ML20236H888

Ack Receipt of NRC Form 483 Dtd 980625,as Condition of General License Under 10CFR31.11 Authorizing in-vitro Testing W/Byproduct Matl Under General License

ML20236H888
Person / Time
Issue date:	07/02/1998
From:	Kime T NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS)
To:	Walsh T ST. FRANCIS MEDICAL CENTER - WEST, EWA BEACH, HI
References
SSD, NUDOCS 9807070406
Download: ML20236H888 (2)

Text

_ _ _ _ - _ _.

. July 2,1998 l _.

l Clinical Laboratories of Hawaii ATTN: Theresa O. Walsh, Manager,

. SFW Lab St. Francis Medical Center-West 91-2135 Ft. Weaver Road, Suite 300 Ewa Beach, HI 96706

Dear Ms. Walsh:

This letter verifies the receipt of the completed NRC Form 483 dated June 25,1998. 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 8916. 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 i

Regulatory Commission, Washington, DC 20555.

If you have any questions or need further assistance, please contact me at (301) 415-8140.

1 Sincerely, N

Traci Kime, Acting Registration Specialist Materials Safety Branch Division of Industrial and Medical Nuclear Safety Office of Nuclear Material Safety and Safeguards l

DISTRIBUTION I

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J DOCUMENT NAME: a:\\walsh.483 T' recohne e cop ' of this document, indcote in the box: "C' = Copy without attachment / enclosure

• E' = Copy with ettachment/ enclosure "N" = No copy OFFICE MSB l

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NAME' TKime ( ft_

l DATE 7L2 /98-OFFICIAL RECORD COPY 7

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SSD

_ _ _ _ _ = _ _ _ - _ _ _ _.

l NRC FORM 483 U. S. NUCLEAR NEGULATORY COMMISSION APPROVED B7 OMB. NO. 315G400 EyPIRES: 6-30-99 l

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I c Gecten toquest 7 erunutes The valtdated vegistraten sovvos es swiderw.e REGISTRATION CERTIFICATE -In vitro TESTING

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d WITH BYPRODUCT MATERIAL UNDER Re,u,,- !"' "*"op"ec"t (31ao.co38)W %",tl*"'

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GENE p

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. Othee of Management and Budget, Washmglon. Oc 20503. NRC rnay not conduct somnsor and a N

w perman a not voquired b respond h, e collecten af informaton unless si displays a currently vahd OMB control nurnber Section 31.11 of 10 CFR 31 establishes a general hcense authonzing physicens, chnical laboratories, hospitals, and veterinarians in the prachce of vetennery medicine to possess certain small quantities of byprodud matertal for b vitro chnical or laboratory tests not invoMng the intemal or extemal administration of the byproduct material or the radiation therefrom to human beings or animals. Possession of byproduct material under 10 CFR 31.11 is not authorized until the physician, chnical laboratory, bspital, or veterinarian in the prochee of veterinary medcine, has filed NRC Form 483 and received from the Commissien a validated copy of NRC Form 483 with a registration number.

1. NAME AND ADORESS OF APPUCANT (See Instruccon 3 8. below)

2. APPLICATION (Check one box onty)

CLINICAL LAB 0RATORIES OF HAWAII l hereby apply for a regestratton number pursuant to 10 CFR 31, Sechon I

ST FRANCIS MEDICAL CTR-WEST 31.11. for use of byproduct matenals for l

9l'-2135 Pt Weaver R6 ail suito'300 A. Myself, a duty hcensed physician authortzed to disperse drugs in J

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Ewa Beach, HI 96706 the practce of medicine.

l ry B. The above named chncallaboratory TELEPHONE NUMBER (incbde Arne Code)

C. The above named hospital.

l (8OR) 677-799Q D Veterinanan in the practee of vetennary medmine 3.

INSTRUCTIONS:

4. REGISTRATION A.

Submit this form in dupicate to:

REGISTRATION NUMRER:

Medical. Academc and Commercial Use

/p* "Eog'o Safety Branch (T-8 FS)

Division of induatnal and Medcal Nuclear Safety

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bc1:nr W Qr*. r l

Office of Nuclear Material Safety and Safeguards y

U.S. Nuclear Regulatory Commisason g

g 17 tj,.1an 4

WanNngton,DC 2055S4001 e

(At NRC, a registration number will be assagned and a validated copy o'****

O of NRC Form 483 win be retumed.)

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7/ 2 B.

In the box above, print or type the name, address (including ZIP (7/fNs an hibaf repstraht,$ eave this space blank - number to be # '

Code), and telephone number of the registrant physcian, chncal laboratory, hospital, or veteiinanan en the practce of vetennary asssgnedby NRC. ff this is a change ofhfbrmaDon from a prevrously medcane for whom or for whch this togestration form is filed.

rogsstored generaI 6 cense, befude your regrstrabon number.)

5. If place of use is different from address hated above, give complete address.

6. CERTIF) CATION 1 hereby certify that:

l A.

All informabon in thes registration certificate is true and complete.

B.

The regratrant has appropriate radation measunng instruments to carry out the tests for which byproduct mate ini will be used under the general beense of 10 CFR 31.11. The tests will be performed ordy by personnel competent in the use of the instruments and in the handling of the l

byproduct rnatenals.

C.

I understand that Commission regulatons require that any change in the hformaban fumashed by a registrant on this registration certifcate be reported to the Director of Nuclear Material Safety and Safeguards within 30 days from the effective date of such change D 1 have reed and understand the provisions of Section 31.11 of NRC regulabons 10 CFR 31 (repnnted on the reverse side of thn. Srm), and I understand that the regretrant is required to comply with those provissons as to all byproduct matertal which he receives, acquires, an==a==a=, uses, or transfers under the general beense for which this Regestrabon CerttHcate is filed with the U.S. Nuclear Regulatory Commission.

PRINTED OR TYPED NAME AND TITLE OF APPLICANT SIGNATURE OF APPLICANT DATE Theresa O.

Walsh, M a rn a e r SFW Lab NM-Y b

06/25/98 WARNING: FALSE STATEMENTS IN THIS CERTIFICATE MAY BE SUBJECT TO CML AND/OR CRIMINAL PENALTIES. NRC REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRC BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECTS.185 U.S.C. SECTION 1001 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 WITHIN ITS JURISDICTION.

NRC FORM es3 (tLe8) g

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