ML20155F607

General License Static Eliminator Device Collection Form

ML20155F607
Person / Time
Issue date:	06/16/1988
From:	Wallace W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
References
REF-QA-99990001-880616 88-067, 88-67, NUDOCS 8806160443
Download: ML20155F607 (3)

Text

_ _ _ _

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F66 UV '06 15 24 NkU REGION 3B P03' 3

amit:#iW Q%N GENERAL LICENSE STATIC ELININATOR DEVICE COLLECTION F0lm 1.

Name and Address of General Licensee:

Fisher ce;edik.

chem;c~l oasis ~

one Recd Lne Fa:< L wn, NT 03w o 2.

Date of Inspection:

824rck

/l,

, /'} f f Signature of Inspector (s):_

// 24xe

[d b t/

3.

Principal Business of Licensee:

AC1N M hackv re r Ch hlNC Cf1&n1 Eca J l

4.

Purpose for which device (s) are used :

P> \\ ow i on ;ze-cl a;e i <>

Ne to loo Oles k,

remo n dush l>eSer S'll;)v9 5.

Device Specifics:

a.

Model Number:

g g

b.

Activity of Po-210 source aCl j

c.

Date Received:

RENRN ORIoINAL M rag 10s I d.

Date lease expires: _

6.

Did it*ensee receive 3M notification: Yes No _

li c e u s e_ c_ Oogha d

• JoIW Sk l.e r bogt # [Jol) 7% -7/ 0 0

m4ie_:_57., sJJy,J t q N~~4 a-Cow b eo_kee Pcc. stet X

'6 s

-- No.

M e - ard. er ene W ea h cle k % d : _ soo o oem 8806160443 880616 REG 1 OA999 ENVFSC

._2(__. rn t.k e A 5 tr uut 99990001 PDR

FEB 09 '80 15:24 NRC REGION 3B PO4 i

3 7.

Survey:

a.

Has survey been performed by 3M:

Yes No By Consultant: Yes 1 No If Yes list consultant's name and location:

% W w M % c n rA % t/.7 m eL a &<nnrT k v.s& :

1 b.

Survey Perfonned by Inspector:

Serial Number of Device:

Direct Survey Of Device:

_ alpha dpm/

cm8 Direct Survey Of Work Area:

Smear Survey of Device:

, alpha dpn/

car Smear Survey of Work Area:

Survey Instrwnent Used:

Model:

Serial No.:

Date of Calibration:

(If more than one unit use additional sheets)

If direct survey shws contamination, samples of product must be obtained.

Type of product:

a

Phb UV '80 lb:2b NRC REGION 3B P05 s

I llo,'

Serial Number of Device: _

Direct Survey of Devica:

alpha dps/

co' Direct Survey Of Work Area:

Smear Survey of Device:

alpha dpm/

cm8 Smear Survey of Work Area:

Survey Instrument Used:

Model:

Serial No.:

Date of Calibration: _

Serial Number of Device:

Direct Survey Of Device:

alpha dpm/

cm' Direct Survey Of Work Area: __

Smear Survey of Device:

alpha dpm/_cm2 Smear Survey of Work Area: _

Survey Instrument Used:

Model:

Serial No.:

Date of Calibration:

_ ___ _