ML20195C879
| ML20195C879 | |
| Person / Time | |
|---|---|
| Issue date: | 06/07/1999 |
| From: | Kime T NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS) |
| To: | Trombly S AFFILIATION NOT ASSIGNED |
| References | |
| SSD, NUDOCS 9906090015 | |
| Download: ML20195C879 (2) | |
Text
{{#Wiki_filter:I June 7,1999 l l Steven Trombly, M.D. P.C. l 5195 Fifteen Mile Road Sterling Heights, MI 48310
Dear Dr. Trombly:
This letter verifies the receipt of the completed NRC Form 483 dated May 24,1999. This form is a condition of the general license under 10 CFR 31.11 authorizing in-vitro testing with byproduct material under general license. l i The fo m has been assigned registration number 7163. When making changes to any of the information on the form, please reference the registration number and address the correspondence to Director, Office of Nuclear Materia! Safety and Safeguards, U.S. Nuclear Regulatory Commission, Washington, DC 20555. If you have any questions or need further assistance, please contact me at (301) 415-8140. Sincerely, /s/ Traci Kime, Registration Specialist [ j/ Materials Safety Branch Division of Inductrial and / Medical Nuclear Safety Office of Nuclear Material Safety and Safeguards DISTRIBUTION: IMNS r/f NEO3 DOCUMENT NAME: h:\\traci\\trombly.483 j T3 receive. copy of this docum.nt, hoic.t. in the box: c - copy wnhout attachment / enclosure "E" - Copy with attachment / enclosure
- N" = No copy OFFICE MSB
,F l l l NAME TKime 7 DATE & 7/99 I OFFICIAL RECORD COPY l 9906090015 990607 PNt RC SSD ppg l J
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- NRC FORM 483 U. S. NUCLEAR REGULATORY COMMtSSION APPROVE D BY OM6 NO. 31f40038 EXPIRES 6 30 99 to so)
Entmetod twoon pe* resporme o compy vmh eus memtatory mfummten collecten request 7 mmutes The wahdated +vgestration serves as evidence REGISTRATION CERTIFICATE --in vitro TESTING
- ',""'f*l',,fii""'To'n"d fm',*, ' 'l*,'*7d" ;*""*' * '";"*'
t,,, od de,,, t,n WITH BYPRODUCT MATERIAL UNDER n"%u"*.'*,y"*"'n,"""* v"*e"b*"'"n Ec"'%i"xl"e'd."em c GENE L LIC*ENSE Peperworti Reducean Project (315oo338). Ofree of Maregsmeni enrJ Budget. Washmpton. Dc 20503 NRC may not conduct ce sponsor. and e person as not required to faapond to, e cohoction or enformehon unless it empiays e cunenny vahd OMB control numtet Smhi 31.11 of 10 CFR 31 estabhshes a Deneral hcense authortzing physicians, etnical laboratories, hospitals, and veterinarians in the p vetertnary medcine to possess certain sinall quantitles of byproduct matenal for h vitro chnical or laboratory tests not involving the intemal or e administratson of the byproduct matenal or the radiation therefrom to human beings or animals. Possess #on of byproduct material under 10 CFR authortzed until the physician, chnicallaboratory, hospstal, or vetertarian in the practce of vetennary medicine, has filed NRC Form 483 and received fro Commission a vahdated copy of NRC Form 483 with a registration number.
- 1. NAME AND ADDRESS OF APPUCANT (See Instruccon 3 B. below)
- 2. APPLICATION (Checkore boxonly)
\\
- b. b,.
I hereby apply for a regishitson number pursuant to 10 CFR 31, Section 0eO tb 31.11, for use of byproduct materials for &M [A. Myself, a dulylicensed physician authortzed to disperse drugs in S%) le nu W3 / o
- 8. The abovocamed chnicallaboratory.
'" a'=" = ""=a
- in NUMBER (F%es Case) bOi 2.lt 2 - C[OO l C. The above named hospital D. Veterinarian in the practice of.- ;,.oiy medicine 3.
INSTRUCTIONS:
- 4. REGi! TRATION A.
Submit this form in duphcate to: i REGISTRATION NUMBER: j Medcal, Academic and Commercial Use l[ph i Safety Branch (T 8 F5) go" "'%q Division of Industnal and Medcal Nuclear Safety p f0R TFE U.S. NUCLEAR REGULATORY offee of Nuclear Matenal Safety and Safeguards l COMMISSION U S. Nuclear Regulatory Commission g g Washington, DC 20555-0001 e (At NRC, a registration number will be assigned and a validated copy of NRC Form 483 will be retumed )
- g B. In the box above, pnnt or type the name, address (inck; ding ZIP d,d./ L
~h Code), and telephone number of the registrant physician, clinical I 'ts an in/Dalregr ' n, kave this space blank - number to be bboratory, hospttal, or veterinanan in the practice of vetentury assignedbyNRC. If this Is a change ofintbnnabon from e previously medcine for whom or for which thus regtstratnon form is filed registered generalicense, include your registrabon number)
- 5. If olace of use es different from address hated above, give complete address:
E CERTIFICATION I her=by ei that: A. AB informaban in this regtstraaon certificate is true and complete. a B. The regestrant has appropnate radiation measuring instruments to carry out the tests for which byproduct material will be used unde beense of 10 CFR 31.11. The tests will be performed only by personnel competent in the use of the instruments and in the handkng of the byprodud matennis. C. I urtierstand that Commrssion regulabons require that any change en the information fumished by a registrant on this registration certifcate reported to the Director of Nuclear Material Safety and Safeguards within 30 days from the effective date of such change D l han reed and understand the provis6ons of Section 31.11 of NRC regulations 10 CFR 31 (reprinted on the reverse side of this form), understand that the registrant is required to compty wtth those provisions as to all byproduct material which he receives, acquires, poss or transfers under the general license for whch this Registration Certificate is filed with they.S. Nuclear Regulatory Commission. PRINTED 9 TYPED NAME AND TITLE OF APPLICANT SIGNATURE Of APPLICA T ~ DATE Y% 5' JD /1 M WARNING: FALSE STATEMENTS IN THIS CERTIFICATE MAY BE SUBJEpT TO CML AND/OR CRIMINAL PENALTIES. NRC REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRC BE COMPLETE AND A ALL MATERLAL RESPECTS,18 U.S.C. SECTION 1001 MAKES IT A CRIMINAL OFFENSE TO MAKE A W1LLFULLY FALSE STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATE ANY MATTER WITHIN ITS JURISDICTION. =cWm 3 piei}}