ML20137W501
| ML20137W501 | |
| Person / Time | |
|---|---|
| Site: | 07000391 |
| Issue date: | 12/27/1984 |
| From: | Faust J PRINCETON UNIV., PRINCETON, NJ |
| To: | |
| Shared Package | |
| ML20137W321 | List: |
| References | |
| 03276, 3276, NUDOCS 8512100260 | |
| Download: ML20137W501 (18) | |
Text
-
m A
NetC FORM 313 U.S. NUCLEdi WEGUL A7077 COMMISSION 11 4,
w e
ti M 30. 32,33,34 APPJ Ovf D S 7 0Me 31560120 3S e~"O APPLICATIIN FOR MATERIAL LICENSE E..e s3 s7 INSTRUCTIONS: SEE.THE APPROPRI ATE LICENSE APPLICATION GUIDE FOR DETAILED INSTRUCTIONS FOR COMPLETING APPLICATION. SEND TWO COPIES OF THE ENTIRE COMPLETED APPLICATION TO THE NRC OFFICE SPECIFIED BELOW, FEDERAL AGENCIES FILE APPLICATIONS WITH:
IF YOU ARE LOCATED IN:
U S. NUCLE AR REGULATORY COMMi$$10N ILLINOIS, INDI ANA, IOW A, MICHIG AN, MINNESOT A, MISSOURI, OHtO, OR OlV16AON OF FUEL CYCLE AND MATERIAL SAFETY,NMS$
WISCONSIN, SEND APPL 8 CATIONS TO:
WASHINGTON,0C 20555 U.S NUCLE AR REGULATORY COMMIS$3ON, REGION iil ALL OTHER PERSONS FILE APPLICATIONS AS FOLLOWS,IF YOU ARE MATERI ALS LIC N$ LNG SECTION LOCATEOlN:
799 ROOSE VELT OAD GLEN ELLYN,IL 60137 CONNECTICUT, DELAWARE, DISTRICT OF COLUMBIA, MAINE, MARYLAND, Ma se arHUSE TTS, NEW JE RSE Y, NE W YOR K, PE NNSYLVANI A, RHODE ISLAND, AFiKANSAS. COLORADO,lDAHO KANSAS, LOUISIANA. MONTANA, NE8RASKA, OR VERMONT, SENO APPLICATIONS TO:
NEW ME XICO, NORTH DAKOT A, OK LAHOMA, SOUTH DAKOTA. TEXAS UT AM, U S. NUCLE AR REGULATORY COMMISSION. REG'ON I NUCLE AR MATERI AL SECTION S U S. NUCLE AR REGULATORY COMMISSION. REGION IV S31 PARE AVENUE MATERIAL RADIATION PROTECTION SECTION KING OF PRUS$1A,PA 19406 Ell RYAN PLAZA DRIVE,SulTE 1000 ALASAMA, FLOnlOA. CEORGIA, K E NTUCK Y, MISSitSIPPt, NORTH CAROLIN A, PUE RTO RICO, SOUTH CAROLINA. TE NN ESSE E, VIRGINI A, VIRGIN ISLANDS, OR ALASK A, A RIZONA, CALIFOR NI A, H AW Ali, N EV ADA, OR EGON, W ASHINGTON.
WEST VIRGINIA, SEND APPLICATIONS TO:
AND U.S. TERRITORIES AND POSSESSIONS IN THE PACIFaC, SEND APPLICATIONS TO:
U S. NUCLE AR REGULATORY COMMISSION, REGION 11 MATERI AL R ADI ATION PROTECTION SECTION U.S NUCLE AR REGULATORY COMMISSION, REGION V 101 MARIETTA STREET,8UITE 2900 MATERIAL R ADIATION PROTECTION SECTION ATLANTA, GA 30323 1450 MARIA LANE, SUITE 210 WALNUT CREEK.CA 94596 PE RSONS LOCATED IN AGREEMENT STATES SEND APPLICATIONS TO THE U S. NUCLE AR REGULATORY COMMISSION ONLY IF THEY WiSH TO POSSESS AND USE LICENSED M IN STATES SUBJECT TO U1 NUCLE AR REGULATORY COMMIS$10N JURISDICTION, THl318 AN APPLICATION FOR (ChechRNwspraete itern)
- 2. NAME AND M AILING ADORESS OF APPLICANT (tsiricalelip Codel Princeton University A. NEW LICENSE Occupational Health & Safety -
8 AMENDMENT TO LICENSE NUM8ER SNM-356 T
C. RE=EWAt OF uCENsE =uMsER Forrestal Campus Princeton, NJ 08544
Princeton University - Main Campus & James Forrestal Research Campus (s. NAME OF PERSON TO OE CONTACTED A80UT THf5 APPLICATION TELEPHONE NUMBER Mr. Jack C.
Faust (609)452-5294
$Utuff ITEMS S THROUGH 11 ON 84 m It" PAPER THE TYPE AND SCOPE OF INFORMATION TO BE PROVIDED IS DESCRISED iN THE LICENSE APPLICATION GUIDE.
- 5. 7ADIOACTIVE MATERi AL e, Element sad mass number, tk. chemical and/or phys.cel lorm, and e me..enum emowns 6 PURPOSEIS) FOR WHiCH LICENSED MATE F'I AL WILL 0E USED, enhech eveal be possessed at say one time.
I RAINsNG A P
E C
$ TRAINING FOR INDIVIDUALS WORKING IN OR FREQUEN'ING RESTRICTED ARE AS.
" ~ 51210 0260 851023 8
REG 1 LIC70 ENSEEF 5,
O e,I, Soc.e. no n, si WASTE MA SNM-0356 PDR e
1
( a) ( 4 )l AMOU=7 FE Cart Rv ENCtOSED s none
- 13. CERTIFICATION 14fust 8etemp/eleday ens 6reer) THE APPLICANT UNDERSTANDS THAT ALL STATEMENTS AND REPRESENTATIONS MADE IN THtS APPLICATtON ARE SINDING UPON THE APPLICANT THE APPLICANT AND ANY OFFICIAL E NECUTING THis CERTIFICATION ON SEMALF OF THE APPLICANT NAMED IN ITEM 2,CERTiFV THAT THiS APPLICATION 85 PREPARED IN CONFORMITY WITH TITLE 10, CODE OF FEDERAL REGULATeONS, PARTS 30,32,33,34,35 Aly0 40 AND THAT ALL INFORMATION CONTAINED HEREIN, IS TRUE AND CORRECT TO THE DEST OF THEIR KNOWLEDGE AND SELIEF WARNING 18 U $ C. SECTION 1001 ACT OF JUNE 25,1940.62 STAT 749 MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTER wtTHIN ITS JURISDICTION.
SIG=ATURE-CE RTIF ring OF FiCE TvPEDiPRi=TED N ME lTirtE Director, Office od W YP7 dcg Jack C. Faust Occupational Health & Safety 14 v0LONT Aav i CONosa'C DAT A r
. ANNu a R cit *rs a NUMgER OF EMPLOVEES tresos ter a WOULD v0U SE WILLING TO FuRNISM COST INFORMATION /Je<ser ead/orsteN Aewest
<$2SOK
$1M-3 SM
- 'd* 8#'rP est&asar overade teatracteruf ON THE ECONOMIC IUPACT OF CURRENT NRC REGULATIONS OR ANY FUTURE PROPOSED NRC REGULATIONS THAT MAY AFFECT YOUP (N#Cservdeceassermer
$250K-600K
$3 5M-7M
- ' e agency de tenfsdrie'refd'**#'d'"#8"""**8'#******#-8'88F""'#**"'****#
8 JR
$500K-750K
$7M-10M
- c. NUMBER OF SEDS FOR NRC USE ONLY E OFFEE FEE LDG FEE CATEGORY COMMENTS APPROVED 0 Y l
/70 // O p'
_ _ TRE.IVED CHE_eM.ER D.,1
&faE 3 0 occ 2 819t4I y6' PR,v+ AC, $,ATEMEN,0N,HE REWERSE
PRIVACY ACT STATEMENT Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by section 3 of the Privacy Act of 1974 (Public Law.03 579),the follow-ing statement is furnished to individuals who supply information to the Nuclear Regulatory Commission on, NRC Form 313. This information is maintained in a system of records designated as NRC-3 and described at 40 Federal Register 45334 (October 1,1975).
- 1. AUTHORITY: Sections 81 and 161(b) of the Atomic Energy Act of 1954, as amended (42 U.S.C. 2111 and 2201(b)).
- 2. PRINCIPAL PURPOSE (S): The information is evaluated by the NRC staff pursuant to the criteria set forth in 10 CFR Parts 30,32,33,34,35 and 40 to determine whether the application meets the requirements of the Atomic Energy Act of 1954, as amended, and the Commission's regulations, for the issuance of a radioactive material license or amendment thereof.
3.- ROUTINE USES: The information may be (a) provided to State health departments for their information and use;
' and (b) provided to Federal, State, and local health officials and other persons in the event of incident or expost;re, for their information, investigation, and protection of'the public health and safety. The information may also be dis-closed to appropriate Federal, State, and local agencies in the event that the information indicates a violation or potential violation of law and in the course of an administrative or judicial proceeding. In addition, this information may be trans-ferred to an appropriate Federal, State, or local agency to the extent relevant and necessarpfor an NRC decision or to an appropriate Federal agency to the extent relevant and necessary for that agency's decision about you.
- 4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVID-lNG INFORMATION: Disclosure of the requested information is voluntary. If the requested information is not furn-ished, however, the application for radioactive material license, or amendment thereof, will not be processed. A request that information be held from public inspection must be in accordance with the provisions of 10 CFR 2.790. Withhold-ing from public inspection shall not affect the right, if any, of persons properly and directly concerned need to inspect the document.
- 5. SYSTEM MANAGER (S) AND ADDRESS: U.S. Nuclear Regulatory Commission Director, Division of Fuel Cycle and Material Safety Office of Nuclear Material Safety and Safeguards Washington, D.C. 20555 UNITED STATES
,n'@'s e [s r' Iso NUCLEAR REGULATORY COMMISSION uspc WASHINGTON. D.C. 20666
,$','((, 'm OFFICIAL BUSINESS PENALTY FoR PRIVATE uSE. s300
?
w_-.
O O
Page 1 SUPPIBfENT 'ID NRC LICENSE RENEWAL APPLICATION Item 5.- Radioactive Materials 5(a) Element and 5(b) Chemical and/or 5(c) Amount
' blass Ntaber Physical Fonn 1.
Pu-239 Encapsulated Pu-Be Neutmn Sources Nominal Monsanto Research Corp. Curie Grams Mfgr's No. M-381 0.1 1.6 M-741 1.0 16.0 M-742 1.0 16.0 M-743 1.0 16.0 M-941 1.0 16.0 See Note 1 below.
2.
Pu-239-See Note 2 below.
2.0 32.0 3.
Pu-239 As plated alpha 0.016 counting source standanis 4.
U-235 Any 100.00 Note 1.
All the Pu-Be neutmn sources listed are presently in
~
Princeton's possession. All sources are right cylinders consisting of.a Pu-Be alloy encapsulated in an inner tantalta container and an outer stainless steel welded container.
Note 2 The additional two (2) Curies authorization is requested to pennit acquisition of other sources up to two (2)
Curies in total amount without the necessity of filing for a license amendment.. If obtained, these sources will be of similar construction and design as the others listed.
l
s LO O
page 2 Itah 6 Purpose for which licensed materials will be used Education, training, and education-related research.
Item 7; The Office of % m tional Health and Safety'is directed by Mr. Jack C. Faust, who holds a Masters Degree in Health Physics
'(A.E.C. Fellow) frm the University of Rochester (1959). Mr.
- Faust was employed by Brookhaven National Laboratory as a Health Physicist fr m August, 1959, until he was appointed University Health Physicist at Princeton University in July of 1963. He was appointed Director of the Health Physics Group in July of 1967. Since ~ September 30, 1971, he has been the Director of the office of Occupational Health and Safety, with broadened safety responsibilities including, in addition to radiation safety, industrial hygiene, sanitation, and general.
safety..
Primary responsibility.for the radiation safety program lies with the University Health Physicist whose name and qualifica-tions follow:
Mr. Robert R. Milwicz, the University Health Physicist, holds a-B.A. degree in Physical' Sciences frm Montclair State College (1968). Mr. Milwicz was etployed on a part-time basis, totaling about 18 months, during the period 1964 to 1968, as a Health' Physics Technician. After obtaining his degree in 1968, he rejoined the Group as a full-time' professional-W r and has functioned in that capacity since that date.-' While working full-time at Prirs t.eu University, he studied part-time at Rutgers University, earning his M.S. degree in Radiological Science in 1976. Mr. Milwicz is assisted by Mr. David Dicello, Assistant University Health Physicist.
Mr. David C. DiCello received a B.S. in Biology (1981) frm the University of Pittsburgh and ocupleted the requirenents for a
-M.S. degree in Radiation Health (1983) frm the University of Pittsburgh Graduate School of Public Health. He worked pre-viously for the Monsanto Research Corporation monitoring uraniun milling sites in Canonsburg, Pennsylvania.
Other Health Physics staff include two Health Physics hchnical Sprialists: Mr. Kent r amhart who received a B.S. degree frm Texas A & M University (1978) in Radiation Protection Engineering, and Mr. Charles Mansfield who received a B.S. degree frm Texas A & M University (1983) in Radiological Health Engineering; and a Health Physics Technician, Mr. Joseph Sundra, who has been with the University for 20 years and is a Certified Radiation Protec-tion Technologist.
m_
page 3 Its 8 Training for individuals is as explained in Section 6.2 Its I of the Uni'ersity Radiation Safety Guide which you have in your v
possession.
Its 9 The Office of Occupational Health and Safety has a number of pcrtable ionization chamber survey meters with sensitivity rarges frca 3 mR/hr to1000R/hr full scale; portable survey meters with geiger instruments (thick and thin walled), large area alpha and/or beta contamination survey probes, scintilla-tion probes; lw energy beta /ganma survey meters; x-ray dosi-meters and dose rate meters; two lw level counters for smear and leak test analyses; multi-channel analyzer spechwad.ers with sodim iodide crystals (solid and well types); neutron survey meters; several portable bonnersphere neutron detector systss; a thermolminescent dosimetry systs; two precision long counters; a thyroid counting system; high and l w volume air sanpling equipnent; two hot wire anemcmeters for checking fune hood and other air flw rates; and the necessary electronic test bench equipnent for maintenance and repair.
All dose an1 exposure measuring radiation safety-instrmentation is calihrated on an approximate three month schedule.
Ioniza-tion chamber instrunentation is calibrated using radium-226 or cobalt-60 sources previously calibrated by the National Bureau of Standards. All neutrm detecting equipuent is calibrated using plutonium-beryllium neutron sources calibrated by Mon-santo Laboratory. Radiation counting syst es are calibrated periodically using check sources calibrated by the National Bureau of Standards or bearing certificates traceable to the Bureau of Standards.
Item 10 The radiation safety program is described in the University Radiation Safety Guide, Fburth Edition as amended, which includes both laboratory and administrative procedures. A brief sunnary follows:
1)
Responsibilities and Authority The University Radiation Safety Ccmmittee, a subommittee of the Ccamittee on Occupational Safety and Health, is charged with the responsibility and has the authority to review all proposed usage of radioactive materials. The Ccumittee is enpowered to authorize the usage of radio-i active materials, including the materials under this license, upon the rumnnndation of the Office of occupa-l tional Health and Safety. The Chairman of the University
{
Radiation Safety Ccumittee is an ex-officio mrunbar of the Ccumittee on Occupational Safety and Health.
\\
^
Page 4 Item 10 The University Ccmnittee on Occupational Safety and Health (cont'd) is the policy-making body and is appointed by the President of the University. Policies of this Ccmnittee are inple-mented by the Office of Occupational Health and Safety with regard to radiation safety as well as other occupational hazards. Mmbers of the University Radiation Safety Ccmnittee and the Ccmnittee on Occupational Safety and Health are iden-tified in Appendix A of the University Radiation Safety Guide.
- 2) Meetings The Ccmnittee on Occupational Safety and Health meets on a rx2ninal monthly schedule during the acadenic year and during the simner months when appropriate and necessary. Normally, the Ccmnittee has met on the average of five times per year.
Minutes of all meetings are prepared, distributed, and retained on file.
The Radiation Safety Ccanittee is a working group which reviews applications, on a continuing'and regular basis, for-1 the use of sources of radiation. Because of this and because at least two and usually more m mbers of the Radiation Safety Ccmnittee also serve on the Ccmnittee on occupational Safety and Health, the Radiation Safety Ccmnittee meets only on an as-needed basis. Routine matters relating to radiation safety are reviewed at the meetings of the Ccmnittee on Occu-pational Safety and Health.
- 3) Authorization to Use Radioactive Materials All persc5ns desiring to use radioactive materials must apply for internal authorization through the Office of Occupational Health and Safety. Application is made by ocrnpleting the appropriate Occupational Health and Safety forms as follcws:
- 1 (personnel data and exposure history), #4 (statement of training and experience), #20 (application for isotope auth-orization ' number), #20a (supplanental information), and when appropriate #30 (irradiation).
See attachments. Foun #20 calls for basic information regarding the intended use of the isotope (s) and must be signed by the Departmental Health and Safety Coordinator signifying departmental acknculedgment and/
or approval for such usage.
The application and supporting information is forwarded to the Office of Occupational Health and Safety for review. The applicant is interviewed by a professional Health Physicist during which the proposed usage is discussed and evaluated.
The investigator is also acquainted with the University Radia-tion Safety Guide, appropriate parts of 10 CFR, the New Jersey
E.
O O
page 5 Item 10 Radiation Protection Code if apewe iate, and informed of r
(cont'd)-
internal procedures. The laboratory space is inspected for =Arruvy of' facilities such as fine hoods, i=na-ahle bench tops, washable floors, diapnaal facilities, availa '
bility of Marmte equipnent to survey working areas, etc.
E en the application is approved by the Health Physics Officer *,. copies of the application, supporting infonnation, and a r e adation regarding approval are mailed to all available members of the Radiation Safety Ccmnittee for their review and approval. If all available mamhars of the conmittee unanimously approve the application, an authoriza-tion ntuber is issued to the applicant' for the specific iso-tope (s) in the possession limit requested. In the event a Ccunittee menber objects to the application, effort is then made to remove the objactionable situation in order to obtain unanimous approval.. If this fails, this request is denied.
The applicant may then request an extraordinary meeting of the RMiation Safety Cmmittee to discuss the-application and usage. Authorizations are issued on a conditional basis when appropriate.
'Ihe Radiation Safety Cmmittee has authorized the Health Physics Officer
- to approve applications for use of small anounts of radioactive material. See the Idmited Possession =
Ntaber Prnmarhwe in the Radiation Safety Guide for details.
- 4) All purchases and acquisitions of radinart.ive materials must be approved by the Office of nen=tional Health and. Safety.
'Ihe Purchasing Department will not pwsss any order without prior nrngational Health and Safety Office approval. 'Ihe individual users are responsible for insuring that they stay within-their authorized possession limits.
- 5) The leak testing of sealed sources, smear testing of labora-tory and work areas, personnel radiation history and exposure records progran, isotope inventories, the administration of the authorization ntuber pwwdure, radiation surveys and 1
related Health Physics are line responsibilities of and are perfonned by the Office of %=tional Health and Safety under the direct.Mn of Mr. Jack C. Faust. Additional and more detailed infonnation regarding the entire progran may be found in the Radiation Safety Guide.
6)
Film, TID, and Track Etch badge service is supplied by a ccnmercial service, presently R. S. Landauer, Jr. & Caparry, Glenwood Science Park, Glenwood, IL 60425. Bioassays are contracted by Teledyne Isotopes, Inc., 50 Van Buren Avenue, Westwood, RT 07675.
- the. University Health Physicist is the Health Physics Officer
O O
page 6 Item 11 Waste disposal service is supplied by a duly licensed camer-cial organization, at present Teledyne Isotopes, Inc., Radio--
logical Service Department, 50 Van Buren Avenue, Westwood, NJ 07675, N.R.C. License No. 29-00055-14.
'Ihe University is considering alternate means of radioactive waste disposal. These are under study and if necessary will be addressed in an amendment application.
Attachments to Supplement OHS Fom #1 OHS Fom #4
- OHS Fom #20 -
OHS Fom #20a CHS Fom #30
7 s-)
i PRINCETON UNIVERSITY 0FFICE OF OCCUPATIONAL HEALTH & SAFETY PERSOM4EL DATA AND EXPOSURE HISTORY PLEASE PRINT DATE FULL NAME BIRTH DATE (las t)
(firs t)
(middle)
(month, day, year)
SOCIAL SECURITY NO.
SEX AGE IN FULL YEARS DEPARTMENT EXTENSION POSITION OR TITLE DATE EMPLOYED WIVERSITY MAILING ADDRESS IM4EDIATE SUPERVISOR OR ADVISOR EXTENSION PRINCETON WIVERSITY STATUS: FACULTY MEMBER O STUDENT - GRADUATE EMPLOYEE LNDERGRAD 0
OTHER IF YOU ARE. EMPLOYED BY ANOTHER ORGANIZATION, PLEASE INDICATE YOUR AFFILIATION:
1.
HAVE YOU PREVIOUSLY MD' REGULAR FIW BADGE SERVICE AT PRINCETCN?
YES NO APPROXIt%TE DATES 2.
l%VE YOU EVER WORN A PRINCETON VISITOR BADGE (YELLOW HOLDER)?
YES NO APPROXIt%TE DATES 3.
MVE YOU EVER RECEIVED ANY HIGH OR LNUstRL RADIATION EXPOStRE?
YES NO 4.
HAVE YOU EVER INHALED, INGESTED, OR BEEN INJECTED WITH ANY RADIO-
-ACTIVE MATERIAL?
YES NO 5.
HAVE YOU EVER BEEN TESTED FOR INTERPMLLY DEPOSITED RADIOISOTOPES BY URINE OR FECAL ANALYSIS OR BY WHOLE BODY COUNTING 7 YES NO IF "YES" TO QUESTIONS #3, #4, AND/OR #5, PLEASE EXPLAIN:
6.
HAVE YOU RECEIVED ANY OCCUPATIONAL RADIATION DOSE DURING TFE CURRENT CALE? OAR QUARTERM FROM SOLRCES NOT LNDER PRINCETON'S CONTROL?
YES NO IF YES, PLEASE INDICATE AMOWT AiO NATURE OF ANY DOSE RECEIVED DURI?G PERIOD TO (FILL IN DATES"):
% ATES OF CALEPOAR QUARTERS ARE: 1/1-3/31, 4/1-6/30, 7/1-9/30, OR 10/1-12/31.
PLEASE TURN OVER AND COMPLETE OHS FORM 91 (REV n /_8_0,)
l
7 HAVE YOU PREVIOUSLY WORKED WITH RADIOISOTOPES?
YES N0 IF YES,- PLEASE INDICATE '.lHEN, WHERE, AND IDENTIFY TM ISOTOPES AND TYPICAL AMDt.NTS USED:
8, HAVE YOU PREVIOUSLY kORKED WITH A RADIATION-PRODUCING MACHINE?
YES ND IF YES, PLEASE INDICATE WHEN, WHERE, AND DESCRIBE TYPE OF.
EQUIPMENT:
S,HAVE YOU EVER BEEN MONITORED FOR AN OCCUPATIONAL RADIATION EXPOSURE?
YES ND IF "YES" TO QUESTIONS N6, 97, 98, AND/OR #9, PLEASE PROVIDE TN FOLLOWING ADDITIONAL INFORMATION:
DATES OF PERIODS OF PREVIOUS EMPLOYER'S NAW AND I?+EDIATE SUPERVISOR EMPLOYK NT EXPOSURE ADDRESS AND DEPARTE NT (FROM--TO)
(FROM--TO)
IF EXPOSURE WAS RECEIVED IN THE MILITARY, PLEASE PROVIDE THE REQUESTED ADDITIONAL INFORMATION:
DISCHARGE DATE R M M ER E E M STA M DI CERTIFICAT!J4:
'l CERTIFY THAT THE EXPOSURE HISTORY GIVEN ABOVE IS CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
DATE (signature) bis FORM fil (BACK) (REV.1/80) g h
~
PRINCEION UNIVERSITY OFFI
_0F OCWPATIONAL HEALTH 6 SAFLTY
- Name Date Highest Academic Degree Title or position An individual who is planning to work with radioactive materials or radia-tion producing equipnent, must satisfy the University Radiation Safety Committee that he is qualified by virtue of training and experience to handle such materials and equip-ment safely. The information requested below is reviewed by the Committee when consi-dering your application.
TRAINING 6 EXPERIENCE Dur ion Type of Training Where Trained Fonnal On the Courses Job Tra W A. Principles and Practices of radiation pro-yes no yes no tection B. Radioactivity measurements, standardization, monitoring, and yes no yes no instunnental techniques C. Mathematics 6 Calculations basic to the use 4 measuranent of yes no yes no radioactivity 4 radiation EXPERIENCE WITH RADIATION (actual use of radionuclides or equipnent)
Duration Isotopes and Amounts or Where Used of Type of Use Equipnent Used Experience cc:
P.E.P., folder signature 0.11.4S Form #4 (Fev.10/73)
O 0
~
PRINCEiON UNIVERSITY
~
OFFICE OF OCCUPATIONAL FALTH 4 SAFETY Radioisotope Application
- Applicant Posit'ica or Title (Print or type)
. Department Building Room #
Phone Possession (1)
Type of(2)
Physical Buildings (s) 4 Room (s)
I8 t Pe Limit (mci)
Source Form Whem Used and/or Stored
' 0) Amount requested should be large enough to cover the maximum inventory which will be in your possession at any one time, including wastes and stores.
(2) Indicate open or sealed.
N ~
Do you pasently hold valid Authorization Number (s)?
yes
[
no Do you presently hold valid Limited Possession Nmber(s)( yes
~
no On the back, of this form or on a separate sheet, if necessazy, provide answers for the following questions.
Identify your answers by indicating the question ntaber.
ETE: It is necessary to explicitly answer each of the following questions for each isotope requested above.
If the answers to the questions are the same for each isotope, requested, then please explicitly indicate this. If not, answer the questions for each
. isotope on a separate sheet, clearly referencing the relevant isotope.
1)
In any case where this application is a request for an increase in the Possessicn Limit for an isotope already authorized, please identify that isotope and indicate your present possessim limit.
- 2) Briefly describe your experiment.
Indicate typical amounts (mci) of radioactive materials to be used, and frequency of use. Describe physical or chemical manipulations intended.
- 3) Explain briefly your intended use.
- 4) Will this material by used by persons other than you?
yes no If yes, provide information to identify these persons, their qualifications, and indicate how you intend to insure that they receive adequate supervision.
Q 5)
Will animals be used in this work?
yes no.
If yes, indicate the ntmber and types of animals and describe how they will be used.
If this work with respect to the instruction of animal caretakers,pecial precautions you nianventila involves in vivo use of radioisotopes indicate the s contaminated cages and other equipment, and the disposal of the excreta wastes and carcasses.
O. H. 4 S. Form #20 (Rev. 7/77)
1 ANSWERS:
{
DOClNENTATION REQUIRED IN ADDITION TO HIIS FORM:
1)
If this is your first application for either type of radioisotope authorization, couplete and submit O. H. 4 S. Foms #1, #1a, #2a, #4, and #20a.
.jp M
- 2) -If this is your first application for an Authorization Nunber, couplete and submit O. H. 4 S. Foms #4 and #20s, even though you hold a Limited Possession Number.
- 3) If you hold a valid Authorizatial Number, no additional infomation is required.
Forms are available from the Office of Occupational Health 4 Safety (ext. 2-5294) or fmm your Departmental Safety Coordinator.
CERTIFICATION:
I certify that the work perfomed with the materials requested in this application will be done in acwrdance with the rules and regulations contained in the Radiation Safety Guide.
Applicant's Signature Date Acknowledgement and/or Approval by:
Date (Departmental Safety Coordinator)
Approval by:
Date (Health Physics Officer)
Approval by:
Date (Radiation Safety Conmittee Member)
REMARKS:
O
, S Fo'rm #20 (back)' (Rev. g7) h 0H L.
g G'
O O
~
PRINCEION UNIVERSITY
]
OFFICE OF OCCUPATIONAL HEALTH 6 SAFE 1Y Applicant Phone (typed or printed)
Department Building Room Application for:
' Isotope Amount nCi Irradiation to produce Amount cCi In the spaces provided below, please answer the following questions and provide a reasonable amount of detail.
1.
Do you have in your possession and are you familiar with the provisions and regulations in the: University Radiation Safety Guide, Federal Regulations 10 CFR Parts 20 and 30, University's NRC and/or State Licenses and the New Jersey Radiation Protection Code? -
2.
What survey and mmitoring equipment do you have? Itemize specific items owned or those which you plan to order if this application is approved. A monitoring device is generally required if millicurie amounts are requested.
O w
F 3.
hhat are your specific plans for the disposal of radioactive waste and for the keeping of receipt, use, and disposal records?
4.
hhat arrangements have you made with the Office of Occupational Health 6 Safety with respect to personnel monitoring requirements?
~
O
- 0. H. 4 S. ' Form #20a (Rev. 7/77)
- 5. ~Nhat plans do you have for the orientation of assistants, staff, students, jani-tors or visitors in relation to Items 1 and 3 above and with respect to radio-logical safety in general?
cp) 6.. What storage facilities do you plan to use and how do you plan to secure your isotope (s) to prevent use or possession by unauthorized personnel or to prevent accidental loss?
i 7.
What facilities and protective equipnent are available to you?
(Hoods, absorbent paper, labels, tags, shielding,etc.)
8.
What precautions will be taken to test for leakage and/or contamination upon receipt of these materials?
O 9.
What measures will be taken to prevent, detect, and handle a " spill"?
9
- 10. Please provide any other relevant infonnation.
i Date Appligant's signature-
,'0HS Form #20a (back) (Reh7/77) h
r-o o
glication f6r (check one):
PRINCE 1tN UNIVERSI'lY ATI N E m 4 N Limited Possession No.
Irradiation Authorization No.
Applicant Position or title (print or type)
Department Building Room Phone Building and Room (s) where isotopes will be stored and/or used:
This material will be used as a:
[
sealed source an open source-Target:. Isotope or Compound Dimensions Amount Physical Form 4 Description Irradiation:
Particles Energy (MeV) 2 Current or Flux (pa or sec-cm ) duration of irradiation (hr.)
Facility at which irradiation is to be done Principal isotope of interest Other isotopes produced This request is for a:
Single irradiation or about
,or
] A series of irradiations over the period of at intervals of EXPECTED ACTIVITY AND DOSE Principal Vessels RATES FR(N TOTAL SAMPLE Isotope 6 Wrappers Isotopes At end of irradiation (mci)
Upon Arrival at Princeton U. (mci) or at a time of initial handling Gamma Dose (R/hr 8 30 cm) l Beta Dose (Rad /hr 810 cm)
On a separate sheet please provide the following infonnation. Identify your answers by indicating the question number, j
- 1) Explain briifly your intended use.
@, P& 4 & Fosim #30 (Re% 7/77)
J
- 2) Brisfly describe your cxperiment. Indicate typical amounts (mci) of radioactive mat; rials to be used and frequency of use. Describe physical or chemical manipu-lations. intended.
- 3) Will this material be used by persons other than you?
Yes No. If yes, provide sufficient information to identify these persons, their qualifications, and how you intend to insure that they receive adequate supervision.
- 4) Will animals be used in this work?
Yes No.
If yes, indicate the number and types of animals and their location and describe how they will be used.
If this work involves in vivo use of radioisotpes, indicate the special precautions you plan with respect to the instmetion of animal caretakers, ventilation, the control of contaminated cages and other equipment and the disposal of the excreta wastes and carcasses.
- 5) How is sample to be handled and transported from site of irradiation to or from your laboratory? (Specify handling equipment, shipping container, means of transportation and route in some detail).
6)
If you intend doing multiple irradiations, what is the maximum amount (mci) of these isotopes you will have on hand at one time?
Other valid Authorization of Limited Possession Numbers you' hold:
Number Isotope Amount Number Isotope Amount Number Isotope Amount l
l l
i l
l I
I DOCLNENTATION REQUIRED IN ADDITION TO THIS FORM:
i) If this is your first application for either type of a radioisotope authorization, complete and submit OHS Forms #1, #1a, #2, #4 and #20a.
2)
If this is your first application for an " Authorization Number", complete and sub-mit Olis Foms #4 and #20a, even though you hold a " Limited Possession Number".
- 3) If you hold a valid " Authorization Number", no additional information is required.
Forms are available from the Office of Occupational Health 6 Safety (c'xt. 2-5294) or from your Departmental Safety Coordinator.
CERTIFICATION:
I certify that the work performed with the materials requested in this application will be done in accordance with the rules and regulations contained in the Radiation Safety Guide.
Applicant's Signature Date Approved by:
Date (Departmental safety coordinator)
Approved by:
Date (Health Physics Officer )
Approved by:
Date (Radiation Safety Committee Member)
.S! ARKS; e
w 0.* H. 6 'S, Fom #30 (back) (ig 7/77) g
,