ML20248G974
| ML20248G974 | |
| Person / Time | |
|---|---|
| Issue date: | 06/04/1998 |
| From: | Kime T NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS) |
| To: | Kellams W AFFILIATION NOT ASSIGNED |
| References | |
| SSD, NUDOCS 9806080012 | |
| Download: ML20248G974 (2) | |
Text
o June 4,' 1998 Men's Medical Center of Michigan
. Walter R. Kellams, D.O.
3333 South Pennsylvania Ave.
Lansing, MI 48910
Dear Dr. Kellams:
This letter verifies the receipt of the completed NRC Form 483 dated June 3,1998. 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 9143. 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, Acting Registration Specialist Materials Safety Branch Division of Industrial and Medical Nuclear Safety Office of Nuclear Material Safety and Safeguards DISTRIBUTION J
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SBaggett IMNS r/f NEO3 DOCUMENT NAME:
Ta vecehre e copy of this document. Indicate in the box: "C' = Copy without attachment / enclosure
- E* = Copy w th attachment / enclosure "N" = No copy OFFICE MSB l
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NAME TKime DATE 6/ ///98 OFFICIAL RECORD COPY
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MN ORY N REGISTRATION CERTIFICATE --In vitro TESTING
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N Ne WITH BYPRODUCT MATERIAL UNDER EOc'es' R "'271 URoc'"F#L"Toi^t,JM%"f
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REGULATORY COMMSSc"N. W ASHfNGTON, DC 20L%3001. ANo"
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w THE cAPERWORK REPUCTION PROJCCT (U 640o2e). OFFICE OF MA.MoEMENT ANo adoGET. WASHINGTON. DC 2o5o3 Section 31.11 of 10 CFR 31 establishes a general Icense authorting physic!ans, clinical laborato'ies, hospitals, and vetennanans in the practice of vetennary rnedicine to possess certain smalf quantities of byprod#, matenal for in v#ro clinical or laboratory tests not invoMng the internal or external adminstration of the byproduct mater:a1 or the *ad.ation therefrom to human beings or animais. Possession of byproduct material under 10 CFR 31.11 is not aJthor2ed untf the physician, choical latoratory hospital, or veterarian in the practice of veterinary medcaro, has filed NRC Form 483 and receved from the Commission a vakdated copy of NRC Form 483 wrth a registration number.
- 1. NAME AND ADDRESS OF APPLICANT (See Instruccon 3.B.below)
- 2. APPLICATION (Check one box onry)
I hereby apply for a reg:stration nurnber pu'suant to 10 CFR 31, Section MEN'S MEDICAL CENTER of MICHIGAN 31.11, for use of byproduct matenals for-WALTER R.
KELLAMS D.O.
y A. Myself, a duly iconsed physician authortzed to esperse drugs in 3333 SOUTH PENNSYLVANIA AVE.
/s the prachce of medcine.
LANSING, MI 48910 B. The above-named cuncallabe story.
IEEPHONE NUMBER (mcWe koe Coo */
C. The above named hospital.
D. Veterinarian in the oractice of vetertnery medic.ine tc1,3 o p 9 _ 7 r3 e r)
- 4. REGISTRATION 3.
INSTRUCTIONS:
A Subm!t this form in dupica*e to.
REGISTRATION NUMBER:
Medcal. Academc and Commercial Use 9143 Safe *y Branch (S H3)
$aucg Dmsion of industnal and Medica! NJClear Sa'ety
^
Office c' Nuclear Materia! Safety and Safeguards U.S Nuewar Regulatory Commin on j
g U.S. Nuclear Regulatory Commission Washington, DC 20555 4001 (At NRC, a registration number will be assigned and a vakfated copy k
of NRC f orm 453 will be retJf ned)
Steven L. Baggett 6/
/98 B. In the box above, pnnt or type the name, address (Including ZIP Code), and telephone number of the registrant physician, clincal Of this an inl#alregrstraDon, leave flus space blank - number fo be assigned by NRC. If ttis is a change o/information from a preeously laboratory, hospcal, or vete'inanan in the prachce of veterinary repstered general #conse, include your regsfrafion number.)
rnadicine for whom or fon which this reg:stration form is filed.
- 5. If place of use is d<f*erent from address listed above, g've comp ete asdress:
- 6. CERTIFICATION l hereDy certify that:
A All information in this registration certificate is true and comp:ete.
B The registrant has appropriate f adiation measunng instruments to carry out the te6ts for which byproduct matend will be used under the generaf heense of 10 CFR 3111. The tests will be performed onty by personnel competent in the use of tne instruments and in the handling of the bgroduct materials.
C l understand that Commrssion regulations require that any change in the information furnished by a registrant on this registration certificate be reported to the Director of Nuclear Material Safety and SafegJards Within 30 days from the ef'ective date of such change D I how read and understand the provisions of Sechon 31.11 of NRC regulations 10 CFR 31 (repnnted on the reverse sxie of this form); and I understand that the registrant ts required to comply with those provisions as to all byproduct matenal whch he recerves, acqwres, possesses uses.
or transfers under the generat bcense for wnich this Registration CertJcate is fied with the U.S. Nuclear Regulatory Commission.
PRNILD OR D PED NAME AND TITLE OF APPLICANT SIGNATURE OF APP!JCANT DATE gy[g[g
[.f '
WALTER R.
KELLAMS D.O.
WARNING: FALSE STATEMENTS IN THIS CERTIFICATE MAY BE IUBJECT TO civil AND/OR CRIMLNAL PENALTIES.
NRC REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRC BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECTS. 18 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 ST ATES AS TO ANY MATTER WITHIN ITS JURISDICTION.
.mc w e m I
9960-688-4}S d22tBO 86 CD u n t-