins Materials Licensing / Inspection Branch 2 Division of Nuclear Materials Safety 1

Enclosures:

1. NRC Form 241 - Elekta Instruments Inc.
2. Agreement State License - Georgia GA.1153-1  ;

I l

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l January 10, 1997 -

State of Ohio I Bureau of Radiological Health  :

ATTN: Mr. Robert E. Owen Chief Department of Health 5um , io 43266-0118

SUBJECT:

NOTIFICATION OF RECIPROCITY RECOGNITION - CALENDAR YEAR 1997 {

Gentlemen:

l The enclosures to this letter are a Report of Proposed Activities in Non- h Agreement States (NRC Form 241) and an Agreement State License. This notice  ;

is provided to you as a courtesy.  !

This' office has granted recognition of an Agreement State license for i activities to be performed within your boundaries. This recognition is .

authorized under Title 10. Code of Federal Regulations. Part 150. Section 20 (10 CFR 150.20). We have reviewed this license. The license is valid for the -

activities and devices described and for the time frame requested. The  :

license does not limit the licensee to a particular location, j Further notifications of activities by this licensee within your boundaries 1 may be made. We shall notify you should this happen. Should you have any L questions concerning this matter, please call me at (404) 331-5624. Our fax l numbers are (404) 331-7437/5559.

Sincerely.

M  !

F David J. Collins

! Materials Licensing / Inspection Branch 2  !

Division of Nuclear Materials Safety i Enclosures-

1. NRC Form 241 - Elekta Instruments. Inc. i
2. Agreement State License - Georgia GA.1153-1  !

i l

i January 10. 1997 i State of Missouri Bureau of Radiological Health ATTN: Mr. Kenneth V. Miller Chief .!

P.O. Box 570  !

Jefferson City. Missouri 65102 l

SUBJECT:

NOTIFICATION OF RECIPROCITY RECOGNITION - CALENDAR YEAR 1997 i Gentlemen:  :

1 The enclosures to this letter are a Report of Proposed Activities in Non-Agreement States (NRC Form 241) and an Agreement State License. This notice is provided to you as a courtesy.

This office has granted recognition of an Agreement State license for 1 activities to be performed within your boundaries. This recognition is '

. authorized under Title 10. Code of Federal Regulations. Part 150. Section 20 (10 CFR 150.20). We have reviewed this license. The license is valid for the activities and devices described and for the time frame requested. The license does not limit the licensee to a particular location.

Further notifications of activities by this licensee within your boundaries may be made. We shall notify you should this happen. Should you have any questions concerning this matter please call me at (404) 331-5624. Our fax numbers are (404) 331-7437/5559.

Sincerely.

I N  !

David J. Collins i Materials Licensing / Inspection Branch 2 )

Division of Nuclear Materials Safety j l

Enclosures:

1. NRC Form 241 - I
2. Agreement State License - '

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l-l January 10. 1997 State of Pennsylvania Bureau of Radiation Protection ATTN: Mr. William P. Dornsife Director Department of Environmental Resources P.O. Box 8469 Harrisburg. Pennsylvania 17105-8469

SUBJECT:

NOTIFICATION OF RECIPROCITY RECOGNITION - CALENDAR YEAR 1997 Gentlemen: ,

The enclosures to this letter are a Report of Proposed Activities in Non-Agreement States (NRC Form 241) and an Agreement State License. This notice is provided to you as a courtesy.

This office has granted recognition of an Agreement State license for activities to be performed within your boundaries. This recognition is authorized under Title 10. Code of Federal Regulations. Part 150. Section 20 (10 CFR 150.20). We have reviewed this license. The license is valid for the activities and devices described and for the time frame requested. The license does not limit the licensee to a particular location.

Further notifications of activities by this licensee within your boundaries may be made. We shall notify you should this happen. Should you have any questions concerning this matter please call me at (404) 331-5624. Our fax numbers are (404) 331-7437/5559.

Sincerely.

M David J. Collins Materials Licensing / Inspection Branch 2 Division of Nuclear Materials Safety

Enclosures:

1. NRC Form 241 - Elekta Instruments, Inc.
2. Agreement State License - Georgia GA.1153-1 1

i

i. .

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l January 10, 1997 ,

' State of. Michigan Division of Radiological Health ATTN: Mr. George W. Bruchmann Chief Bureau of Environment and <

r Occupational Health l

Department of Public Health P.O. Box 30195 Lansing, Michigan 48909

SUBJECT:

NOTIFICATION OF RECIPROCITY RECOGNITION - CALENDAR YEAR 1997 Gentlemen:

The enclosures to this letter are a Report of Proposed Acttvities in Non-Agreement States (NRC Form 241) and an Agreement State License. This notice is provided to you as a courtesy.  ;

This office has granted recognition of an Agreement State license for activities to be performed within your boundaries. This recognition is 1 authorized under Title 10 Code of Federal Regulations, Part 150 Section 20 (10 CFR 150.20). We have reviewed this license. The license is valid for the activities and devices described and for the time frame requested. The license does not limit the licensee to a particular location.

Further notificatiors of activities by this licensee within your boundaries may be made. We shall notify you should this happen. Should you have any questions concerning this matter, please call me at (404) 331-5624. Our fax numbers are (404) 331-7437/5559.

Sincerely, David J. Collins Materials Licensing / Inspection Branch 2 Division of Nuclear Materials Safety

Enclosures:

1. NRC Form 241 - Elekta Instruments Inc.
2. Agreement State License - Georgia GA.1153-1

r l

January 10, 1997 State of Indiana 4

Radiological Health Section ATTN: Mr. David Nauth, Chief

State Board of Health

~

P.O. Box 1964 Indianapolis Indiana 46206

SUBJECT:

NOTIFICATION OF RECIPROCITY RECOGNITION - CALENDAR YEAR 1997

! Gentlemen:

1 The enclosures to this letter are a Report of Proposed Activities in Non- ,

Agreement States (NRC Form 241) and an Agreement State License. This notice

is provided to you as a courtesy.

This office has granted recognition of an Agreement State license for

{ activities to be performed within your boundaries. This recognition is '

, authorized under Title 10, Code of Federal Regulations. Part 150. Section 20

~

(10 CFR 150.20). We have reviewed this license. The license is valid for the activities and devices described and for the time frame requested. The-  !

license does not limit the licensee to a particular location.

1 Further notifications of activities by this licensee within your boundaries may be made. We shall notify you should this happen. Should you have any questions concerning this matter, please call me at (404) 331-5624. Our fax l numbers are (404) 331-7437/5559.

Sincerely, M l David J. Collins Materials Licensing / Inspection Branch 2 Division of Nuclear Materials Safety

Enclosures:

1. NRC Form 241 - Elekta Instruments. Inc.
2. Agreement State License - Georgia GA.1153-1

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l January 10. 1997 i

! State of Connecticut 4

Radiation Control Division -

i ATTN: Mr. Kevin T. A. McCarthy 1 Director Department of Environmental Protection 165 Capitol Avenue Hartford. Connecticut 06106

)

SUBJECT:

NOTIFICATION OF RECIPROCITY RECOGNITION - CALENDAR YEAR-1997 i

Gentlemen:

1 The enclosures to this letter are a Report of Proposed Activities in Non-

Agreement States (NRC Form 241) and an Agreement State License. This notice
is provided to you as a courtesy.

, - This office has granted recogaition of an Agreement State license for 4

activities to be performed within your boundaries. This recognition is

authorized under Title 10. Code of Federal Regulations. Part 150. Section 20 (10 CFR 150.20). We have reviewed this license. The license is valid for the
activities and devices described and for the time frame requested. The license does not limit the licensee to a particular location.
Further notifications of activities by this licensee within your boundaries may be made. We shall notify you should this happen. Should you have any
questions concerning this matter, please call me at (404) 331-5624. Our fax l

! numbers are (404) 331-7437/5559. j 1

Sincerely.

i David J. Collins i

Materials Licensing / Inspection Branch 2 l Division of Nuclear Materials Safety l 4

Enclosures:

1. NRC Form 241 - Elekta Instruments. Inc.  !

i 2. Agreement State License - Georgia GA.1153-1 I

I i

i 9 'A .e--- w - --

i I

January 10, 1997 l State of New Jersey l Division of Environmental Quality l ATTN: Jill Lipoti. Ph.D.

l Assistant Director for l Radiation Protection Programs l Department of Environmental Protection and Energy l 729 Alexander Road i

l Princeton, New Jersey 08540

SUBJECT:

NOTIFICATION OF RECIPROCITY RECOGNITION - CALENDAR YEAR 1997 l Gentlemen:

1

The enclosures to this letter are a Report of Proposed Activities in Non-l Agreement States (NRC Form 241) and an Agreement State License. This notice is provided to you as a courtesy.

This office has granted recognition of an Agreement State license for activities to be performed within your boundaries. This recognition is authorized under Title 10. Code of Federal Regulations. Part 150. Section 20 (10 CFR 150.20). We have reviewed this license. The license is valid for the activities and devices described and for the time frame requested. The license does not limit the licensee to a particular location.

l Further notifications of activities by this licensee within your boundaries  !

may be made. We shall notify you should this happen. Should you have any questions concerning this matter, please call me at (404) 331-5624. Our fax numbers are (404) 331-7437/5559.

Sincerely.

4 David J. Collins Materials Licensing / Inspection Branch 2 Division of Nuclear Materials Safety

Enclosures:

1. NRC Form 241 - Elekta Instruments. Inc.
2. Agreement State License - Georgia GA.1153-1

January 10, 1997 l State of Oklahoma  !

Radiation Protection Division  ;

. ATTN: Director l Consumer Protection Service l State Department of Health  ;

1000 N.E. 10th Street  :

Oklahoma City. Oklahoma 73117-1299  :

i  :

r

SUBJECT:

NOTIFICATION OF RECIPROCITY RECOGNITION - CALENDAR YEAR 1997

]

Gentlemen:

The enclosures to this letter are a Report of Proposed Activities in Non-Agreement States (NRC Form 241) and an Agreement State License. This notice

! is provided to you as a courtesy.

l This office has granted recognition of an Agreement State license for activities to be performed within your boundaries. This recognition is authorized under Title 10 Code of Federal Regulations. Part 150, Section 20 (10 CFR 150.20). We have reviewed this license. The license is valid for the

! activities and devices described and for the time frame requested. The l license does not limit the licensee to a particular location.

Further notifications of activities by this licensee within your boundaries may be made. We shall notify you should this happen. Should you have any questions concerning this matter, please call me at (404) 331-5624. Our fax numbers are (404) 331-7437/5559.

! Sincerely.

l l

David J. Collins Materials Licensing / Inspection Branch 2 Division of Nuclear Materials Safety l

Enclosures:

l

1. NRC Form 241 - Elekta Instruments. Inc.
2. Agreement State License - Georgia GA.1153-1 l o

4 l

I

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January 10. 1997 l Commonwealth of Virginia I l Bureau of Radiological Health

! ATTN: Mr. Leslie P. Foldesi Director Division of Health Hazards Control Department of Health Main Street Station ,

, 1500 East Main Room 104A Richmond. Virginia 23219

SUBJECT:

NOTIFICATION OF RECIPROCITY RECOGNITION - CALENDAR YEAR 1997 Gentlemen:

The enclosures to this letter are a Report of Proposed Activities in Non- l Agreement States (NRC Form 241) and an Agreement State License. This notice l is provided to you as a courtesy. '

l

This office has granted recognition of an Agreement State license for activities to be performed within your boundaries. This recognition is authorized under Title 10. Code of Federal Regulations. Part 150. Section 20 (10 CFR 150.20). We have reviewed this license. The license is valid for the activities and devices described and for the time frame requested. The license does not limit the licensee to a particular location. I Further notifications of activities by this licensee within your bocndaries may be made. We shall notify you should this happen. Should you have any questions concerning this matter, please call me at (404) 331-5624. Our fax numbers are (404) 331-7437/5559.

Sincerely.

M

, David J. Collins "aterials Licensing / Inspection Branch 2 Division of Nuclear Materials Safety

Enclosures:

i

1. NRC Form 241 - Elekta Instruments. Inc.
2. Agreement State License - Georgia GA.1153-1 I

I l

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19. CLRTIFICAT10N (MUST BE CCMPLETED BY APPLICANT)
1. THE UNDERSIGNED. HEREBY CERT.FY THAT:
a. Alllefo nation in this report Fs true and cor'tolete,
b. d Itohave complyreadvamand t%eseunderstond thetoprossiori per.'sions as of the all tryere'A.ct, sour:egeneral 16 cense er special nuc'est10 CFR 1SC metenal mA,ch20 reprinted

! pe. e a and 0,i u.e the cere.r s. heelClates in me+Ag,eneenat of Itusorform set;wn!ars edehore and I tederstand it s u'U$er lie gene'al license for whict this report is filed unth the U.S. Nucient Regulatory CcmrNssion.

c. I underf.end it'at act% tics, includhg s'orspo. oondu;f.ed in non-Agreements States under geners' licento 10 CFR 150l0 prs lirmited to e tetal of 120 days in ca endar veer,
d. I unoerstand that i rney be irspecied ty NRC at the ebeve l'sted i werft sJie locations and si the Licensee horre crice nedress for actvitics performed in non-AgrcomeM States of offshore waters ! em also eware that I will be rnponsible for ery fees assoc.ated with sue? IPspec!!oes.
e. I uncerrtand that conduct of att activitics 90t doscfitod above,includrng coeduct of ectmlies or, dates or toes'ior's dtrerert from those desenbad staove er l l without NRC sathontatica, fr.sy subject me to enforcement acuan. includmg civil or c'imiPal panailros.  !

l ChaTiP.NO CU ;ER dso e, weaage*mt mapa eist e preva,emass #vres ens T*.i 6 G s AL+ E Ca M MARTIN WOTTS/DIR OF TECHNICAL SERVICE WARNWG; PALSE STATE'WlENTS IN THIS CERTiPICATE WY BE $US.!ECT TO CIV',L AND/OR CR!M;NAL FENALTIES. NR* RE*,ULATICNS REQUIRE TMAT

$USME$10NS TO THE NRC RE COMi>LETE AND A0 CURATE IN ALL WTER:AL RESPECTS.15 U.S C. SECTICN 1001 MAVES :T A CRMINAL O'FENSE TO MAKE A W:LLFULLY PALSE STATEYENT OR REPRESEtiTATION TO ANY DEFARTMENT CR AGENCY Or TNE UNITED STATES AS TO ANY MAT ~ER WITHIN iT3 JUM13DICTICN FOR NRC *"""^**""~"**'"*"*'"' - I *** ^*

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19. CERT 1Fl CATION (MUST BE CCMPLETED B Y APs'UCANT) t, THE UNDER$lCNED. MEREBY CERT;FY TMAT:
e. AllInfo rraccet in this report ;s true and complete,
b. 1 have read and understand tne provision of the generallicense 10 CFR 150 20 repnmes on Ite cover cheet of inis to m sat and i 6acerntand trat I am reituired to comply wdh these prov sions es to all bypredi,cl soweto, or sessiel musloor meloeist which I possess ord use in non Agreement Stolos or of'r.here w:sters under the peeral license for which this report is filed with the U.S. Nuclear Regulatory Cemmes.on.
c. I understnad that activiles. Includng storage, conducted in nor>. Agree r en's States under general license 10 CFR '5010 are litrited to e total cf 120 days
  • calender year.
d. I 6nderstand that I rnay be inspoeted by NRC et the above listed warti site locahons and at t*'e Uconsee beme off;ce address for ac5vities performed .n non Agreeerent Steles or offshore vueiers. I am siso evenre that I will be responsibio far any fees ess.ocated with sach inspecions.
p. l 6ndersiend that co'sdud af any activlhes not described above including concwet of activities on dates or locat;orm dif'erc91 frcen IWo detcrted al>ove or wi'.hout NRC authontailen. may subject me to enforcemeit ecleon. ;ncludmg crvil or cntmest peesit es.

CEM[f TNS DNER e R$) of Wn.peett R.pTeeer& Lee fyM6hnWO ,WFPe one TM SiUNA IbN 6 08t r g MARTIN IWOI'TS/DIR OF TECHNICAL SERVICE WARNING: FALSC STATEMENTS IN TMIS CERTIFICATE MAY B! SLBJCCT TC CIVit. ANDIQR CRIMINAL PENALTit3. NRC REGULATICNS REQUIRE TNAT SUBMISS 13NS TO THE NRC $$ COMPLETE AND ACCURATE IN ALL MATERIAL REE8CCTS.18 U 5.C. SECT lCN 1001 MAKE5 IT A CRWilNAL OFFMSE TO MAKE A WILLFVLLY FAL!E STATEMENT OR REPRESENTATICN TO ANY DEPARTMENT CR AGENCY OF THE UNITED STATES AS TO At# MATTER WITHIN its orUmspictioN. __

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.m , nunsen pe teneones n .. ,s. ,e t.o compry we..th1 maridate nye,site e anon o caa m me

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e e._s ie e e e, - cue a, e 1 NAME OP UOMI,Et (Pereed er rem Fomenf 2 80nduet Po stM*s eesoaam sammy ai CONTRQ6 NUMBER

2. TYPE OF REPORT (Leave Blank - NJr9CefIo DQ ELEKTA INSTRUMENTS, INCe _

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  1. EVLtCN d ADQ4ES$ CP WCEN6E2 (Meeng gegrave y emeNeca,en weare decenses may be scento) CLAR1PICATION 8 EXECUTIVE PARK WEST ATLANTA, GA 30329 MARTIN IOMTS e rss ic~a mout i uca. w sa o~ase Are. cses v uae A e c-e>

404-315-1225 404-315-7850

8. ACTIVITIES TO BE CONDUCTED IN NON AGREEMENT STATES UNDER THE GENERAL UCENSE GIVEN IN 10 CFR 15MO WELL LOCalNG LEAK TESTING ANC/CR CAJBRATIONS TELE &ERAFftA9ACATCR SERVCE

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14. DATES SCHEDULED 8 l 16. LOCAT'CN REFERENCE NUMBER seam to LEAa a ras < F;a e.LAi, W Fca m nEacM5 NU8vl6f A T3 $$ A$$CN&2 SY N8tC Eni Nov. Foal tec- TwD ooo i 39 l

s I l Y dPI C. ( ' @7 LIST ADDITIONAL WORK sf7Es oN SEPARATE SNEET TO INCLUDE ALL INFCRMATION CCNTAINED IN ITEMS 818 ABOVE.

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19. CERT 1FtCATION FMUGT BE COMPLETED BY APPLICANT)

I, THE UNTJEROGNED. rte 8tESY CE4 TTY THAT:

a. M infcrmation in this toport is true and ccmplete,
b. I have read and unders'e9d its prov6sion of the Somcral ficense 10 CP*R 1$0 20 reprinted on the covet shcel of the fort, set; and i unde st.md ther I am reawred to cofrply wMi these provisione es le 38 byproduct, source, or specisi nucieer rnelens! WNch I possess med 6se in non. Agreement States or offshore wole's under lhe general license for which this report is filed with the U.S. Nuclear Pegalatwy Comrn ssici,
c. I L nderstand thel sedvitics. includeg storage, condscled in non4greements States under General lic.ense 10 CPR 150 20 are lirnited to e tomi of 950 days in celender yriar.
d. I understued that I rney be inspected by NRC at the esovo listed work slie bcut ons and et the Usonsco tomo off.ca address for activitics performed in tscn-Agresnont States or offsioro wetem. I am s!se swore that I will be responsible for any fees assoc sted with sucli inspr>chens.
e. I undoestand that conduct of any activities not desc9Dec above. Includvig conduct of acbvities on dates or iccabors dSerent frcm tho$e descrite$ above or withot NRC ethonzelion, may s6bject me to enforcernernt action,Inclading crvi or cr!%nal peail;es, geMenNG 0socgs.mtc or ver.g ,,em mep.esemarve f rypen%ied home ane Leiej S. GNAT M D.6 f 6 MARTIN DCITS/DIR OF TECHNICAL SERVICE -

WARNING; PALSE STATEMENTC W THIS CERTFICATE MAY EiE SUBJECT TO CJVfL AND/CR CRIMINAL DENALTiES NRC REGULATICNS REculM T IAT SLtBAeSSIONS TO THE NRC RE coupLETE AND ACCLRATE IN A1.1. MATERIAL RESPECTS. 18 U S.C. SECTICH C01 MAirFS 17 A CRMWAL CFFENSE TO MAKE A wtLU'ULLY FALSE STATEVENT OR REPRESENTATION TO ANY CEPARTMENT CR AGENCY Cr THE UNITED STATES AS TO ANY MATTER WITMN ITS JUMISDiCTION.

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NRC FORM 241 U. S. NUCLEAR k E2VLATORY COMM!sstON APPut3VEB .y own no H8(,. cot 4 t>1 riandat0'y mf0 CA.%&s. trion.s (m e89fnema..Durde.n

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  • con *c+o" et caom'ano" 6aie n aiu en e s.e-wmi.e Cve cerm 1 Nave ce esce e e .,rmisme,as = ewwe me eerw ee.-ess **'*** 2. TYPE OF REPCRT 3. cCNTR06 $bMBE R (Leon Bienk - twmber to be EIEKTA INSTRLVINTS, ItC. _

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REVISCN 4 AucMuis op ucunska (u.mt esamse .r eineriscerton eaere usecess t'isy se escesse) CLARIP1 CAT 10N 8 EXECUTIVE PARK WEST ATIANTA, GA 30329 M N KNO'NS e rE,EPPCNE N6MlbE3L pnewee Am cans) 1, ,1nciuse

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_ __ 404-315-1225 404-315-7850 8 ACTMTIES TO BE CONDUCTED IN NON-AGREEMENT STATE 5 UNDER THE GENERAL UCbSE GIVEN !N 10 CFR 150.20 WELL LOC 0iNC LEAK TESTING AND/OR CAUBRATIONS *gLgTHgRApyjj,stAD.Atcp, gggyeg PCRTABLE GAUGES nAss>OgtAr.cN cA PRCQRW APPROVAL.NO. & REY. NO AEG.STeAI3 45 LSEA D# P ACVG,NC3 (OMPdATES OF CCWuANCE NCS )

O CLDT NAME, AOCAES1 Ce*'r/CCWNTY, QTA*E ZIP CODE 10. WOltK LOCATCN ADCRES$ (freef artir NJites er er elfter Joiaf,ed G.ve es e - e e n ,w - s,, n s>

RESEARCH MEDICAL CENTER 2316 E. MEYER BLVD.

KANSAS CITY, NO 64132 raEeNcre mousEA 11 wcw Location ?E MNcAN Aumcatm To PERFemu weitic 13 WC mcLAliUN TEJP4NE NMf 7t ~

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14. DATES SCHEDULED 16. LCCATICN REFERENCE NUMEER FROW Ta RAvf R ANil k;.4 M.AL Ni<G QM 2di nsM.,TD WMBEA TO SE AssCNED Ov NRC Feb (-tw6) Feb CTB$) l om * (

h 6 3 I AY ' CC @d UST ADDm0NAl. WORK SITES ON SEPARATE SHEET TO INCLUDE ALL INFORM ATION CCNTAINED W ITEMS 916 ADOVC. _

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  • 0. AGdEEMENT eiTA'E &PEC4,C UGbseis WMice= A,/?MOAtr.Es THE wNGemelGNda TO CCCwCT AChvi! ss WniGm AAs ?p4 sAME bcskT FCA 6.OCaT ON C8Wst, A3

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19. CERTIFICATlCN (MUST BE CCVPLETED BY APPUCANT)
1. THE UNDERSIGNED HER15Y CERTW THAT:

a, AllInfo mal.on in itiis report is true end complete.

b. I have read and understand tre provision of the goncret ficense 10 CPR 15020 reprinted on the cover secet of ths fo'm sot: and 1 unde strar d tnet I am required to compiy with tese areW4 eae os to all hyprocuet, naures, or openial nucieer meierial whleh I postees and una in nen.Agreament S'ates or offshore wetors under me general license for which this report is filed with the U,$. Nuclear Regulatoy Comm ssion. I l

g, I undersland that sciivitics, in:lvfing e'erego, conducted irt nonJpsewnts Sates under General itceese 13 CM 15020 are firsted to a lots: of '60 toys in cwenderyear. l

d. I understand that I may tie inspecled by NRC at the above listed work site local: ens and at the Licenses hor-e office address fer activities performed in i nonJpoornent States or offshcro wetors. I am alee owere met I will be responsete for any fees assoc stad w,tn euc'i inspecisons.  ;
e. I uncerssend the'. cimduct or any activities not 6eceribed abcNe, haludlng conduct or activtiiss on daies or locallons dil'arent 'rorn troso descritusd ubove or wtmobt NRC au:ho t:ation, may subjec: me to er forcement e@cn, including civH or enminal penalties, cv.'iFilNG OFsCfA - RSO or verageai.ni Reemenebre (JypooAmruo A.mo eaa Tve/ 6.GNAME Gait FARTIN CGTS/DIR OF TEGNICAL SERVICE VvARNING. FAL&! STATEMENTS lN Tet!S CERTLPICATE MAY BE SUBJECT TO C!Vil AND/CR CRMINAL FENALilES. NRC REGULATICNS pEculRE THAT SUphaSSCNs TO THE N#C BE COMPLETE AND ACCURATE IN Alt. MATERIAL RESPFCTS 18 U S C. SECTION '301 MAKES 4T A CRMINAL CFFENSE TC MAKE A WILLFULLY FALSE ST8TEMENT 04 REPRESENTATION TO ANY DEPAR" MENT OR AGENCY CP THE VhlTED $TATES AS TO ANY MATTER WITHIN 6

ITS JUR1&OtCTION.

S ON 4 b[tr'- 1 /h ecm.i taw 90 'd 98899Ek0# '0N XV3 Nid4.!. E 3 Wd 1E:10 30!. 96-lE-030

. - . - - _ _ __ - _. -, . - . - . ~ - - - _ - - _ _ . - -. --

NRC FORM 241 U. G. NUCLEA."( REGULATORY COMMIS&lON Au.me sureen to own am u s.smos pe. mo. Mo.cour ressons to comply vm his trano.tsty do.mation cane

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  • 2. TYPE oF mrPORT a coSrRot vuMuR iNIT;AL ttom van numcar fa ce ELEKTA INSTRUPINTS, INC. _

ass 9ned ey NRC) i REVISCN 6 AOCPe38 C* LCENd66 (M.me .cososs er ar., es. ace waere scenses mey se mes seJ CtAR PjCATION

5. WCENCEE CON'ACT l 8 EXIrUTIVE PARK WEST I

ATIANTA, GA 30329 MARTIN KNOTTS

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404-315-1795 404-315-7850

8. ACTMTIES TO BE CONDUCTEDIN NON AGREEMENT STATES UNDER TriE CENERAL LICENSE GIVEN IN 10 CFR M0.20 WELL LOGGING LEM TESTING ANG/OR CAUBRATONS TELETHERAPY.iRRAC'ATOR SERV:CE

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WIILS EYE HOSPITAL GAMMA KNIFE SUITE 900 WAIEUT STREET PHILADELPHIA, PA 19107 9W x QCA N TLEPMONE NWtmM ngEjT, rgP e Ni.ket." n weam LocaTcNischN C AN AUTHOR 2fD TC PEREOPM WOR <

215 029-3000 MARTIN KNOTTS/JAWR mtNPR - 215-928-2000 1A CATES SCHEDULE 0 10, LOCATICN REFERENCE Nt.NBER TROM r3 J.A v5 BWK M .K AaM;; r CMM ;41 C4tliI4 1%;WEER TO GE ASS:GNED BY N4C Thul Cmh mo/OT@ ym g i Nov (Tsp) Nov Preip b4tCMicies LIST ADCITIONAL WORK SITES ON SEPARATE SHEET TO INCLUDE ALL INFORMATION CCNTAINED IN ITEMS 8-16 ABOVE.

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LCEMt NurEiFA CATr. E.xp RArcm c Arg rpAasaci cA sJ wA.g CA 1153-1 GEORGIA JUE 30,1999

18. CCRTWIC ATlON (MUST Cl! COMPLCTto B f APPUCAND 1, THE UNOER$1GNEO PCREBY CERTIFY THAT:
a. Allinfonation in this report is tNe sfid compiete.
b. I have r:ad snd unde stand the prodsion of.he general fleerse 10 CFR 160 20 repnnted on the coser sheet of this form set and I uwerstand tholI sri recuired to c.msty Wth these provisions as to s!! tyyproduct sourte. of sp.cial nuclear molemal whic> 1 pcssess and usa in non Agreement Sintet or offahere waiers under tre general license for w*uch this report is med with me U.S. Nuclear Reguistory Commessior!.
c. I understand thol acti.itics. Includirig storage. conducted in ner> Agreements States under gerierallicense to CFR 150 23 are limled to a total of 150 dets h calendar yenr.
d. I underCand that i mey tio mspected by NRC st the atzwe listed werit sie lecchons end al the Licensco home off'ce adi ess for actanties perfortrod h rion Agreement States or afshore welers. I am also swere that I wH be respons@e for ary fees assoc:sted udh such inr+cchoes.
e. 1 understand that corduct of any acirvees not descreed abo.e. includmg ecedact er eclNities on deles or tocations different from mese desc Itec abcvs cr wihout NRC sutherttalion, rney subject pas lo efiforcement action, including civil or enmenal penalties.

l C*fE l cwit tc c%a - N or m.nagemei 4.p . -:..we (Tre oAa'.8 tve+e .no T.*> 3 CNATuat E MARTIN NOTTS/DIR OF TECHmCAL SERVICE W ARNiNC: FALSE STATEMENTS IN TH:S CERTflCATE MAY BE $UBJECT TO CML AND/CR CRMNAL PENALTIES. NRC REGULATICNS RECUlRE THAT i

SUwsscNS TO THE NRC BE CCMPLETE AND ACCURATE IN ALL MATERIAL RESPECTS.18 U.S.C. SECTICN 1*01 VAvir$ IT A CR'MWAL CFFEN$E TC MAKE A WILLFULLY FALSE STATEMENT OR REPRESENTATCN TO ANY DEPARTMENT CR AGENCY OF THE UNITED STATES AS TO ANY MATTER MTHIN rTs n.R;soiCTicN.

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4 U. 3. NUCLEAR REOULATORY COMMISSLN E. P3 us i4s. s.sas NRC FORM 241 AP'.m.vseo me e v 5,

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2. TYPE OF REPCRT )

ELEKTA INSTRIEENTS, I!C. _

smAL (L,o.we B.!anbr Narnber to be ugn atyune;  !

REVIS;CN

4. AcoaEr.,3 Cp uc auet tus=ag eoewes or em assauen waev noem mey se cos'*U CLARIFICATION 8 EXECUTIVE PARK WEST <

ATIANTA, GA 30329 m m WOTTS l T*C ucr.E uwnR 7 sa: Am.E NwsEa ranewre Asse Cese; l

pes me Ace Csee) J

. 404-315-1225 404-315-7850 . . - -

8 ACTIVITIES TO BE CONDUCTED IN NON-AGRElMENT STATES UNDER THE GENEP.AL UCENSE GIVENiN 1C CFR iSC 20 WELL LOGO lNO LEAK TESTING ANC/OR CAJBRATICNS TELETHERAPv/lR: TAD ATOR SERT 1CE I PORTABLE GAUGES TRAN300RTAT'CN QA ARCGRAM APFAOW L NO & REV No PE3 $TE RE3 AS USER C$ pag 4A3y33 (;gRTpc Aq3 Cfi COMPLMNCE NCS )

$TA4 OP C30E 10 WORK LOCATON AOCREES i3 rec eW Wmcor a em Ascaf.ofi 3.ve sa

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14. DATES SCHEDULED 8 16. LOCAtCN REFERENCE hUMBER PROM TQ LEAvt SLAM 80R 1% tat NRG Q6tM 24% %Qw.ETE AlWMBE4 TD BE A35 GNED SY NRC

& CTB@ 35A bTFJD coo g y_

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I COBAIC 60 I

6 AGRE*'*CNf 3IA'd 3MEC 4,iCEWE Wm?M AJMORd&S THE WNDER$tGNEL TO CONDUCT AGTWmA3 WnTM APE NE SA5it, CACEPT PGR LOCA'Cw M wK AS ,

SPEC. Pig 3 :N trEM S AlcyE. Pour cos es el me speeiric tipense must acenetpany t%e indel NRC Fone 241 }

LICE.NS. NLVRER STATE wm.AT.aN LATE T;JA U5Asa LAr3 TJ DATE GA 1153-1 GEORGIA JUNE 30, 1999

19. CERT 1FIC_AT10N (MUST)E COMPLETED BY APPUCANT) l ThE UNCERSIONSD.MEREBY CERTIFY THAT: i
s. Allirifc' frat oR in this report is true and corrpete.
b. I Mvs wd and understand me provision of the generalli:ense 10 CFR 150 20 repnnted on the cover sheet cf ins fo m set: and I unde stand that I ett rcastred ,

to comoly with mose procsicas as to all hyp*osuct. source, or spec;al muinear matens whis% l possene a id use in non4,leoement EtMes er onshore wete s i unrior e. gener21 lim se for wNch this report is f;&ed with the U.S. Nuciw Regulalo'y Commessici.

c. I understand that ac!Wes. includs,g strege, conducted in nonJgreemen's States under general fcense 10 CFR 16010 are limited to a totn' of 120 rays in wencar ent, r e
d. I understaM that i may be inace:ted by NPC at the stee listed warit site locolons and at the Linnese home che address for acti itiera v perfumed ht non, Agreement sieles or onshore waters. I arri also see test I will be responsAle for ey foes assoc sted w tm such inspectiors.
a. I onders:and mal conduct of any actMties not dese Ibed abeve, including conduct af setMt;es on sta!ss or locatloes Werent from troso described above or wlmot,t NRC outhortretion. may subt ect me to enfo'otimoit action, including civl! or enmmel penstlies.

CewiNo OnctR - R50 er .saaageme i Represeetswo (fysea*rr.smo aseme eae T p.s &ish AT.AE P TE MARTIN KNCfrTS/DIR OF TECHNICAL SERVICE WARNING. TALtt STATENtENTS lN T 4tS CERTlF;CATE MAY BE SUBJECT TO CIVIL AN3CR CRMINAL PENALTIES. NRC RE3ULATIONS R!oulAE THAT -

SUDhassiONS TO THE NRC BE COMP.ETE AND ACCURATE IN ALL MATER;AL RESPECTS.18 U.S.C. SECTION *001 MAKES JT A CRM!NAL CFI'ENSE TO MAKE A WILLFULLY FALS! STATEMENT CR REPRESENTATION TO ANY DEPARNENT OR ACENCY OF TPE UN:*ED STATES AS TC d MAT *ER WITHIN 4TS .rLR30tCT CN FOR NRC * " " * * * " * *

          1. ** - 5'"^'R "<

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NRG FORM 241 U. S. NUCUEAR REOULATORY COMMISSION APPnwam av oust no sin 4 cia amnee, s,3cm

  • Esemsies eareen ser reseense te coery -m ese manca:ory e'ere.eme

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..,-.en newsno.n,,.co. is saw.,ev.no

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.e. en e ch REPORT OF PROPOSED ACTMTIES ~~ar e n e - -.as .e.r.Re m,o v.a.n..m.n n we a-= ,m -

% o m . n Nw....,an.g.m .-..

IN NON-AGREEMENT STATES c- = * *a == c: == as * * **~a

mmm. on.'w.i u ...r.nm. a.e,= w.wn. ce m we .,,=i aa==n  % .i (Pteese reeH)e ensmictons en the covet sheet befbre compenng this form.) cosa:t er asenne, en. e nemece net wwren to oneort to a co-enon e' roo m.wn union as a mveae.m neo.i.scue ranrroine ar t Nwe op u:er.see waa er w ,meo,me ,. m-r e, e.. . ume . > t wpg op agpegy 2. cowTnot wusta gosse atamt . twrnoor to ce ELEKTA INSTRUl M S, INC. _

INITIAL auigneoernac; REVISION 4 AOCAtss op .CiEMEE (Meneng somas er peier noepen wears wena.e may se nesmai CL.ARimCATICN 8 EXECUTIVE PARK WEST ATIANTA, GA 30329 s' MARTIN 1030TTS-

, e A03%E s.We24 M.wisEM

- %tiP (Frow. CNE.Conel Ar. trnere er Me Cadet 434-315-1225 404-315-7850 8 ACTIVITlE S TO BE CCNDUCTED IN NON.AGREEVENT STATES UNDEst THE GENERAL L%ENSE GlVEN IN 10 CER 153 20 WELL LCCC.NG LFAX TESTING AND/CR CAlJSRATIONS TELETP'ERAFY"**ADIATOR SERVCE PORTABLE GAJOES TRAN320RTA*.CN CA P40 GRAM APPROVA.NC. & REV AC RE3 3 TERES A3 UstA C' eA;OciNC5 (csff ;ATES CF C0frPUANCE NO2) 9 GUENT .sAuG ACCRE 38. CITY 8CCUNTf. ETATE. LP CCDE to work LCCAMN ADO *ESS (3 rem eef Nwnserer orce tore 9en Gl.s .:

cCn'0!tt M eddmbs at 6rectbers sa possible )

INDIANA UNIVERSITY MEDICAL CTR 550 N. UNIVERSITY BLVD.

INDIANAPOLIS, IN 46202 g 0 / g l l

ti cuNr rwNu'*. Ne u. weanocAT.cici.cNNiCiAN AuTNoaizza To psaronu wogg cmewoo rw coaer 93 WCh. fonca AneLOCATION cue) !sLUMCwE NAff!M i MARTIN KNOTTS/ JAMES MOUNTS

14. DATES SCHEDULED I 16 LOCATION REFERENCE Nf48ER we:u Tc tm.s a.w:a nciA.Nac rownsvinssis l9k 7 [u,N ND m.wsER T3 GQS CNED BY NRC

. my(

s f'h4

$RC_ lN7 MC TDD <

Q  ;

usT ADDmONAL WORK SITES ON SEPARATE $ MEET TO WCt.UDE ALL INFORMATION CONTAINED W ITEMS 916 ABOVE. j 4 .c..s. w s.. ~ m w . w w ,.w.m m e w u m pnewe m mn.w,,e e m.w rn ee,.w meswoeweme.w

% .u c u uso. e ueen orav.wo es wm COBALT 60

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  • 0R$68*dN1 m o m rr #fCd 3*2M4 blM%t's.vvnmCP=

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i.enu wa whCERJinGr.Ei.i TC c.CNcvCT enn es en.s.. AnC rorm :.5 3 AC.T vnsa ,vni;;.n AA6 fi 3A'el* CAMP f eCrs LOCATsC1 CF t,M As LJCD.S.L MNEtA STATE EAP.RA3GN ;&Ts TD*At L5A;t. C8 v3 I; r,4TE CA 1153-1 GEORGIA JUNE 30, 1999 10, CEnTsFtCATICN <uusi se COMPLETED B Y APPUCAtm __

1, THE UNCERS!GNED. HER!5Y CERT 7Y THAT:

e. An wormal:en in we rencriis true end compieie.
b. I huvo esso and understand the provisic.n of the general license 1C CFR 150 20 reprated on the cover sheet of ins form set 09d i unce ward that I am required to acreply vath these procsio os as to all bypreewst, soweto, or specisi nwstcarrmaleesl which I possess and use in non Agreement $lates or er fshoto moto's uretor 'fte general license for which this report is filed vath the U S. Naciear Regulatory Comm tsion,
c. I knde'aiad that acdvities, includhg s.orage, conducted in noreAnroerr*ents S:sb under general licertse 1C CPR 150.20 are limited to a Ive' of '80 days to cele'idar year,
d. I undemisnd tNi l may be irspe:;ted by NR0 at the oneve listed work tite locarons and ut the Licenseo rome oftco ace,ess for acl.wilies performed in non,8poemen! Steles or cl'ahore wefers, I am also own's that I vnli be respor: sable for s9y fees assoc e'ed w'th sur.h ins;iectior 3.
s. I kna.rstund that coriduct of any sclivities not desc6 bed above, including conduct of actNit'es on dates or localices d Ifereal from lut.e ce+.tr$ed nbeve nr ghout N9C avmort:alion, may sutnect me to enforcement schon,includ nD  ! civit or crimmel penalben.

CcAf #mG OMER - R50 at W.n. gem.m ner,eunwe,e (TrawP'tnme tweme one f ue) 64NAT.!P E OAIE PARTIN YNCn'TS/DIR OP '"ECHNICAL SERVICE WARNING; FALSE STATEMENTS N T+5 CERT (ICATE MAY BE SUBJECT TO CML AND.CR CRIMWAL PENALTIES. NRC REGULATIONS REQU1AE THAT SUOMISSCNS TO TFE NRC PE CCMP.ETE AAQ ACCURATE IN AU, MATERIAL RESPECTS,18 U.S C. SECT.CN *001 Mart $ IT A CRMNAL CFFEN52 70 hnKE A WILLFULLY FALSE STATEMENT CR REPRESENTAT!ON TO ANY DEPARNENT OR A3ENCY CF THE UNITED STATES A$ TO ANY MATTER WITHIN ITS JURiSOiC*lON

^^*""^d"""" "*""' ^* ^ /

FOR NRC USE ONLy MbM 7jeder 7ft -[etde Mda~ b

/ / M N iG PmM *41 (64e} /

60 'd 989992Er0# 'ON XVd Hid- 0 313 Wd EE:10 30J 96-lE-030

NRC FOPM 241 U. 3. NUCLEA,5 REtutATORY Commission N B WI O AP.'80*e

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Thise.e un/e4. Don,,is requred,so m e..e,e ,Scil.4C.rney

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REPORT OF PROPOSED ACTIVITIES **a- a a* ~

w, *"., m.., R .m. M., ...-e ....a~" gm v -s-aos. . .a, n" ma a -

IN NON. AGREEMENT STATES ~ a** '**

(Pieese reed the instructons on the com sheet belbre complekng this tomt) ca~'*o'nce oinceit ****er55* **

  • s,d usesament $'e"n=.

r som. wnhine De ": ses NRc"aw as conset er s**'ser. ** a avun e not rwet to 'u*ene to. e ed nun ce sntemacan on ess li s.soleys a eweg varie cme eewei onw .

1 NAVE OF L.CENoEs evaan or renveroamy fu seasvot ras esMes assereope">

2. TYPE OP ftEPORT 8 CCNTROL NWBM ELEKTA INSTRUMENTS, DC. _

NT:AL (Loev,0 en neof Gl.nnk fmej - A, umber to be ReveioN 4 AooREss or uCaNsss pr , a ,emx..ow.,u --

=,.,a awee etAReieATioN 8 EXECUTIVE PARK WEST *""'"*'

ATIMIA, GA 30329 MARTIN KNOTTS m bVWtt 6 'E ca,EPHONE.

va A ca.)misR 7 FpwA A.,Cu,e:.,te cm 't 404-315-1775 404-315-7850

8. ACTIVITIES TO BE CONDUCTED _IN NON-AGREEMENT STATES UNDER THE GENERAL tl CENSE GIVEN IN 10 CFR 150 20 WELL LOCGING LEAK TEST!NO AND/OR CALISAATIONS TELETHERAPY /lRRADIATOR SERVICE I

' )

PORTA 8LE GAJ3ES i

TRAMSPOR*AtoN QA peOGR AM APPROVAL NO. & REY. N3.

nEG18'ERED AS VGER C~ PACKAOtN05 (CCtTOOATES CF CCW81. LANCE NO3)

9. CL't'4T NAME. ACDrtGSs C'TYtCCUNTY, STATE, Z
  • CODE e SC.compione WORK LOCAT'ON AD, DRESS en etense dact,ono (Sveer erad a punible) Number,cla ckwonen. he as YALE-NEW HAVEN !OSPITAL 20 YORK STICET NEW HAVEN, CT 06510 11.CLikNi it.LkoMONE NUMcL4 11 WORK koCAT10N TECMNic AN NTMCnJED To *EAF09M WGRK ss wcu LocaTics TEw% Nmisem MARTIN KNOTTS/ JAMES MOUNTS 14 DATES SCHEDULEO 18. LOCATION REFERENCE nun /ptR FROM TQ LE 4.E EL ANe( FOE ele.T.AL N.eC POMM Di REQ,) SETS HVVDER THE AsscNt3 EY NRC Dc. MO) AcND WD 066 N

' A nW i ceion UST ADDm0NAL WORK SITES ON SEPARATE SHEET To lNCLUDE ALL INFORMATION CONTAINED IN ITEMS 916 ABOVE.

u wf= Ha.ct,A.a,mn ve M er A,icw. m.w.r,m.s.aE.Po.ss.E.S isa, wiE.a.,r.e ; A,.L.tv mc

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COBALT 60 it AMEEMENI sPr:no ih rrEv5e TAIT!Aeovs.6*!OIP.C

r. LC.ENSE s s .r ee .e.e.e uenieWN.CM AUTHOR.ZF.4 r,um ae ms.ny m .n.w NRC Form TWNCE.%ioNt.0To 2N CCNDJCT ACT:vmEfWG ARE TraE EAvt E LCENSE lWMBE.R STATE EXPIRATlQN LA s t TQ'AL WSAGE DAr$ lo Dog GA 1153-1 GEOPGIA JUNE 30, 1999
19. CERTIFICATION (MUST EE COMPLETED B Y APrUCANT)

I, THE UNDER5GNED. PEREBY CERTIFY THAT:

e. All Informelkin in this report is true and complete.
b. I have read and understand she provin;en of the general hsense 10CFR 150.20 reprirted on the cover sheet of in a form set erd I underWend tfialI am required to comply with these provisions as to all Dyproduct. asurte, or special nuciser meterial which I possess ord use in non Agreement States et ohhote wutors under Lne poneral licenso for v.hich tMie report la filed wth the U.S, Nucinar Regulatory Commission.

e, j understand that act'wll es. Insfuding storego, condweted in non-Agreeme*its States under generst lice 9se 10 C'R 13010 are lirrsted to e total of 160 days in celefidar year.

d. I understand that I rney lie inspected by NRC et the abovo l'ated wcrit s4 locallons and el the Licensee horre off'ce addresa for actMiics po forrr.od in non-Agreerren! Staies or offshore nelers. I am also aware lhel 1 mil be re opensibio for eey feee saaecided crith mh lar.postians.

e 1 ufidarsiend the! conduc1 of any activities not descrbed above, including cond. set t.f screvilies on dates er loentions edlerort from thoso described et;ove or wtmout NRC outhorization. may subject me to enforcement scilon, ecludmg civil or enmmal pen +t;et.

CEAToina crricLA . F.m, u.a.g .rict meece.em.o (rfp ws.w h.m. .no r .j a.aw: gee FARTIN MUI"IS/DIR OF TECHNICAL SERVICE WARNING FALSE STATEMENTS IN THl3 CERTIFICATE MAY $5 EUBJECT TO CML AND/OR CRMNAL PENALTits. NRC RESULATICNS RECV.RC THAT SUOMISSJONS TO THC NutC BE CCVPLETE AND ACCURATE IN ALL MATER 6AL RESPECTS.18 U.S.C. SECTICN 1DCl MAKES IT A CRIMINAL OFFENSE TO MAKt A WILLNLLY FALSE STATchtENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE ONiTED STATES AS TO ANY MATTER MT*flN ITS JURISDICTION.

r FOR NR M b"" "' M USE ONLY IESId* '

/ d wom., <.n J

01 *d 9R899BEk0# '0N XVd Wid4.DI313 Wd EE:10 3M 96-lE-030

. . . . ~ ~ _ - . - -- - _- -_. - -

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j NRC FCAM 241 U. S. NUCLEAR REGULATORY COM Mission APPROvt3 ev on No. U56m Esemated weven per resnonne n camp) e r.e erneswy w..ene,s,sonm smu s,3cru t

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. . e . e e 4sis rot - .4stien

, ,. .s ',.a,w.e.d.so ibar a,, soe.o.

.,,. ayesc.heaue me REPORT OF PROPOSED ACTIVITIES a-saa ae is --w er e".~.c~.cs,o u. s,.m.a-d a~ nmo..*.*. a -ma R..

wmst u s u .m IN NON-AGREEMENT STATES caa~a*"

  • w a-O'SC.Do*U. Ofr"ee e'g ment u.r.o.c

' * ** *~ aa=a r=

sed== ". WasNeg'nat. DC 2CSCI N% mar eat Dadr,.t (Ptease read Ma irtstruefors ori vis ecver sheef betors compiegng eis /cet.) eenduct = souse

.,mo ..s.... .t sg ed.,as,wn as actove'e. .

wee

~,,es es.soas m to, a es1ema of ieto rmw

, swa or uCEum P-s - w -, . c=~, m..-- .-n */ ~2. TYPE OF REPORT 1 OONTAGL NUMBER ci,oave sw - numoer to a.

ELEKTA INSTRUMENTS, INC. __

"TA assignedbr NRC)

REVIS;ON 4 A0; Ass 4 QF uCEN466 (ae. meg nesse er err., escavon .aere acers.e esy se mes.non CLAR#iCATICN t uccuca coNueT 6 EXECUTIVE PARK WEST ATIANTA, GA 30329 MARTIN KNCfrTS cw,,. c,,; ,

, o,,,,w.

, ,,,_y,,

two w. c-404-315-1225 404-315-7850

8. ACTMTiES TO BE CONDUCTED IN NON AGREEMENT STATES UNDER THE GENER AL UCENSE GIVEN IN 10 CR 150 20 i WELL LOGGING LEAK TESTING AND/OR CALL 5 RATIONS TELgTHgAAPY/IRRACIATCR S!RV Cf GTVM Groecrfy)

PORTA 0LC CAVGC3 TRANSPOR"A*1CN QA PROGRAM APPRCVAL NQ & An NC REGCE:C A$ yg(8t GB PACQCiNC5 (CE%P'CATE5 0F CCWrt:ANCt! NCS )

e CL ENT NauE. 400 ness. C.TMCVNTY. EfATE. Le COCC to. WCRK LOCATION ADDR$5a (Syser.nd Alumenr.r emer ler.reen Oop as JFK MEDICAL CENTER l 65 JAMES STREET EDISON, NJ 08820 11 cuest reaemn wuwatit tt w;quecAticsTscascAN AgTH:ssgm to PEtsonu nCRR oc taneA,no me cou> *s. pnaw Acm.m.Anca cave) rettPmos2 wve MARTIN KNOTIS/JAE9 NOWT9 F%M 14, CATC$ $CHCDVLED TO

( 16 LOCATICN REFERENCE NUMSER LEA *I BwAPA ka ,%% NRC FCUpIN M[ss5!5 NUMSER TO EE A1$~GhEO GY HRC Tec. MM AclM7 Tap eco #5 j n N 0 A 'c b %

LIST ADDITIONAL WORK SITES ON SEPARATE SHEET TO INCLUDC ALL INFCRMATION CCNTAINED IN ITEMS 916 ABOVC.

R ...v. . ....

u cnE.A_acd,.6.vr s.M,,,ss ..Aw.2-

.n. -w u.m a. .,c.m.~6&c

..d ~wea.o- n.sTAu.r.a . ss.u..c.en .o,n m sa e.~

COBALT 60 4 AGREEWENT & TATE grEC PtG UGE. Net WHICM ADORJ.ss THE VNCE8tsiCNED TQ GQNGsGT ACTYlT E.s M ca MtE TE sAv&, CACUTFCR. COAT CN G7 Us1 A6 SPEOFED IN fTEM 8, ABCVE. (Feur rep..a of te. sp.oris h:ense enust accompany es metral NRC F.rm 201) ycs.u . hsus.ka blATh Q.APf RA%N ;,Al k !CTAq t$nA7ss OAYS T.) DA!s GA 1153-1 GEORGIA JUNE 30, 1999

19. CCRTIFICATlON (MUST GG COMPLETED BY Afr2UCANT) t, THE 'sNDERSIGNED, HERE BY CERTlPY TPIAT:
a. A!Iinfo mat;en in thrs repet is true and complete.

b.

Ilohave read and unoersta9d the provislo's chhe generalliconee 10 CFR 150.20 eprinted on the sevc'.sheel ofINs 'o m set e9d I understand that I arn re comply with lhese prossiens as to all tyyproduct, source, or snaciel nuciaer meiertel which I pus es ed use ist eomAgreeretat States or o4hore ., ele s undar the gonoral license for which this report is fhed str the U,$. Nucioat Regulatory Comm4 sto't.

c, I undet,tand that activities, ine!6dMg s!crage, conducted let nonJg'eemens SWtes under general hconte 10 CFR 150.20 are tirei:e:I to a tofa' cf 160 ceys 'n calendar year,

d. I t:nderstand that I enay to inspected by NRC et the above ?isted wortt site locebons and at me Uceene home office address for actwities perforraed in no&Agreemen: States or ohnere waters, Iam also owere that I wil be respons;ble for ey foes assocaled with such inspect: ens, e, 16nderstand that conduct of any ac'.tvides not described above, including conduct of activitt.s en edies or Icc, Cans $Ferem from those describes above or I vel'.hout NR0 sulhonastion, enay subject rne to enforcement scieen, including civd or chrn+al peatties.

l C s au- . ua e, ........~ a.. .. g,,.,,m.o s n., sosm m l MARTIN ICCITS/DIR OF TECHNICAL SERVICE j TARNING-. msE STAT!MENTS 'N TMS CERTIFICATE MAY B! $U$JCCT TO CML AND'CR CRMiNAL PENALTE3 NRC REGULATIONS RECUlRE l SUBMSSONS TO THE NRC Bf CCYP'.ET1 AND ACCURATE IN ALL MATERIAL REsoECTS 18 U S C. SECTICN '001 MAKFS IT A CRMNAL CFFENSE TO MAKE A WILLFULLY FAL$E STATEMENT C4 REPR!sENTATION TO ANY CEPAR* MENT OR AGENCY CP TVE UNITED STATES AS TO ANY h%TTER WITKN ITS WRLSDICTICN.

FRE ~M 568 W' 'S ^ '"" *

/t U E ONLY A NACW5' PrNE NRC F#19 E41 ff-M)

H 'd 988993Er0# 'ON W3 Nid-El373 Wd #E:10 301 96-lE-030

--- _= . - -. - -- - . - - - .

U. S. NUC'. F.AR REGULATOnY COMMISSION APPE.e 6-: ED.v,.y e .o.ne.

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g,c ,n N,RC FOLM 241 1

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REPORT OF PROPOSED ACTMTIES i-em e - ,..ree * = a .a.ie-e

-ee pc-a r

  • 5-~*o m .i m m ss.N wam .u.., -. ,,,. .n IN NON. AGREEMENT STATES * * * '

omomi o*, ".w,e Sa *m.e,,,r . ..m..,,.

ca**a*", c t *** ** ',n '.". o*c-*m'" a"*u*n=cae ~ .; a',.*:'

(Pfosse reed the ins'nictons on the caver sheet tebre comp 6eting this form.) mn to re see.e te. a cae.cncs er rac,ncon connues 6n e aeww smsv,a au.an.s we.eus

... ret ten,uoua. r w c .

i Nwe oe ucem.ee rem e r,,,,,,, ,n, =, eoc, e .eo. ne. e. ,e ,

2. TYPE OF REPORT 3.CONTROLNUMaE (LeaW #iD*8f a NI//n/Jer.'C De ELEKTA INSTRUMENTS, INC. _

t'c6 ougnar dy uRc; mEv.s.CN

. Acous s c, ocsms tu , ,m . .,. . ,, .n =.m. -., e. . , CuumCAYeoN 8 EXECUTIVE PARK WEST ATLANTA, GA 30329 MARTIN K!DITS e !$dhCNg NUM.S4% 7 EAc.5 w a. w M c.,,,5.*,4 eNLV coicoua Am ca >

404-315-1225 404-315-7850

8. ACTIVITIES TO BE CONDUCTED IN NON AGREEMENT STATES UNDER THE GENER AL UCENSE GIVEN IN 10 CFR 150 20 WELL LOCO.NG LEAAC TESilNG AND/CR CAUBRATIONS igLgTPERAFf!!RRA3'ATOR SERVICE PORTABLE CAUSES TRANgaQRTA'10N CA PROGR AM AAPROVA4 NC & AEv No PE4istEtzo As tisam or PAwoACs (Cet:ft: Arts er c vr'UANCENOE)
3. CUENT n.AME ADDRc23. CifYdCCUNTY eTATE 2* CCCE to. WCM Lo0AT ;N ADORC33 (gre,i en w,naw y om messpi Ch. es CENTER FOR IMAGE-GUIDED NEUROSURGERY ccw u saeuer><s-rw ass w o)

PRESEYTERIAN UNIVERSITY HOSPITAL UNIV OF PITTSBURGH MED CTR 200 LOTHROP ST., STE. B-400 PITTSBUTCH. PA 15213 . -.

12 WCA4 LOCATICN TeCMNiC.AN AUTHQRCE3 70 PERPCRM WCatg i t. C,,, LENT 9e - TEEPH.O.r,4 NUMrsEA 13. WOM. LOCATION., TELE *PGh NJMt!B c n - c.e 412-647-7756 MARTIN KNOTTS/ JAMES tCUNTS 412-647-7756 14 DATES SCHEDULED 18. LOCATiCN REFERENCE NUMBER

,. m m _ ~_ N_ . , __

leVVEER 70 SE AS$CNE SY NR0 Fe b 3, st7 Feb. M, M O N doo g 1 (n Q /* Cf f LIST ACDITIONAL WORK SITES ON SEPARATE SHEET 70 INCLUDE ALL INFORM ATION CONTAINCO IN ITEMC 816 ABOVE.

Cet Wu dE PC55E5MU, Whsd INNsy. bsROCED On sa sim, .N NA ahud FA35 o ust n.acc*r,r .e m orroeps.n er MA rypered.i_. W orreono.mo mer.r see og uvme or seven to ee uses) on euserity CCBALT 60 '

sa Acmetwe.r state pecvc ucesis Wnic i4wr cus. T E wucas.;~s::,To coNovcv Ac'inse ecw an. r.=Aus ac&:T A;a soctrice. c. ur.r.. As SPECIFIED IN hTDi' 8. ASOVE (F.us eep.e of tre spee,*.c heerse m$st accompany tre encai NftC Form 2411 Ucs%s eevWbkid AI A rt EAP!RATGN GA ff Tgf AL UbaGd Def s TJ DATE GA 1153-1 GEORGIA JUNE 30, 1999

10. CERTIFICATloN (MUST 95 CO_M_PLETED B Y ADDUCANT)
1. TNE UNDElmSIGNED, PERE 6Y OCRTiFY THAT;
s. Allinformal<cn in this report is true arid cornplott.

b.

Itohave read cornpiy and vnth undeesland thou provisecas asthetoprov'sien o,f the a!! t yproeuct. poneral source, li:ensenuclear or specuL 10 CFR 150.20 ma:e 404 whiciirepn posseu i,ted ensnd its use cover sheel in non. of ths to SlJISS Agreement m set; or and I undewaie offshore stard s that I am reout urider the ;eneral1 cense for wNeh this report is filed wilr the U.3, Nudsar Regulato y Comm ssios.

c, l undarstand that activities, includhg storage, conducted in norg-Ag,eemer?s States under general licer.se 10 CFR 15030 are litrited to a tote: of 150 coys in esiendar year.

d. I understand ttiat I may be inspected tiy NRC at stie chave I:ared worn tite locouent and at tre Uconsee home efCca address for ac:rvities perfortnod in j non-Agreement Sietes or offshore sveters. I am also aware Ibet i vnll be rossonsible for imy fees assoc.ated with such mopections.
e. I underslund that c,onduct of any activuies 901 described abcve, includm; conduct of acrtvities ci psies or locatio s dtfre eq from thos.a descrit:ej atxive or wrhoul NRC autho uatiott may sub tect me to enforcement actron,lncludmg ctve' of cnminal penalbes.

cs-m orecs . m e, ...e,,,. ... ..e <T, ~.e ~.mo e,e ti,., sia w .=e c.re j MARTIN ENJI'TS/DIR OF TECHNICAL SERVICE I WARNING; FALSE STATEMENTS lN TH:S CERTIFICATE MAY BE SU5 JECT TO CML AN3/OR CRIM:NAL PENALTIES. NRC REGULATICN5 P!! QUIRE ThAT Sune4SSCNS TO THE NRC BE COMPLETE AND ACCURATE IN ALL MATER:AL RESPECTS.18 U.S.C. SECT 0N 1001 MA<ES IT A CRMNAL CF'ENSE TO j MAKE A WILLFULLY FALSE STATEMENT CR REPRESENTATICN TO ANY DEPARNENT OR ACENCY CF THE LN:TED STA?ES AS TO ANY MATTE't MTHN l'8 JURISCIC*iCN.

p avimmG rn.c Ag Spacer e . rei,.j , .,

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4 NRC FORM 241 U. $. NUCLEAR REGULATORY COMMISSION 'a"m^e.ve E

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REPORT OF PROPOSED ACTIVITIES aS e e ree.~+e e. ,. ne w a.w.e-ee, sv* e Sw . .e wau a

m. v s w..m, neum,o IN NON-AGREEMENT STATES um ca"""o"r n o"ne o

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(Please read the last/uc#cas on es cever sheer be/cre coinve6ng this htr1) .enndus o.r. se.a,sw. is ne wed to e,ae a p se. eus cew r.oruessere to. s conem er.forr-acer

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1. NAME CP LCEME.2 # raon er /m propotag to cowcTe echveres sucnces peow) 2. TYPE OF REPORT N*M L CCNN'anM (Leave Bl = NumDo'to be ELEKTA INSTRUMENTS, INC. _

INTIAL assgned cy MC)

REViscN

4. A00RM.5 CP L CO.N5E2 (we ewws gr etw @CA@ wNgro Mo499 they se 8008f90) CLAR PICATICN 8 EXECUTIVE PARK WEST ATLANTA, GA 30329 MN NS

( w e EuuMeEn 1. can uca nE ua,<n,a emeeucm, e un ce

_ . _ _ _. __ 404-315-1275 404-315_-7_85_0 8 ACTIVITIES TC BE CONDJCTEDIN NON AGREEMENT STATES UNDER THE GENERAL UCENSE G1VEN iN 10 CFR 15MO WELL. LOCCINC LEAK TESTIN3 ANC/OR CAUBRATiCNS TELETHEUAYrRPMSTCR SERVICE PORTABLE CAUGES

  • RANSrCRTAT!CN CA PRCCRAM App 8tGVAL NQ & Rf( NQ. P CO ETEMg3 A5 LSER CF P AC4AG.NG$ lCgW CAf f$ C,4 gqM3(;%05 NO3 }
9. C. ANT NAME. ACC8E55 CrrYrCCATY. STA 3. Z:P CODE 'O WOM LOOAT.CN ADDMf 53 how .ad Numt er ur o.rier teton Sw as compger .a acetas er guechone as poss68 /

COLUMBIA GAMMA KNIFE CESTER PRESBYTdRIAN HOSPITAL 700 NE 13TH STREET OKLAHOMA CITl, CE 73104-5070

11. 0LiiN fsLE4CNA %WsEE 12. WCalK LOCATCNTECFh:C;AN AVTHCR.ZEDTO DEU;8tv WCoA O *W LOC ^lb EENE hWW TOT-Y/N912 MARTIN ICK7ITSMAMES MOUNTS [d N 1-T912
14. DATES CCMcDJLED 16 LOCATION REFERENCE NW5tR MOM TO LE%E s. Aw( fcR AT.AL MO FC,w ;.) EC6m5

%v6E8L.TO BE assionEC SY NR0

&Q D'& k M / 50 Nov hwn Ncv rw I JJc db A 1 LIST ADCITIONAL WORK SITES ON SEPARATE $NEET TQ INCLUDE ALLINPCRMATION CONTAINED IN ITEMS 316 ABOVE.

o. ua uc car.4 mare,%. u.c n a ea es...w w.w.a.smaa. ssav cza. sa .5Taa e,a+Aade~asi si2ss.

firtluce ducnphort of type 8 Ad bem1V orre6a06eftve Ptannel,8ee88Q SQstsA cr conoces to be unstt)

CCBALT 60 16 AORf teENT si AT s 2P6041C LeCsNoE W-m;* AUTHCRGa T*E UNGE45*GNt3 TQ CcQ.CY AGfivrf g4 WMGn AAf T-g 6mL QCW (CA yTiCN Of 663. AS

$PEMED IN .TN 8 A60vf. / emes er me nec he kona mm ammpe9ps W M; Fm HQ LC&N!.4 NUMBEM STs EAP8i ATCN LATE TCTAi. LSAGE C Ai $ 10 J A Tai GA 1153-1 GEC MIA JUNE 30, 1999 i 1

19. CCRTIFlCATION (MU5Y CC COMPLETED BY APPUCANT) _

\

l

1. THE UNDERS;GNED. PCRE5Y CERVY THAT
a. Allinformation in this report is ne and semplete l
b. I have road s94 unde stand the prtmsion of to cenerallicenso 10 CFR 1'O 23 repr:nled on the cover sheet of th s 'orm sol: and I w9de s'and that I arn recuired to comply with these proWaiers as to edt bypro4ct. soures, or scoe el nuclear matesal which I pestesa ord ute in notwAgree<r est States or df.horo mters under the geeernd ricenes for wh.ctuhrs report is Tod with the U.S. Nucioer Regulatory Comrmssior..
s. I bnderstand that actnrtties,iricluding storage, conducted in ncrt Agreements $lates weser generallicenso 10 CFR 153.20 are lienited to a total of 180 cays m calender year,
d. I underniand that I rney ts ir.spected by NRC al the above listed worlt sie Iccations and at !be Licensee horas c5cs addrecs for ::tialas pederr ed i9 non.Agrectnent Stales or offsnore wmeet. I ar's also swore that i vcll be responsbo for ary leen associated #th such mspecticris.

e_ l understana that cor. duct of cry oc1N4es not descrbed above, msluding coedsst of a::tNitiaa on daies or locat oes diff; tem from LP.ose catenbec occve er without NRC aut'iontation, may si.t oct f me to enforcement action, including civd or ontmnal prmalties.

etT.fmi cP* cEM - mso or waragement Rwesona
a Apev-mtse rvame ew Me> SGNA M E Dalt MARTIN ICOTTS/DIR OF TECHNICAL SERVICE WARNNG. IrALSE STATEMENTS IN THt$ CERTIRCATE MAY BE SU5 JECT TO CML AND!OR CRMNAL MNALT.E!. NRC RCCULATiONS RECUlRE THA SUBA,sssiCNS TO THE NRC BE CWMETE AND ACCURATE IN ALL MATERAL RESPECTS 18 U S.C. SECTicN 1301 MAKf 317 A CNMNAL OFFENSE TO VAKE A WLLPULLY FALSE STATEMENT CR REPRESENTATICN TO ANY DEPARTMEhT OR AGENCY CP TFE LNft!D STATES AS T3 ANY MATTER W ITE Mt:4DtGT:ON.

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N!'.C FCRM 241 U. S. NUCL, EAR RL.tULATORY COMMissicN 0 Emm

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REPORT OF PROPOSED ACTMTIES = we .w. .e.n....e.e,-

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w e.

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= = *oi . ,. ene u . ti ,,m, ira,,rea

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== N,C m, a ea,r (P!sese read the mm/cfons on the cover sheet be@e comp;elfag mia fotm ) om conde

.aw er seev.of.

. . - ..ns r, perica

.. . .sous rotmm.ved to. , innoso

. to. a ca ctos of mfw en t uAus Op uct:.su (Person .e w ,,eueme evem ene emen enen..o . ; 2, CONMCL NwMEER

2. TYPE OF REPORT (Leave C!ank - tvurrber to be ELEKTA INSTRUMENTS, INC. _,_

umL owgnee py naC; nEv:sioN e Acc%ss osucrosss (m *ag seeen a, ow.ac sen snee asenees my a es.W1 CLAR FICATICN 8 EXECUTIVE PARK WEST A'IIANTA, GA 30329 MARTIN 10CITS e.'i xpr;sek+ set 1. FAc5mus Nxen turun Hn cones tmerunkn cm

_ 404-315-1925 404-315-7850 8 ACTIVITIES TO BE CONDUCTED IN NON.AGRIEMENT STATES UNDER Tr'E GENERAL, UCENSE GIVEN IN 10 CFR 150 20 WELL LCCCING LEAK TEST;NG AN0/CR CAllflFATiONS TELE *HERAPY!!RPADtATOR SERVCE

~ ^

OTHER (5 pouff)

PORTABLE OAUGES TftAf%9CMAhCN CJ PRCGRAM APPROVAL NO & RE't NO RE5$'EAE3 As ll5ER CF DACAAGlNGs (d23TNAi!$ CF CCMPUANCE NO3 }

9. CUENT NAME ADCRE88. C.TYicovNfy, stuC bP CODE 90. Wo LOCATION A00CES (Spect and Numer seetter seeer.en Cae a.

n e... - u -e - ..., - o, L. LEKSEIL CTR FOR GAMMA KNIFE RADIOSURGERY l

UNIV OF VA HEALTH SCIENCES CTR (BOX 484)

PRIMARY CARE CENTER, FOCM G506 CHARIDITESVILLE, VA 22908 '

Oh 12, WCRM LOCAT.ON TY.CNNCAN AUTHCR ZED 70 PERcCRM WOR <

It Gutm TtttP" ace,c! NVMGsR (Inc.ude Nee C 13 t>cwe W4 LDC. CON i!LEPr1GNE NVMW ko Code:

804-982-0091 MARTIN KNCfrTSMAMES MOUNTS 804-982-0091

14. CATES SCHEDULED 16. LOCATION REFEitENCE NWSER pCM Io te. ave sahn eLas MA., N% FvW 24i REQwE5Ts I WMtER TO BE A55 CNED BV NR0 I JUJE (TBG) TLtat b$ I o<'o / 5/ m QC ("T DC N I Mt1 C h _ _

N g ( c q,o LIST ADDITIONAL WORK SITES ON SEPARATE SHEET TO INCLUDE ALLINFCRMATION CONTAINED IN ITEMS 9-18 ABOVE. '

uw s As.cAcas em u om is5Ta;, n ucnasm 4Tagi,.

onewe een em ucunwCa nt ee ess,3.w orwe end woov.rau us.o r uee.sc . ret.Au.a.c.

num . ord sawC.:n..ed) mu m COBALT 60 se SPECWiED AC.EEMENT & TATE GPECIFtC LCEN4E WHIGN AWORn3 rhe .fhDEE5.GNED TC C.Ch0uCT ACTv.T.Es W$Cd Ama TPE & AWE. E.ACEP IN ITEM 6. ASOVE. (Four capies eline .oeci6c lisens. rawet accomper y me min i hitC F.ren 241 )

WCZNEE N4MBE% STATS E.AMR aT.C N CA rg TCTAL. V1 AGE DMS TO Dart GA 1153-1 GEORGIA JUNE 30, 1o99 19, CERTIFtCATION (MUST BE CO_MPLETED BY APPLICANT)

I, THE UNCER$1CNEO. etEREBY CERTiPY Tr%T:

s. AI information in this report is true and complete.

b required -

itohave covepayroad and with undJrstand these provimienetheas provision to all bypro ofuct,the enerall.

ocures censemuelear or special 10 CirR 150.20 repr:nted matenaleich on the I pecaste arid use cever sheet of this in nor-Agreement form States not: and I ante stand thalIl or offeo '

under the gene'el licenso for whic't ins reecrt is filed with the U E. Nutteer Regulatcry Commsaicn.

e. I unde stand that activities, Ireluding storage, conducted in rion-A0reemerts S:stes under ge'teral ficarse 10 CFR 150.20 a>s firnited to a total of 150 days in j esiencer year. j
d. I understand that I may be rspected by NRC el the above listed verk aire locations and at the Ucensee liome offi:e address for activiles perfor ned in non.Agroomet Stoies or of'shere woiers. I am also owere that I will be rssponsible for any fees ossoci.a ec we.h such inspections.
e. I unde, stand that oceduct or sey soilvities riot descrtbod above, including conduct of e:tivil'cs on detes or local lca. dWorent from those descr; bed oliove or wit *iout N8tO autP. ort:stion, mey subject me to enforcement action, including Civil or cnmanal genetties.

CL OfflNC QWsR. M3 e, Ma,agemm R.peesemasve ('ypee*MMee Am*e one hfief SdGAAT# tai CATE MARTIN KNCTIT5/DIR OF TZEMNICAL SERVICE WAstNNG: FALSE STATEMENTS IN THl3 CEltfimCATE MAY SE SJEllECT TO CML ANhCR CRMNAL PENALTCS. NRC REGULA SL'8MISSON3 TO TH! NRC BE COMPLETE AND ACCURATE IN ALL MATER;AL RESPECTS 18 U.S C. SECTCN 1001 MAKES IT A CRIM:NAL CFFENSE TC MAKE A WILLFULLY FALSE STATEMENT CR REPRESENTATION TO ANY DE=ARTMENT CR AGENCY CF TP'E UNITED STATES AS TC Af# MATTER WitMN 873 ofo'RISDICTION.

AU*=iC41NG Q&P G' AL (Typedsw.nepo kame en. s. p MNA Tw A G /~_ _

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