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ENS 5707816 April 2024 15:57:00The following information was provided by the California Department of Public Health, Radiologic Health Branch (RHB) via email: On 4/15/2024, the California Office of Emergency Services (OES) forwarded a report from Testing Engineers, Inc. The radiation safety officer (RSO) notified OES that one of their nuclear gauges (CPN MC-1, serial number MD71108870 containing 10 mCi of Cs-137 and 50 mCi of Am-241) was stolen from a storage unit that is located within a public storage facility in Concord, CA. The gauge was stolen from the storage unit at an unknown time between 04/13/2024 and 04/14/2024, but was discovered missing at 1541 (PDT) on 04/15/2024. A car was used to ram the door of the storage unit, and a pry bar was used to remove the gauge from a locked cabinet. Local law enforcement was notified, and a reward was posted on Craigslist, Facebook, and Nextdoor for the safe return of the gauge. RHB will investigate the incident." 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
ENS 5693223 January 2024 20:20:00The following information was provided by the California Department of Public Health Radiologic Health Branch (RHB) via email: On 1/23/24, California Governor's Office of Emergency Services (CAL OES), contacted RHB to report a stolen moisture density gauge. Per the CAL OES report, at around 2200 PST on 01/22/24, a portable gauge was stolen from the bed of a parked truck belonging to the reporting party. On 1/23/24, RHB contacted the reporting party (gauge user) and learned the following: The stolen gauge is a CPN Model 131, serial number, MD 00705803, containing 10 mCi of Cs-137 and 50 mCi of Am-241. On 1/22/24, around 2030 PST, the gauge user was feeling ill and was not able to return the gauge to the storage unit and decided to leave it in his work truck parked at his residence. On the next day morning (1/23/24) at around 0700, the user drove his truck to a job site in Palo Alto, CA, opened the cover of the bed of the truck and discovered that the gauge was stolen from the vehicle. There were no signs of a break-in, so the truck bed may have been left unlocked. The gauge storage box was chained through two handles and was attached to the bed of the truck. On 1/23/24, at around 1400 PST, the gauge user notified the Daily City Police Department of the stolen gauge (Report No. T24000071). RHB will be following up on this investigation. CAL OES Report CENTRL No.: 24-0397 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
ENS 5667410 August 2023 15:31:00The following information was provided by the California Radiation Control Program (RHB) via email: On 7/12/23, Tesla, San Rafael facility contacted RHB to report a lost radioactive source. The lost item was a Po-210, 10 mCi source, Model P-2021-Z705, serial number A2LZ130 (air-gun), originally shipped to the facility by NRD, LLC on 5/8/2020, (based on this information, current activity is approximately 26 microcuries). The source was used to blow dust off of auto body panels and prevent static buildup prior to painting. The employees at the shop could not provide an estimate of when the last time the device was used and believe that the device may have been disposed of in the trash. Facility will be transitioning to an anti-static tool that does not utilize a radioactive source. 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
ENS 5584715 April 2022 18:58:00The following was received from the state of California Radiologic Health Branch (RHB) via email: On 4/14/22, Radiation Safety Officer (RSO) contacted RHB to report a Medical Event associated with a High Dose Rate (HDR) unit. Licensee's written notification on 4/15/22, stated the following: Sometime on Friday, April 8th (2022), an HDR therapist replaced a source transfer tube/catheter with a longer length transfer tube/catheter than intended for the three HDR treatments planned for that day. The difference in lengths was 123 mm. Since the treatment plan was with a shorter transfer tube/catheter, the source didn't make it all the way to the treatment locations and resulted in underdosing the three patients on that day, and likely delivering unplanned doses to non-treatment sites for the three patients. The error was discovered on Wednesday, April 13th, as another HDR therapist was getting ready for an HDR treatment. No HDR treatments had occurred since Friday, April 8. The first therapist wasn't certain if she changed the transfer tube/catheter in the morning or after the patients, but she thinks she likely changed it in the morning. The licensee is still evaluating the delivered doses to the patients treated on that Friday, but at least two of them are believed to have received an underdose that is reportable. The doses to non-treatment sites have not been fully evaluated. All three patients and their referring physicians were notified on Thursday, April 14th. RHB is continuing to follow up with the investigation. California Event Number: 041422 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.
ENS 5546816 September 2021 14:01:00The following information was received from the state of California via email: On 9/14/2021, the licensee contacted the Radiation Health Branch (RHB) to report an incident that occurred on 9/13/2021 in which a radiography exposure device failed to retract to the fully shielded position. The licensee reported that after completing their second exposure shot, the radiography crew cranked the source to the fully shielded position which actuated the fully shielded source position indicator. The crew reverse cranked the source to confirm that the source was locked into the fully shielded position and discovered that the source was still exposed. The radiographers were able to lock the source into the final position after manipulating the locking mechanism manually. The licensee reported an exposure maximum of 33 millirem to one of the radiographers due to this incident. At this time, the licensee does not expect an overexposure to either radiographers nor members of the public. RHB will be investigating this incident further.
ENS 5535112 July 2021 18:13:00The following was received from the state of California via e-mail: On Monday, July 12, 2021, (Radiation Health Branch) (RHB) Licensing Unit forwarded a July 9, 2021 email from (Radiation Safety Officer) (RSO) (redacted) (Permanente Medical Group, RML # 0269) stating that a patient received only half of the intended dosage for a Y-90 procedure of the liver. RHB contacted the RSO (redacted) for additional information on July 12, 2021. The RSO (redacted) emailed a statement from the Authorized User (AU), Interventional Radiologist, (redacted), stating that a Therasphere procedure was performed on Friday, July 9, 2021 that called for a prescribed dosage of 2.876 GBq of Y-90 Theraspheres. Prior to administration of the Y-90, the catheter was flushed with saline. AU reported that a slight resistance was felt, but all of the flush went through the catheter. He attributed the resistance to the sharp turns of the catheter in the branch vessel. The administration of 2.876 GBq Y-90 Therasphere was started. Upon administration of the Y-90 Theraspheres, the resistance became appreciated. Administration of the Y-90 Theraspheres was stopped and the catheter was withdrawn. Subsequent Geiger counter examination of the removed catheter indicated greater than normal activity remained. AU later confirmed that of the 2.876 GBq prescribed dosage, only 47.6 percent was delivered. 1.34 GBq Y-90 went to the liver and 0.027 GBq went to the lung. The resulting dose was 162.8 Gy to the liver and 1.37 Gy to the lungs. A written report will be provided to RHB within two weeks. CA Incident No.: 070921 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.
ENS 553406 July 2021 14:44:00The following was received from the California Department of Public Health - Radiologic Health Branch (RHB): On 7/5/21, licensee contacted California Office of Emergency Services (Cal OES) to report a stolen moisture density gauge. The gauge stolen is a CPN Model MC-1, S/N MD 80304167 containing 10 mCi of Cs-137 and 50 mCi of Am-241. Gauge user's vehicle parked in Sacramento, CA, was broken into and the gauge that was stored inside a secured metal box bolted to the bed of the truck was stolen on 7/3/21. Licensee had immediately notified Sacramento County Sheriff's Department of the theft (Report # 21-2016910). RHB will be following up on this investigation. CA 5010 Number: 070521 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
ENS 553341 July 2021 20:17:00The following was submitted by the California Department of Public Health - Radiologic Health Branch (RHB) by email: On 07/01/2021, licensee contacted RHB to report a medical event associated with Ytrrium-90 TheraSpheres. On the written directive, Authorized User's (AU) desired dose to the target volume was 800 Gy. Based on the calculations, radiation dose delivered was 400.2 Gy. During the procedure, patient was infused with 1.067 Gbq of Y-90. Upon completion of the infusion, based on residual exposure readings, it was determined that an estimated dose of 0.522 Gbq was delivered to the patient, 50% of the written directive. Given the Y-90 supply vial was empty, based on the 0.00 mR/hr reading on the adjacent dosimeter, it has been speculated that Y-90 was held up in the micro-catheter. AU suspects this high residual waste reading was due to a slower infusion of the treatment dose and flushing fluid; this will be determined at a later date when the yttrium-90 waste material has decayed and can be safely broken down with individual components measured. The referring physician (AU), informed the patient of the event. RHB will be following up on the medical event. CA 5010 Number: 070121 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.
ENS 5522830 April 2021 17:57:00The following was received via e-mail from the California Department of Public Health, Radiological Health Branch (RHB): On April 30, 2021, (The) ENGEO (Radiological Safety Officer) RSO contacted RHB to report a stolen moisture density gauge, a Troxler, Model 3440, S/N 26157 containing licensed material 9 mCi of Cs-137 and 44 mCi of Am-241. The gauge was stolen from one of their storage locations (Extra Space Storage). The gauge was last in their physical possession on April 22, 2021, and was secured in the facility at approximate 1430 PDT. The facility is secured by a common gate with access granted with an access key code with security cameras that log entering and exiting the facility. The storage unit was secured by a keyed master lock, and the equipment was locked to the inside of the unit with a chain and secured with at least 1 master lock. Since April 22, 2021, (the) staff has visited the unit on a couple of occasions, however (the staff) was not concerned at the time when the equipment was not observed in the unit which is common as the equipment is used during the day on a regular basis and also due to the lock to the unit being intact (showing no signs of forced entry). On April 29, 2021, the individual who the equipment is assigned to, returned to pick up the gauge and noticed someone had removed it. It was determined that no one from their company removed the gauge from the storage unit after it was secured on April 22, 2021. (The) licensee was unable to view security footage due to privacy of other customers. (The) licensee was told by the manager that he reviewed all footage of their staff entering and leaving the facility between April 22 and April 29 and he observed the staff return the gauge to the unit on April 22, and leave without the gauge in his vehicle after he secured it in the storage unit. (The) licensee has conducted an internal investigation into the location of the gauge and determined that no one with their organization removed the gauge in question. This appears to be consistent with the reported observations of the facility manager's review of security footage. (The) licensee has notified Rohnert Park Police Department of the stolen gauge (police report #21-1838). A cash reward has been offered for the safe return of the gauge. RHB will be following up on this investigation. California Report Number: 043021 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
ENS 5495316 October 2020 20:37:00

The following was received via email from the California Radiation Control Program: On October 16, 2020, the (Radiation Safety Officer) RSO of Stanford University emailed (the Radiation Health Branch) RHB to inform a medical event with a Y-90 patient treatment. The physician mistakenly delivered the larger dose (approximately 30 mCi) to the liver lobe that was to get the smaller dose (approximately 13 mCi). The dose to the second lobe was adjusted with left over Y-90 from the dose draw to give the proper dose to the other lobe (approximately 30 mCi). So one lobe received much greater than the intended dose, while the other lobe received the proper dose. RHB will follow up on this investigation. California 5010 Number: 101620

  • * * UPDATE FROM ROBERT GREGER TO DONALD NORWOOD AT 1816 EST ON 12/2/2020 * * *

The following information was received via E-mail: The authorized user prescribed 31.57 mCi (1.17GBq) Y-90 to the right lobe of the liver and 13.22 mCi (0.49GBq) to the left lobe of the liver. The higher dosage, 31.57 mCi (1.17GBq) Y-90 was delivered to the left lobe of the liver. The prescribed dosage of 13.22 mCi (0.49GBq) would result in a dose to the left lobe of 7,000 rad (70Gy), however the delivered dose was 17,500 rad (175 Gy). This is 10,500 rad (105 Gy) above the prescribed dose. Notified R4DO (Gepford) and via E-mail, NMSS (Williams) and the NMSS Events Notification E-mail Group. 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.

ENS 547669 July 2020 14:27:00The following was received from the California Radiologic Health Branch (RHB) via email: On 07/08/20, the licensee's ARSO ((Assistant Radiation Safety Officer)) contacted the RHB to report a stolen hydroprobe, CPN Model 503, S/N H330301362 containing 50 mCi of Am-241. The gauge belonged to Blue Ocean Organics, Inc. and was stolen on 07/03/20, out of a technician's truck parked overnight at a location in Visalia, CA. The ARSO stated that the hydroprobe was removed from the two chain lock in the back of the truck and placed in the cab of the truck overnight when it was stolen along with some other items. On 07/03/20, immediate notification was made to Tulare County Police Department (Deputy G. Canales A344, case # 20-055488). Licensee will be posting a reward for the safe return of the gauge. RHB will be following up with the investigation. The licensee will be cited for several items including failure to notify RHB per 10 CFR 20.2201(a). CA 5010 Number: 070820 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
ENS 547364 June 2020 15:24:00The following was received from the California Department of Public Health Radiologic Health Branch via email: On 06/04/20 (PDT), California Office of Emergency Services (Cal OES) contacted the Radiologic Health Branch (RHB) to report a stolen moisture density gauge (CPN Model MC2, S/N 07226, containing 10 mCi of Cs-137 and 50 mCi of Am-241). The gauge belonged to Twining Inc. and was stolen out of a technician's truck while parked overnight at a Marriott hotel located at 2970 Lakeside Drive, Santa Clara, CA. The RSO ((Radiation Safety Officer)) was aware of the fact that the technician was working at a jobsite away from the permanent storage location. An immediate notification was made to Santa Clara Police Department (Report # T20001625). The RSO will be posting a reward for the safe return of the gauge. The RHB will be following up on this investigation. 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
ENS 5465910 April 2020 15:20:00The following is a summary received from the state of California via email: On 04/09/20, the California Office of Emergency Services (OES) contacted the Radiologic Health Branch (RHB) to report a notification made by a California licensee regarding a lost hydro probe. The gauge involved is a CPN Model 503DR, S/N H380104084 hydro probe containing 50 mCi of Am-241. The report stated that the field user placed the probe into its case without securing its latches and locks and drove off to the next field site. It is believed that the probe had fallen out of the truck somewhere on Crows Landing Road between Carpenter Road and Ehrlich Road. The RSO (Radiation Safety Officer) had notified the California Highway Patrol (CHP) and the local Fire Department of the incident. Repeated attempts made by the RSO, his staff and CHP to locate the gauge were unsuccessful. The RSO will be posting a reward on social media for the safe return of the gauge. The RHB will be following up on this investigation. 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
ENS 5434322 October 2019 15:41:00The following was received from the California Department of Public Health Radiologic Health Branch (RHB) via email: On 10/21/19, the RSO (radiation safety officer) contacted RHB to report a stolen moisture density gauge. The gauge is a CPN Model MC1Elite, S/N 30492, containing 50 mCi of Cs-137 and 50 mCi of Am-241. It was stolen on 10/21/19 around 0230 (PDT) from the back of a truck parked at the gauge user's residence. The gauge was being used at a temporary job site near the user's residence and it was stolen by cutting the locks securing the gauge. The licensee provided video footage of the crime taking place from a video camera at the user's residence. The licensee had contacted the Salinas Police Department to notify them of the incident (Case #19-101002). A flyer has been posted with a reward for the safe return of the gauge. RHB will be following up on this investigation. CA 5010 No.: 102119 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
ENS 5429023 September 2019 15:31:00The following was received from the California Department of Public Health - Radiologic Health Branch (RHB) via email: On 09/21/19, (Saturday), the RSO (radiation safety officer) contacted RHB and left a voicemail message to report a stolen moisture density gauge. The gauge involved is a Troxler Model 3440, S/N 28050 containing 9 mCi of Cs-137 and 44 mCi of Am-241. The gauge was stolen on 09/20/2019, between the hours of 2030 PDT and 0130 PDT, while it was charging at the user's residence. Union City Police was notified of the incident (Case # 190921007, Officer # 4740, Sarah Lings). Licensee will be posting a reward for the safe return of the gauge. Licensee failed to contact CA Office of Emergency Services (OES) regarding immediate notification. RHB will be following up on the incident. 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
ENS 537703 December 2018 16:28:00The following was received from the State of California by email: On 12/03/18, the RSO (Radiation Safety Officer) contacted CA Office of Emergency Services (OES) to report a stolen density gauge. The gauge involved is a Troxler Model 4640-B, S/N 1292, containing 9 mCi of Cs-137 (thin lift asphalt density gauge). The parked vehicle (in San Francisco, CA) was broken into and the gauge was stolen during overnight hours. According to the RSO, at the time of the theft, the gauge was locked inside a Type A container with additional locks securing the gauge to the vehicle. The gauge user was enroute to a field job in the area near Quality Inn where the theft occurred. The RSO has immediately notified South San Francisco Police Department of the theft (Report # 18-7086). Licensee will be posting a reward for safe return of the gauge. RHB (CA Department of Public Health - Radiologic Health Branch) will be following up on this investigation. 5010 Number: 120318 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
ENS 5307818 November 2017 01:06:00The following information was received from the State of California via email: On 11/17/17, the RSO (Radiation Safety Officer) contacted RHB (CA Radiologic Health Branch) to report a stolen moisture density gauge. The stolen gauge is a CPN Model MC-1DR, S/N MD90209216, containing 10 mCi of Cs-137 and 50 mCi of Am-241. The user had taken the gauge home and left it secured in the back of his truck. The truck was parked at his residence . . .. According to the user, most likely between midnight and 5 AM of 11/17/17, the chain locking the gauge to the truck bed was removed and the case was dragged behind a building where the locks on the box were broken and the gauge was removed. The box was recovered without the gauge. (The) RSO had notified San Jose Police Department of this incident (Event # P173210429). RHB will be following up on this investigation. 5010 NUMBER (Date Notified): 111717 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
ENS 5304530 October 2017 19:25:00The following information was received from the State of California via email: On 10/30/17, California Office of Emergency Services contacted RHB (Radiologic Health Branch) to report a lost moisture density gauge. The lost gauge is a Troxler Model 3440, S/N 23171, containing 9 mCi of Cs-137 and 44 mCi of Am241/Be. According to the RSO (Radiation Safety Officer), the gauge user left the gauge on the tailgate of his truck without properly securing it, and drove off to the next job site. A passing driver alerted the gauge user of a falling object from his truck at the intersection of Floyd Street and Oakdale Street in Modesto, CA. The user immediately went back to the intersection, but was unable to locate the gauge. The RSO has notified the Modesto Police Department of this incident. He will be posting a reward for the safe return of the gauge on Craigslist. The RHB will be following up on this investigation. 5010 Number: 103017 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
ENS 5219724 August 2016 15:47:00The following report was received from the California Department of Public Health via email: On August 23, 2016, NRC (Nuclear Regulatory Commission) contacted RHB (California Radiation Health Branch) to inform of an incident involving missing Tritium signs. According to NRC report, the AT&T EH&S RSO (Environmental Health and Safety Radiation Safety Officer), Kim Kantner, contacted NRC to report six missing H-3 (Tritium) signs from one of their locations at 730 Carolina Street, Vallejo, CA. Each sign contained 2.7 Ci of H-3. These six signs were in a box to be returned to the vendor, stored inside a locked basement at the Vallejo AT&T facility. Some renovations were going on at this site. According to Kim, AT&T still believes that the box may have been misplaced by the workers. The investigation is still ongoing. RHB will be following up on this matter. CA 5010 Number: 082316 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
ENS 5216810 August 2016 18:35:00

The following was received from the State of California via email: On July 28, 2016, (the Radiation Safety Officer) RSO at CB&I contacted RHB (Radiologic Health Branch) to report an incident on stolen check sources from their storage location at Hunters Point in San Francisco, CA. Theft occurred in the afternoon of July 26, 2016, between approximately 1330-1400 hours, while CB&I personnel were conducting business in adjacent project trailers. Items stolen included tools, equipment and locked posted radioactive check source safe. No other radioactive materials were stored inside this trailer. Source description is as follows: Source Date S/N Activity (uCi) Th-230 Plate Jul-92 92TH1002842 0.0061 Th-230 Disk Nov-09 G4-791 0.01566 Tc-99 Disk Nov-09 G4-797 0.03111 Tc-99 Plate Nov-09 G4-788 0.01648 Cs-137 Button Jan-16 216 10 Cs-137 Button Aug-91 1065/91 9.9 Co-60 Metal Nut Unknown Unknown 0.624

Note: (only Th-230, 0.01566 uCi exceeds 10X Appendix C value) CA 5010 Number: 072816 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

ENS 428251 September 2006 12:23:00The State provided the following information via facsimile: On 8/31/06, the Geosyntec RSO contacted the Radiologic Health Branch (RHB), Richmond office to notify that one of their Troxler gauges, Model 3430, S/N 28743 containing 8 mCi of Cs-137 and 40 mCi of (Am)-241 had been run over by a compactor at a job site in South San Francisco (333 Oyster Point Blvd.) around 2:00 pm. The RSO stated that the gauge operator tried to stop the compactor backing up towards the gauge but it was unsuccessful due to the noise. The gauge was severely damaged with the source rod in an unshielded position. The RSO contacted Troxler to have the unshielded source transported for disposal. Troxler was not able to provide transportation on 08/31/06. Per RSO, the gauge is secured on the job site inside a locked storage container and the unshielded rod is placed in a 5 gallon bucket of soil. They expect to transport the damaged gauge as soon as assistance from a local gauge manufacturer is received. The RHB will investigate this incident for any items of non-compliance. The State has indicated that the licensee intends to contact Campbell Pacific Nuclear (CPN) to transport the damaged gauge.
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