ML20210E618
| ML20210E618 | |
| Person / Time | |
|---|---|
| Issue date: | 07/27/1999 |
| From: | Kime T NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS) |
| To: | Matthews O AFFILIATION NOT ASSIGNED |
| References | |
| SSD, NUDOCS 9907280278 | |
| Download: ML20210E618 (2) | |
Text
4.
July 27,1999
$j O.L. Matthews, M.D.
3800 Woodward, Suite 1022
' Detroit, MI 48201
Dear Dr. Matthews:
This letter verifies the receipt of the completed NRC Form 483 dated July 21,1999. This form is a condition of the general license under 10 CFR 31.11 authorizing in-vitro testing with byproduct material under general license.
The form has been assigned registration number 9169. When making changes to any of the information on the form, please reference the registration number and address the correspondence to Director, Office of Nuclear Material Safety and Safeguards, U.S. Nuclear Regulatory Commission, Washington, DC 20555.
If you have any questions or need further assistance, please contact me at (301) 415-8140.
Sincerely, s/
Traci Kime, Registration Specialist Materials Safety and Inspection Branch Division of Industrial and Medical Nuclear Safety Office of Nuclear Material Safety and Safeguards DISTRIBUTION:
IMNS r/f NEO3 DOCUMENT NAME: H:\\TRACl\\Bhagat.483 79 receive e copy of this document, indicate in the box: 'C' - Copy without attachment / enclosure "E" = Copy with attachment / enclosure "N" = No copy OFFICE MSIB l
NAME TKime t Ig_
DATE 7kr//99 OFFICIAL RECORD COPY l
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9907280278 990727 PDR RC SSD PDR
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1 NRC FORM 483 U. S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB; NO. 3150 0038 EXPlRES: 6-3c 99 fikse)
Esammand tusen per renconee b comply wnh two mandatory wdormation
-=-*,m #ewest 7 marmens The vehdsind repatrabon eerwes as sudence REGISTRATION CERTIFICATE -In vitro TESTING
",%T'l'",,",,%"frw".",e*',*l,**L*, *,"es'.*,*.*ne* *
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WITH BYPRODUCT MATERIAL UNDER Ollllll 7 """*' w"Zllll"' Oc"*$*soi,",*d M GENERAL LICENSE M."*,*,0.'.'n oc""Esollac"; n ".'.* # T.nU i
m a not reen,.d b re pand an, e a*-*m or ansarmsson woese a desplays a cimently vehd Oh5 consol number.
Sechon 31.11 of 10 CFR 31 estabilshes a general heense authortang physicians, clinical laboratories, br=r*=la, and veterinerinne'in the practice of wiertnery medcine to possess certain small quantities of byproduct rnatenal for b utro clinical or laboratory tests not IrwoMng the intomal or extemel admmistration of the byproduct material or the radebon therefrorn to human beings or animals Possession of byproduct material under 10 CFR 31,11 is not authortred untd the phyacien, clinical laboratory, hospital, or veteriarian in the prachce of veterinary medicine, has flied NRC Form 483 and received from the Commsemen a validated copy of NRC Form 483 with a registrabon number.
- 1. NAME APO SS OF APPUCANT (See InstrucWon 3.B. below)
- 2. APPUCATION (Choc* one box oni/)
IM,
I hereby apply for a registrabon number pursuant to 10 CFR 31, Section h,b, M
32oo %A.a %10w 4
/ Myself, a duly licensed physician authortzed to disperse drugs in Mrok, rec qwc j
~ pm-e a e B. The above. named clinicallaboratory.
TREPHONME 1-/774 o v*a =n in a or-ace
- veta v==*ia.
(hcAMus Coms C. The above named hospital
/3/
3.
INSTRUCTIONS:
- 4. REGISTRATION A.
Sutwnst thas form in dupicate t '
REGISTRATION NUMBER:
Modecal, Academc and Commercial Use 9lg9
/g*" Guy'f0R THE U.S. NUCLEAR REGULAT Safety Branch (T-8 FS)
Drnsson of industnal and Medcal Nuclear Safety Office of Nuclear Matenal Safety and Safeguards a
COMMISSION U.S. Nuclear Regulatory Commessaon 7
j Washington, DC 20555-0001 e
(At NRC, a regatration numtzer wiu be assagned and a validated copy
+
of NRC Form 483 wdl be retumed.)
1 B. In the box above, print or type the name, address (including ZIP
]99'.
Traci Kime
' 7/
Code), and telephone number of the reDestrant physcian, chnical (if this an heaf mgistro6m, Joeythis
,bisnk nu
.fo be s laboratory, hospital, or vetennenan in the pracbee of veterinary asa@nedby NRC. If thisis a change oth%me600 hom aprovfously medicane for whom or for which this regetrabon form is filed.
mgistemd generaficese, hcdude pur registra#on number.)
- 5. If piece of use is different from address hated above, grve complete address:
- 8. CERTIFICATION l hereby certify that:
A.
AI informsbon in this registrabon cerisficate is true and complete.
B.
The regatrant has appropriate radiation maseuring instruments to carry out the tests for which byproduct motorted wil be used under the general license of 10 CFR 31.11. The toets wIl be performed only by personnel competent in the use of the instruments and in the handhn0 of the byproduct malertels C.
I understand that Commieeion reguisbons require that any change in the lnformation fumished by a registrant on this registrebon certificate be reported to the Derector of Nuclear Material Safety and Safeguards within 30 days from the effecitwe date of such change D I have reed and understand the prov6eions of Seebon 31.11 of NRC reguisbons to CFR 31 (reprinted on the reverse side of this form); and I understand that the registrant is required to comply with those provtsions as to al byproduct matertal which he receives, acquires, possesses, uses, or transfers under the general lleense for which this Regletration Certtftcate is filed vnth the U.S. Nuclear Regulatory Commisalon
^
PAINTED OR TYPED NAME AND TITLE OF APPUCANT SIGNATUR O APPLICANT DATE 0, L.
%, ik h.
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7:n'i9 WARNING:
FALSE STATEENTS IN THIS CERTIFICATE MAY BE SUBJECT TO CML'AND/ORKCRIMINAL PENALTIES. NRC REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRC BE CONPLETE AND* ACCURATE IN Y
ALL MATERIAL RESPECTS.18 U.S.C. SECTION 1001 MAKES IT A CRIMINAL OFFENSE TO MAREfA WILLFULLY FALSE STATEENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED' STATES AS TO ANY MATTER WITHIN ITS JURISOICTION.
uncom.as pesi J