ML20207H596
| ML20207H596 | |
| Person / Time | |
|---|---|
| Issue date: | 06/17/1999 |
| From: | Kime T NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS) |
| To: | Maniago P INDIANA, STATE OF |
| References | |
| SSD, NUDOCS 9906180172 | |
| Download: ML20207H596 (2) | |
Text
_
l Juns 17,1999 s
'_s Indiana State Department of Health ATTN: Dr. Peter Manlago 635 North Barnhill Drive Indianapolis, IN 46202-5120
Dear Dr. Maniago:
This letter verifies the receipt of the completed NRC Form 483 dated June 4,1999. This form is a condition of the general license under 10 CFR 31.11 authorizing in-vitro testing with byproduct
- material under generallicense.
The form has been assigned registration number 9167. When making changes to any of the information on the form, please refarence the registration number and address the correspondence to Director, Office of Nuclear Material 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, Traci Kime, Registration Specialist Materials Safety and inspection Branch
/
Division of Industrial and
//
Medical Nuclear Safety Office of Nuclear Material Safety and Safeguards DISTRIBUTION: p FSturz 'IMNS r/f NMSS r/f ' NEO3JV DOCUMENT NAME: h:\tracthanlago.483 4 f t receive e copr of this document, Indicate in the boa: "C" = Copy without attachment / enclosure *E' = Copy with attachrnentlenclostre "N" em No copy OFFICE MSIB .
l l l l NAME TKime (ll.
DATE 6/17/99 OFFICIAL RECORD COPY l
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' i 4 person is not required to respond to, a coisacbon of information unsees it d, splays a currently vahd oMB control number 1
Section 31.11 of 10 CFR 31 establishes a general license authorizing physicians, clinical laboratories, hospitals, and veterinarians in the practice of veterinary medcine to possess certain small quantities of byproduct material for in vffro clinical or laboratory tests not invoMng the Intemal or extemal administration of the byproduct matertal or the radiation therefrom to human beings or animals. Possession of byproduct material under 10 CFR 31.11 is not tuthorized until the physician, clinicallaboratory, hospital, or vetertarian in the practice of veterinary medicine, has filed NRC Form 483 and received from the Commission a validated copy of NRC Form 483 with a registration number.
- 2. APPLICATION (Check one box onfy)
- 1. NAME AND ADDRESS OF APPLICANT (Seeinstnicoon 3.B. Delow)
I hemby apply fw a registration number pursuant to 10 CFR 31, Section Indiana State Department of Health 31.11, tw use f bypmduct matenais &
635 North Barnhill Drive A. Myself, a duly licensed physician authortzed to disperse drugs in Indianapolis, IN 46202-5120 the practce of medicine. l y B. The above-named clinicallaboratory.
EPHONE NUMBER pnclude Aree code) C. The above named hospital.
o vetennana,in the practice of vetennary medeine 317/233 R000
- 4. REGISTRATION
- 3. INSTRUCTIONS:
A. Submit this form in duplicate to: REGISTRATION NUMBER:
'~
H 7 Medcal, Academic and Commercial Use Safety Branch (T-8 F5) e* "'804 m -.m r. m7g n. ,y f er q' .
Division of industnal and Medcal Nuclear Safety Offee of Nuclear Material Safety and Safeguards y
[p o n
U S. Nuclear Regulatory Commission 3 j
- c Washington, DC 20555 0001 (At NRC, a registrat>on number will be assigned and a validated copy \ ,* *
- g0 of NRC Form 483 will be retumed.) .
B. In the box above, print or type the name, address (including ZIP Traei.4ino /,/7 6/ /7/%
- number to De (if this an initialrepstrado , ae is spac Code), and telephone number of the regratrant physcian, chnical assigned by NRC. If this is a change ofinfo Don hom a prevfously laboratory, hospital, or vetennarian in the practce of vetennary repstered general Jcense, include your repstrabon number.)
medicine for whom or for which this registration form is filed
- 5. If place of use es different from address trated above, give complete address:
- 8. CERTIFICATION I hereby certify that:
A' All information in this registration certifcate is true and complete.
B. The registrant has appropriate radiation measunng instruments to carry out the tests for which byproduct matenal will be used under the general license of 10 CFR 31.11, The tests will be performed onty by personnel competent in the use of the instruments and in the handhng of the byproduct materials.
C. I understand that Commission regulations require that any change in the information fumished by a registrant on this registration certifcate be reported to the Director of Nuclear Meterial Safety and Safeguards within 30 days from the effective date of such change.
l D 1 have read and understand the provtsions of Section 31,11 of NRC regulations 10 CFR 31 (reprinted on the reverse side of this form); and I understand that the reg 6strant is required to comply with those provisions as to all bM material which he receives, acquires, possesses, uses, or transfers under the general icense for whch this Registration Certifcate is filed witit%e U.S. Nuclear Regulatory Commission.
SIGNATURN OF APP CANT DATE PRINTED OR 1YPED NAME AND TITLE OF APPLICANT D. raw (% aac LW'W Wl'1 WARNING: FALSE STATEMENTS IN THIS CERTIFICATE MAk BE SUBJEdrT TO CIVIL AND/OR PENALTIES. NRC REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRC BE COMPLETE AND ACCUR ALL MATERIAL RESPECTS.18 U.S.C. SECTION 1001 MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFU FALSE STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATE ANY MATTER WITHIN ITS JURISDICTION.
NRC FORM 463 (64s6)