ML23004A060
| ML23004A060 | |
| Person / Time | |
|---|---|
| Issue date: | 12/20/2022 |
| From: | Rolland J Office of Nuclear Material Safety and Safeguards |
| To: | Homes L Paperworks Industries Inc |
| References | |
| GL-704773-28 | |
| Download: ML23004A060 (1) | |
Text
UNITED STATES NUCLEAR REGULATORY COMMISSION WASHINGTON , D.C. 20555-0001 11/16/2022 TO: Users of Devices Subject to General License Registration
SUBJECT:
ANNUAL REGISTRATION OF GENERALLY LICENSED DEVICES The U.S. Nuclear Regulatory Commission (NRC) requires annual registration of certain devices that are possessed under the general license issued in Section 31 .5 of Title 10 U.S. Code of Federal Regulations (10 CFR 31 .5) . Devices subject to registration include those containing the radioactive material and activity listed in Table 1 of the attached NRC Form 664. You are receiving this notice because NRC records indicate that you have one or more such devices. Information about the general license registration program is available at the following NRC website :
https://www.nrc.gov/materials/miau/general-use/toolkit.html Note that under 10 CFR 31 .5(c)(11 ), the attached General Licensee Registration Package must be completed , signed , and returned to the NRC within 30 days from the date of this letter. Read all of the instructions prior to completing the package. Mail the completed package in the enclosed envelope to :
Director, Office of Nuclear Material Safety and Safeguards ATTN : Document Control Desk/GLTS U.S. Nuclear Regulatory Commission Washington DC 20555-0001 Registration Fee: Commission regulations (10 CFR 170.31 , Category 3Q) require that you submit a registration fee with each registration on an annual basis. The registration fee is subject to change yearly, and you are required to submit the fee that is in effect as of the date of this letter. An invoice for the current amount due will be sent to you under separate cover. If you have any questions about the fee or the invoice, please contact the License Fee Billing Help Desk at (301) 415-7554 or e-mail at fees.resource@nrc.gov.
NRC amended 10 CFR Parts 170.11 and 170.31 to provide that 10 CFR Part 170 fees be assessed to Federal agencies, where applicable, in accordance with the Energy Policy Act of 2005. Therefore, those Federal facilities required to register certain generally licensed devices in their possession will be required to pay the annual registration fee.
Attachment:
NRC Form 664 -- General Licensee Registration and Instructions Sincerely, Digitally sign ed by Joseph D. Rolland Joseph D* Roi land Date: 2022. 11 .03 12:50:07 -04'00' U.S. Nuclear Regulatory Commission Office of Nuclear Material Safety and Safeguards Division of Materials Safety, Security, State, and Tribal Programs Materials Safety and Tribal Liaison Branch
INSTRUCTIONS FOR COMPLETING NRC FORM 664 "GENERAL LICENSEE REGISTRATION" Review all six sections of this registration form . If any information is incorrect or missing, make corrections in the applicable boxes. If you have more devices than space provided in the form, copy the form before starting, as needed. Use black ink and print in CAPITAL LETTERS. Start information in the first box provided . If the information contains a number with a dash(-) or a decimal point(.), include the dash or decimal point as an individual character. Use the "0" character to represent the number O (zero).
Verify information about the devices by reviewing the label on the outside of the device. For safety reasons, DO NOT TRY TO TAKE APART any device to verify this information. If you are uncertain how to identify the device's label, contact the device's manufacturer or an authorized service agent for this information. Also, contact the manufacturer for any additional information about NRC requirements. You may also review 10 CFR 31.5 and other applicable regulations on the NRC web site at http://www.nrc.gov/reading-rm/doc-collections/cfr/, or review specific information about the general licensee project at https://www.nrc.gov/
materials/miau/general-use/toolkit.html Note to specific licensees: If you believe the device(s) listed on the registration form are possessed under your specific license, then verify the device label does not state the device is subject to a general license. If the labels indicate the device is subject to a general license, then complete the registration form as instructed below. If not, complete the registration as instructed below, however, in Section 2, follow the instructions for "not in possession of device" and complete one Section 4 page per device transferred to your specific license.
Section 1 - General Licensee Information. Provide the requested information about you, the general licensee.
On Page 1, provide the street address/location where your device(s) are used. For portable devices, provide the storage location. P.O. Box addresses are not allowed.
Do not write in the box marked For NRC Use Only.
On Paqe 2, provide the name, business telephone number, business e-mail address and title of the individual responsible for your device(s), and a mailing address where correspondence about your device(s) can be sent.
The mailing address should be specific to the physical location where the devices are used and/or stored (P.O.
boxes may be used if this is the only available mailing address). The individual indicated in this section as responsible for your device(s) must also verify and sign the form in Section 5.
Section 2 - Devices Subject to Registration. This section lists each device subject to registration and in your possession, according to NRC records. Devices subject to registration include those containing at least one of the radionuclides listed in Table 1, with the activity indicated, at the time of manufacture.
T a bl e 1 C ri*teria . t ra f 10n
. f or Reg1s Radionuclide Activity greater than or equal to:
Strontium-90 , Radium-226 3.7 megabecquerel (0.1 millicurie)
Cobalt-60, Curium-244 , Americium-241, and Californium-252 37 megabecquerel (1 millicurie)
Cesium-137 370 megabecquerel (10 millicurie)
Use the codes from Table 2 when correcting isotope information for devices in this section. If you do not possess a device on this list, blacken the "not in possession of device" circle, and provide the relevant information in Section 4. Note that each device is assigned a unique six-digit number called the NRC Device Key.
Table 2. Isotope Codes for Sections 2 and 3 Radionuclide Code for form Radionuclide Code for form Americium-241 AM241 Curium-244 CM244 Californium-252 CF252 Strontium-90 SR90 Cesium-137 CS137 Radium-226 RA226 Cobalt-60 CO60 Section 3 - Additional Devices. If you have other generally licensed devices (not listed in Section 2) that meet the conditions for registration listed in Table 1, provide information about each additional device. Before starting, copy this section as needed for your additional devices. Also indicate how you acquired each device by blackening the proper circle.
- When entering isotope and unit information for your device(s), use the codes listed in Table 2 of Section 2 for isotope information, and use the codes from Table 3 for unit information:
Table 3. Unit Codes for Section 3 Unit Code for form Unit Code for form picocurie PCI becquerel BQ nanocurie NCI kilobecquerel KBQ microcurie UCI megabecquerel MBQ millicurie MCI aiaabecquerel GBQ curie Cl terabecquerel TBQ pound LB microaram UG milligram MG kilogram KG gram G Section 4 - Not in Possession of Device. Use this section to report any devices that are listed in Sections 2 or 6, but that you no longer possess. Before starting, copy this section as needed for additional devices that are not in your possession. Enter the NRC Device Key, as listed in Section 2 or 6. Blacken the circle (choose only one) that best describes the disposition of the device and complete the rest of the section as appropriate.
Section 5 - Certification and Signature. The responsible individual must certify, sign, and date Section 5.
Section 6 - Devices Not Subject to Registration. This list contains information about devices that NRC records indicate are in your possession, but are not subject to registration. If you no longer have one or more of the listed devices, you are required to make a transfer report to NRC in accordance with 10 CFR 31.5 (c)(8) or (9), as applicable. You may use Section 4 for this purpose. This section does not list any static eliminators containing polonium-210 (Po-210), or luminous exit signs containing tritium (H-3). These devices are not subject to registration, and are not included in this section in an effort to reduce the length of this form.
RETURN THE COMPLETED FORM IN THE ENCLOSED ENVELOPE WITH PROPER POSTAGE.
11111111 1111111111111111111 111111111111111 IIIII 111111111111111 IIII IIII 111111111111111111 IIII IIIIIII Ill llll llll GL-704773-28 SECTION 1 11/09/2022 PAGE 1 of 2 NRC FORM 664 (11 - 2020) U.S. NUCLEAR REGULATORY COMMISSION 10 CFR 31.5 GENERAL LICENSEE REGISTRATION APPROVED BY 0MB: NO. 3150-0198 0MB EXPIRATION DATE: 11/30/2022 Estimated burden per response to comply with this mandatory collection request: 20 minutes. NRG will use this information to track general licensees and their devices to ensure a higher level of device accountability. Send comments regarding burden estimate to the FOIA, Library, and Information Collections Branch (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to lnfocollects.Resource@nrc.gov, and the 0MB reviewer at: 0MB Office of Information and Regulatory Affairs, (3150-0198), Attn: Desk Officer for the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 20503; e-mail: oira submission@omb.eop.gov. The NRG may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the document requesting or requiring the collection displays a currently valid 0MB control number.
Complete all six sections of this registration form. If any of the preprinted information is incorrect, provide the changes in the applicable boxes. USE CAPITAL LETTERS.
General License SECTION 1 - GENERAL LICENSEE INFORMATION
. Registration Number GL-704773-28 .
Enter the company name and the street address for the physical location of use for your device(s). For portable devices, specify the primary storage location. Do not use P.O. Boxes.
Company Name: PAPERWORKS INDUSTRIES INC I I I I I I I I I I I I I I I I I I I I I I Department: SAFETY I I I I I I I I I I I I I I I I I I I I I I Address Line 1: 455 FACTORY STREET I I I I Address Line 2:
I I I I I I I I I I I I I I I I City: WABASH I I I I I I I I I I I I I I I I I I I I I I I I State: IN [I] Zip Code:
46992 I I I I I I- I I I I I For NRC Use Only (Do not write here)
Category:
Packet Receipt Date (MM.DDYYYY):
.rn I I I I . 1* I I I I Accession Number:
I I .I I I l I I *1 . I I I
11111111 1111111111111111111 111111111111111 IIIII 111111111111111 IIII IIII 111111111111111111 IIII IIIIIII Ill llll llll GL-704773-28 11/09/2022 SECTION 1 PAGE 2 of 2 SECTION 1 - GENERAL LICENSEE INFORMATION (Continued)
Enter the name, telephone number and title of the person who is the responsible individual for the device(s).
Last Name: HOMES I I I I I I I I I I I I I I I I I I I I I I I I First Name: LEVI Middle Initial:
111111111*11111 I
D ,
Business Telephone Number: (260) 569-3322 , Extension:
I I I 11 I I 11 I I I I I I I I I I Business E-mail Address: LEVI.HOMES@PAPERWRKS.COM I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I
Title:
PROCESS ENGINEER I I I I I I I I I I I I I I I I I I I I I I I I*
Enter the mailing address where correspondence regarding your device(s) should be sent.
Department: ATTN: HEATHER JESSEE Address Line 1: 455 FACTORY STREET I I I I I I I I I I I I I I I I I I I I I I I I Address Line 2:
I I I I I *I I I I I I I I I I I I I I I I I I I City: WABASH I I I I I I I I I I I I I I I I I I I I I I I I State: IN [I] Zip Code: 46992 \ \ \ \ \ \ - \ \ \ \ \
1111111111111111 IIIIII IIIII 111111111111111 IIIII 1111 111111111111111 IIII Illllllll llll 11111111111111111
- GL-704773-28 11/09/2022 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 Our records indicate that you have these devices. Please update the information as necessary. PAGE 1 of 3 NRC Device Key 815378 (Internal Control Number)
Distributor/Distributed By: Mahlo America I I* I I I I I I I I I I I I I I I I I I I I I I Distributor License Number: GL-142-02
-I I I I I I I I I I I I I I Manufacturer name: MAH LO CONTROLS SYSTEMS AUTOMATION I I I I I I I I I I I I I I I I I I I I I I I I Device Model (Not Source Model): 11-200933 IIIII III II IIII II I IIIIII I Device Serial Number: T1484 I I I I I I I I I I I I I I I I I I I I I I I I Transfer Date: 04/11/2011
[IJ[DI I I I I Not in possession of device (Also complete Section 4.)
MM DD YYYY Isotope (e.g. AM241) Activity (e.g. 1005) Unit (e.g. mCi) 1 SR90 500 MBq 2
1.11111 1111111111111 ~11~11
- 3 1~1~1-1~11 1111111111111 1111 I
I 4
~, ,~,~,~II I I I I I I I I I I I I I I I I I' 5
I I I I I I I I I I I I I I I I I I I IIII
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I I I I I I I I I I I I I I I I I I I II I I
1111111111111111 IIIIII IIIII 111111111111111 IIIII 1111 111111111111111 IIII Illllllll llll 11111111111111111 GL-704773-28 11/09/2022 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 . ,
Our records indicate that you have these devices. Please update the information as necessary. PAGE 2 of 3 NRC Device Key 822689 (Internal Control Number)
Distributor/Distributed By: Mahlo America I I I I I I I I I I I I I I I I I I I I I I I I Distributor License Number: GL-142-02 I I I I I I I I I I I I I I Manufacturer name: MAH LO CONTROLS SYSTEMS AUTOMATION
- I II II II I I I I I II I I i II I I II I Device Model (Not Source Model): 11-200933 I I I I I I I I I* I I I I I I I I I I I I I I I Device Serial Number: TZ254 I I I I I I I I I I I I I I I I I I I I I I I I Transfer Date: 04/12/2012 ITJITJI I I I I Not in possession of device (Also complete Section 4.)
MM DD YYYY
- Isotope (e.g. AM241) Activity (e.g. 1005) Unit (e.g. mCi)
. 1 . . SR90 49.999999 MBq I I I I I I I I I I I I I I I I I I I 1.-----.--1--.----,1I 2
. 3 I I I I I I I I I I I I I I I I I I I I I I I
. 4
~11~1~1~1I I I I I I I I I I I I I I I I I I
~I1-----r--l---r--1-r---,1I I I I I I I I I. I I I I I I I I I 5
6 I I I I. I I . I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I
I11111111111111111111111111 111111111111111 IIIII 1111 111111111111111 IIII GL-704773-28 Illllllll llll 11111111111111111
- 11/09/2022 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 Our records indicate that you have these devices. Please update the information as necessary. PAGE 3 of3 NRC Device Key 851324 (Internal Control Number)
Distributor/Distributed By: Mahlo America I I I I I I I I I I I I I I I I I I I I I I I I Distributor License Number: GL-142-02
- I I I I I I I I I I I I I I Manufacturer name: MAH LO CONTROLS SYSTEMS AUTOMATION I I I I I I I I I I I I I I I I I I I I I I I I Device Model (Not Source Model): 11-200933 1- I I I I I I I I I I I I I I 1* I I I I I I I I Device Serial Number: AM-6080 I I I I I I I I I I I I I I I I I I I I I I I I Transfer Date: 12/18/2018 ITJ[DI I I I I
- Not in possession of device (Also complete Section 4.)
MM DD YYYY Isotope (e.g. AM241) Activity (e.g. 1005) , Unit (e.g. mCi) 1 SR90 500 i MBq 2
111111 1111111111-*II I ~11~11 3
I I I I I I I I I I I I I I I I I I I I I I I 4
1-1-1-1~1.1 I I I I I I I I I I I I I I I I I
~,1-,-,~,1 I I I I I I I I I I I I I I I I I 5
-,1-1-,~,, I I I I I I I I I I I I I I I I I 6
I I I I I I I I I I I I I I I I I I I I I I I
11111111 1111111111111111111 111111111111111 IIIII 111111111111111 IIII IIII I llllllll llll 11111111111111111 GL-704773-28 11/09/2022 SECTION 3 SECTION 3 - ADDITIONAL DEVICES SUBJECT TO REGISTRATION PAGE 1 of 1 Provide information about other devices you have that are subject to registration. Do not report specifically licensed devices.
Manufacturer Name I I I I I I I I I I I I I I I I I I I I I I I I I I I I Initial Transferor Name I I I I I I I I I I I I I I I I I I I I I I I I I I I I Initial Transferor License Number (if known)
I I I I I I I I I I I I I Device Model Number (Not Source Model)
- I I I I I I I I I I I I I I I I I I I I I I I I I I I I Device Serial Number I I I I I I I I I I I I I I I I I I I I I I I I I I How acquired and date (e.g., 0 Manufacturer/Initial Transferor listed above from a_ distributor/manufacturer, 0 other licensee, other source)?
Other General Licensee Date Transferred: [I] [I] / / / / /
O Other Sources MM DD YYYY Isotope (e g. AM241) Activ*ty (e g. 100) Unit (e.g mCi)
- 1. '~~~ I I I I I I
- 2. I
~~~ I I I I I I 3.
I I I I I 4.
I 5.
I I 6.
I I
- 7. I I .
8.
I I 9.
I I 10.
I I
11111111 1111111111111111111 lllll 111111111111111 1111 111111111111111 IIII Illllllll llll 11111111111111111 GL-704773-28 11/09/2022 SECTION 4 - NOT IN POSSESSION OF DEVICE SECTION 4 Provide information about devices listed in Section 2 or 6, but no longer in your possession. PAGE 1 of 1 Part 1 Transfer Date:
MM DD YYYY Location of the Device:
0 Whereabouts Unknown (Complete Part 1 only} 0 Transferred to another general licensee (Complete Parts 2 and 3) I 0 Never Possessed the Device (Complete Part 1 only) 0 Transferred to a Specific Licensee (Not the manufacturer) 0 Returned to Manufacturer (Complete Part 1 only) (Complete Part 2)
- Part 2 License Number of Recipient (if transferred to a specific licensee): .
I I I I I I I I I I I I I I Company Name:
I I I I I I I I I I I I I I I I I I I I I I I I I I I I Department:
I I I I I I I I I I I I I I I I I I I I I I I I I I I I Address Line 1 :
I 1* I I I I I I I I I I I I I I I I I I I I I I I I I I Address Line 2: .
I I I I I I I I I I I I I I I I I I I I I I I I I I I I City:
I I I I I I I I I I I I I I I I I I I I I I I I I I I l State: [I] Zip Code: I I I I I I- I I I I I Part 3 Enter the name of the individual responsibe for this device:
Last name:
I I I I I I I I I I I I I I I I I I I I I I I I I I I l First name: Middle Initial:
11111111111111 D
~~~~~~~ Telephone I I I 11 I I 11 I I I I Extension: ,~1~1~1~1~,
Title:
I I I I I I I I I I I I I I I I I I I I I 1 I I I I I I
11111111 1111111111111111111 111111111111111 IIIII 1111 11111111111 11111111 I11111111111111111 111111111111 GL-704773-28 SECTION 5 SECTION 5 - CERTIFICATION 11/09/2022 PAGE 1 of 1 I hereby certify that:
A. All information contained in this registration is true and complete to the best of my knowledge and belief.
B. A physical inventory of the devices subject to registration has been completed, and the device information on this form has been checked against the device labeling.
C. I am aware of the requirements of the general license, provided in 10 CFR 31.5.
(Copies of applicable regulations may be viewed at the NRG website at:
http://www. nre. gov/reading-rm/ doc-collections/cfr)
I Lµo/7-02.Z.
SIGNATURE - RESPONSIBLE INDIVIDUAL (Listed in Section 1) DATE WARNING: FALSE STATEMENTS MAY BE SUBJECT TO CIVILAND/OR CRIMINAL PENALTIES. NRG REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRG BE COMPLETE AND ACCURATE IN ALL MATERIALASPECTS. 18 U.S.C SECTION 1001 MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY WRONG STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTER IN ITS JURISDICTION.
111111111111111111111111111111111111111111 IIIII 1111111111111111111 IIII I11111111111111111 111111111111 GL-704773-28 11/09/2022 SECTION 6 SECTION 6 - DEVICE NOT SUBJECT TO REGISTRATION PAGE 1 of 1 NRC Device Key: 815377 Manufacturer License No: GL-142-02 Manufacturer Name: MAH LO CONTROLS SYSTEMS AUTOMATION Model Number: 11-200933 Serial #: KN710 Transfer Date: 04/11/2011 Isotope: KR85 Activity: 9.62 Unit: GBq NRC Device Key: 822688 Manufacturer License No: GL-142-02 Manufacturer Name: MAH LO CONTROLS SYSTEMS AUTOMATION Model Number: 11-200933 Serial #: KN805 Transfer Date: 04/12/2012 Isotope: KR85 Activity: 9 .62 Unit: GBq