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The following was received from the California Department of Public Health via e-mail: On May 24, 2021, (the licensee), contacted Los Angeles County Radiation Management regarding a CPN International MC3 (serial number not reported, containing nominally 10 millicuries Cs-137 and 50 millicuries Am:Be-241) moisture density gauge that had been stored in a gauge operators home that was involved in a house fire on May 23, 2021. The gauge was stored in the transport case. The gauge was found to have been melted and was unrecognizable. An inspector from the Los Angeles County was sent to the scene to perform radiation surveys and to evaluate the damage to the gauge and determine if the sealed sources were intact. The disposal of the source will be determined once the evaluation of the damage to the gauge has been completed. The California Department of Public Health will continue to investigate the incident. CA 5010 Number: 052421

• * * UPDATE ON 5/26/2021 AT 2053 EDT FROM ROBERT GREGER TO JEFFREY WHITED * * *

The following was received from the California Department of Public Health via e-mail: The Cs-137 and Am:Be-241 sources were recovered the evening of May 24 by a member of the California radiation control program. The sources were taken to a licensed gauge service provider the next day, where wipes were taken of the sources for leak testing. The leak test results were received from the gauge manufacturer on May 26 showing that neither source was leaking. The serial number of the gauge was reported as M34125843. Notified R4DO (Gepford) and NMSS Event Notifications (email)

The following information was received from the state of California via email: On 4/30/2020, at approximately 1127 (PDT), the RSO (radiation safety officer) of RMA Group, RML Number 8055-19, contacted RHB (California Radiologic Health Branch) Brea concerning a moisture/density gauge, Troxler, model 3440, serial number 25671 (Cs-137, 0.3 GBq, Am-241, 1.50 GBq) that had been stolen from in front of a private apartment complex while the RMA employee was offloading his vehicle. The Troxler radioactive gauge was left on the sidewalk during offloading of the vehicle. (The RMA employee) forgot about the gauge he had left on the sidewalk as he then drove off to have his vehicle washed. When he returned from the carwash at approximately 1730 to 1800 on 4/28/2020, he realized that he had left the radioactive gauge in front of the apartment complex and that it was no longer there. The (RSA employee) finally reported the theft to the RMA RSO on 4/29/2020 at 1215, prior to reporting the theft to Los Angeles Police Department at the West Los Angeles office on 4/29/2020 at 1245. A copy of the theft report and the (employee's) statement has been sent to RHB Brea as part of this report. (The RMA RSO) will utilize local papers to attempt to retrieve the stolen gauge as well as notifying local servicing vendors of radioactive gauges to be alert of the serial number of the stolen gauge in case it turns up for any of their services. The investigation will continue to determine if the radioactive gauge can be recovered in a reasonable time frame. This is being reported to the NRC Operations Center as a 24-hour report under 10 CFR 20.220(a)(1)(i) since the radioactive gauge has been stolen with the source handle locked and the Type A transport container locked. California Report Number 5010-043020

• * * UPDATE FROM DONALD OESTERLE TO DONALD NORWOOD AT 1516 EDT ON 5/4/2020 * * *

The gauge has been recovered intact. A formal closing report will be submitted later. Notified R4DO (Drake), and via E-mail: NMSS Events Notifications E-mail group, ILTAB, and CNSNA (Mexico). THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

The following report was received from the State of California via e-mail: On April 9, 2019, the (Radiation Safety Officer) RSO for GeoSolutions in San Luis Obispo, CA notified the RHB (Radiologic Health Branch) Brea office that a moisture density gauge had been reported stolen from his employee's vehicle that was parked overnight at a residence in Orcutt, Santa Barbara County, CA. Reporting person states that a Humboldt Scientific Instrument 5001C nuclear moisture density testing device, serial number 1749, was stolen. The device contained 0.37 GBq (10 mCi) Cs-137 and 1.48 GBq (40 mCi) Am-241. The theft has been reported to local law enforcement, Santa Maria Police report number 2019R03937, and to the local service provider Pacific Nuclear Technology. The device was in a locked protective case at the time it was stolen; its transport index is 0.2; DOT class 7 type A package. The owner found the chain securing the device to the truck bed was also cut. The operator reported that the Cs-137 source rod was locked in the safe position on the gauge. The device was stolen on 4/9/2019 at an unknown time during the night. RHB will continue to investigate. California 5010 number: 040919.

• * * UPDATE AT 2003 EDT ON 4/15/19 FROM L. ROBERT GREGER TO MARK ABRAMOVITZ * * *

The following was received via e-mail: The moisture density gauge that was reported stolen was reported by the licensee to have been recovered on 4/11/19. The gauge, inside its transportation container (the transportation container lock was missing, but the gauge was locked in the shielded position), was found in a trash dumpster at a local convenience store. Police are currently reviewing security camera tapes in an attempt to determine who placed the gauge in the convenience store trash dumpster. Notified the R4DO (Pick) and NMSS (via e-mail). THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

The following was received from the State of California via email: At 1600 (PDT) on October 5, 2016, the RSO (Radiation Safety Officer) for C. Y. Geotech Inc. reported to RHB (Radiation Health Branch) that one of their nuclear density gauges (CPN model MC-1DR-P; #MD90404953 containing 10 mCi of Cs-137 and 50 mCi of Am-241/Be) had been stolen from a temporary job site. RHB informed the RSO to file a police report and place a notice into the local newspaper offering a reward for information leading to the safe return of the gauge. The RSO will require the gauge operator to make a report of exactly what happened and specifically if the Cs-137 handle was locked in the safe mode. The gauge was not discovered missing until the morning of October 5, 2016 and the operator returned to look for the gauge. The RSO posted a lost gauge sign at the job site notifying personnel of the loss of the gauge and C. Y. Geotech's contact information for its safe return. On Oct. 4, 2016, around 1300 (PDT), the gauge operator had finished his work with the CPN gauge and was completing paperwork at his vehicle. He forgot about the gauge and failed to secure it into the transport case before departing the job site. He believes he left the gauge on the curbside. The gauge had been recently leak tested in May 2016.

5010 Number: 100416 THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

The following report was received from the State of California via email: At approximately 1000 PDT on May 5, 2015, a medical event occurred during a Y-90 Therasphere procedure. The prescribed dose to the organ (liver) was 12,000 rem, but the delivered dose was 6,920 rem. This event meets the 10 CFR 35.3045(1)(i) 24-hour report criteria since the dose differed from the prescribed dose by more than 50 rem to an organ (5080 rem under dose) and the total dose delivered differed from the prescribed dose by 20 percent or more (42% under dose). Although the equipment indicated the entire dose had been delivered to the patient, a large amount of the dose was is still in the tubing and vial and had not actually been delivered to the patient as indicated. The licensee will contact the manufacturer to assist in finding the root cause of the malfunction to determine whether it was an equipment malfunction, operator error, or both. The treating physician is also the prescribing physician. The licensee has contacted the physician to verify if the physician has notified the patient and if there was any effect on the individual from this event. The licensee will provide the written report within 15 days as required which will also describe what actions will be taken to prevent reoccurrence. California Report Number: 050616.

• * * RETRACTION AT 1229 EDT ON 8/21/2015 FROM ROBERT GREGER TO MARK ABRAMOVITZ * * *

The following was received via e-mail: The California Radiation Control Program would like to retract the subject event notification for the medical event at UCLA. Subsequent evaluation determined that the patient received the prescribed dosage. Some contamination on the exterior of the equipment utilized in the therapeutic dosage administration was determined to have misled the licensee staff to initially believe that an under-dosage to the patient had occurred. Notified the R4DO (Hay) and NMSS Events Resource (via e-mail). A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

The following information was received via E-mail: The RSO for Byer Geotechnical contacted RHB (Radiologic Health Branch) to report that an employee working at a construction site at Colorado Blvd. and Glacier St. in Eagle Rock (a suburb of Los Angeles) had a CPN model MC 1DRP gauge (s/n MD50902828) stolen from the back of his pick-up truck around 0730 PDT. This moisture density gauge contains 370 mBq (10 mCi) of Cs-137 and 1.85 Gbq ( 50 mCi) of Am-241:Be. The security chains attaching the gauge transportation case to the vehicle were cut. The employee notified his RSO asap, who contacted RHB. RHB instructed the RSO to contact the local police dept. to make a report and also place an ad in a local newspaper for return of the gauge with a monetary reward. More information will be obtained from the employee via a written report of the incident. Notified Mexico via E-mail.

• * * UPDATE AT 1431 EDT ON 07/23/14 FROM KATHLEEN HARKNESS TO S. SANDIN VIA EMAIL * * *

This CPN gauge was recovered by the licensee on 7/22/2014 at 1500 PDT from the driveway at the same location that it was stolen from.

The RSO notified the RHB inspector on 7/23/2014 at 1000 PDT by phone. The transportation box's latch was damaged and the padlock missing, but the gauge itself appeared intact. The RSO will be bringing it to a CPN service provider for repair of the case and inspection of the gauge prior to placing it back into service. California will continue to investigate. Notified R4DO (Miller), FSME Events Resource and ILTAB (email) and Mexico (fax). THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf