ML20203C717
| ML20203C717 | |
| Person / Time | |
|---|---|
| Site: | 07002258 |
| Issue date: | 04/03/1986 |
| From: | King J FLINT OSTEOPATHIC HOSP., FLINT, MI |
| To: | |
| Shared Package | |
| ML20203C698 | List: |
| References | |
| 326732, NUDOCS 8607210063 | |
| Download: ML20203C717 (1) | |
Text
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gCg--m u.s r,UCtEra REGutATO.;Y COMMISSION arrROvtgegg 3 5,R io se"'""" " =l=
io C CERTIFICATE OF DISPOSITION OF MATERIALS (Allitems MUST be completed, please print)
LICENSEE NAME AND ADDRESS LICENSE NUMBER Flint Osteopathic Hospital SNM - 1632 3921 Beecher Road LICENSE EXPtRAflON DATE Flint, Michigan 48502 May 31, 1986 THE LICENSEE OR ANY INDIVIDUAL EXECUTING THIS CERTIFICATE ON BEHALF OF THF LICENSEE CERTIFIES THAT: (Check murhe campJere the apprwriste item (s) below.)
A. MATERIALS DATA (Check one and complete, as peersesrir) 1.
NO MATERf ALS HAVE EVER BEEN POSSESSED OR PROCURED BY THE LICENSEE UNDER THIS LICENSE.
- 2. ALL MATERIALS PROCURED AND/OR POSSESSED BY THE LICENSEE UNDER THE LICENSE NUM8ER ClTED ABOVE HAVE BEEN TRANSFERRED ON DATE TO WHICH HAS NRC LICENSE NUMBER OR
] 3. ALL MATERIALS PROCURED AND/OR POSSESSED 8Y THE LICENSEE UNDER THE LICENSE NUMBER CITED A8OVE DATE TO WHICH HAS LICENSE NUMBER llSSUED 07 THE ST ATE OF AN AGREEMENT STATE PURSUANT TO SECTION 274 OF THE ATOMIC ENERGY ACT OF 1954, AS AMENDED. AND THE ENERGY REORGANIZATION OR ACT OF 1974.
4.
MATE RIALS HAVE BEEN DISPOSED OF IN THE FOLLOWING MANNER. (Describe specific disponsipIoredures-if additionalspace Is neednf, use the reverse of this form, or provide attachments)
Renewed in 1981 No knowledge or documentation of implantation siYite renewal Any licensed ex,piratig.n_bef.. ore 1981 was done by Michael Wright,D.0
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B. OTHER DATA
- t. OUR LICENSE HAS NOT YET EXPlRED;fLEASE_ TERMINATE'IT.
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- 2. WAS A RADIATION SURVEY CONDUCTED TD CONDRM TWABSENCE OF LICENSED RADIOACTIVE MATERIALS AND TO DET
_ CONTAMINATION REMAINS ON THE PREMISES COVERED BY THE LICENSEP (04eck onel NO YES. THE RESULTS (Check onel Not Applicable ARE ATTACHED, OR Q
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WERE FORWARDED TO NRC ON (Ostel
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THE PERSON TO 8E CONTACTED REGARDING THE INFORMATION PROVIDED ON THIS FORM Michael Wright, D.0.
I"UT' '""E6 2 - 4 6 7 9 4 Mall ALL FUTURE CORRESPONDENCE REGARDING THIS LICENSE TO Becky Shaw, R.T. - 3921 Beecher Rd, Flint, MI 48502 Ronald E. Weigel, D.0. - 3921 Beecher Rd, Flint, MI 48502 CETURN TO:
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CERTIFYING OFFICIAL SIGN A TYRE DIRECTOR. DIVISION OF FUEL CYCLE AND MATERIAL SAFETY DAtt OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS 7< C/h
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..g U S. NUCLEAR REGULATORY COMMISSION 4
WASHINGTON. DC rosss PRuerto NAME ANO ritLE
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u Mr. James Kin,g 8607210063 G60bl6 Director Patient Services NT.f: Form 314 100 PDR S N M -
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