IR 05000232/1971001
| ML20126C814 | |
| Person / Time | |
|---|---|
| Site: | 05000232, 03020439 |
| Issue date: | 11/25/1992 |
| From: | Prange B NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| References | |
| 50-23271-01, 50-23271-1, 571697, NUDOCS 9212230227 | |
| Download: ML20126C814 (37) | |
Text
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l l 50-23271-01 I I MATERIALS LlcENSE 3,,,,,,,,,7,,,,,,,,,,,, g SUPPLEMENTARY SHEET 8 I 030-20439 I I I f i Amendment No. 1 g I I il I t i Ni l Kodiak Testing Laboratories, Inc.
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I l In accordance with NRC form 314 dated November 24, 1992 License No. 50-23271-01 is hereby l l terminated. p i l g j i I N,
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1 t l 1 FOR THE U. S. NUCLEAR REGULATORY COMMISSION 11 j i ,
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, Date By: 82lIV/,24rrm 0 ,lf '
I Beth A. Frange/J B Sr. Health PhyYicist (Licensing) I l Radioactive Materials Safety Branch - g l l Region V' > Pi W I' t I! D E D 1 > I 9212230227.921125 i h I PDR ADOCK-03020439 h I C PDR gi 8 . h*wur-= marmwassw.maavr.was.ws3Eirmw.:r.wsdMDRiMMrWX. ;
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NOV 2 51922 Docket No. : 030-20439 License No.: 50-23271-01 Control No.: 571697 Kodiak Testing Laboratories - P. O. Box 1945 Kodiak, AK 99615 Attention: Alice Bergee President Enclosed is the termination amendment which you requested in your Form NRC-314 dated November 24, 1992.
Sincerely, Beth A. Prange Sr.HealthPhysicist(Licensing) Radioactive Materials Safety Branch _ Enclosure: As Stated . . . .
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Distribution bec w/ original concurrence, copy of license and original correspondence: License docket folder bec w/ copy of license and correspondence: Inspection folder bec w/ copy of license: Reading file bec w/ correspondence and 2 copies of license: Shirley Crutchfield, LFMB, MNBB 4503 License only: State of AK KPrendergast omery DSkov
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/ / / II/25h2 REQUEST COPY REQUEST COPY REQUEST COPY REQUEST COPY YES a NO O YES a N0 o YES O NO a YES o N0 er
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* t P E f o#6 ARCED To NaC ON <ove 3 f eE Pr %3N TO BE CONTACTED htG Am>Na tst iNeDaM ATION PROVIDE D ON THil f 0 AM iii.ut ,6t&*M0%t cv.Ih Alice Bercee (907) 06 65fA 4 Malt ALL evTwet ;.oa goy.g R10.no.N0 tgi5 uttNst To
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1 CERTir Y UNDER PE dLILCE JEhJuni TN+AbTwENORICorNG IS TRUE AND CORRECT.
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m%t o wawa .%d 1.,6 b L. t C. <* b e f G e* f._ L 8 D e a)T WARNING: F ALSE STATtVENTS IN THr$ CE RTIFICATE MAY BE SUNECT TO CIVf L AND/OR CRIMINAL PEN ALTIES NRC REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRC Bt COvPLETE AND ACCURATE IN ALL MATERIAL REfJECTS 18 U.S C. SECTION 1001 MAKES IT A CRIMAAL OFFENSE TO MAKE A WILLFULLY F AL$E STATEVENT OR REPRESENTATION TO ANY DEPARTVENT OR AGENCY OF THE UNITED STATES A5 TO ANY MATTER WITHIN IT6 JUR1SbtCTION.
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Device . Model #34ll D , Serial #jv&qh This certfios that the
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Source (s) Serial # d3U7 Serial #4IIT-77 fh so m as been Dateof Test:#/TJ/M N IT WN analyzed using an f approved monitorInD i rc fhsa ys
*MMI shows the removable eY001 K % @ .>9(,) I activity to be less than ,
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LEAK TEST ANALYSIS Device - Model #77%D --- , S orial # 30 g This certifies that the somate accompanying Source (s)-Serial #Cil37 #UK, Serial #Aff MB *I this form has been analyzed using an ' Date of Test:ad'h -i 5 /*L approved monitoring method that measures Nase print legibly and firmly. Ilus as your retum address label. both beta /D amma & alpha h - - contamination; and, that
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: INFORMAi!ON FROM LTS btiwilN: '
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License fee Management Branch, ARM : Program Code: 031?) and Status Code ? Regional Licensing Sections fee Category: 3P
: lap. Date: 199?l031 : Iee Connents Decom Iin Assui~ ret F W ::::::::::::::::::::::::::::::::::::::
LIC[N51 f[[ TRANSM11TAL A. RfCION 1. APPilCATION ATTACHID
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Applicant / Licensee: KODI AK lt511NG LABORA10Ril5. INC. n Received Date: 9?O930 L- / Docket No: Control No.: 3020439 YW Q 571fs97
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Signed . [N N'NI O Date * //- 6 - 65 B. LICINSI f[[ HANAG[MlN1 BRANCH (Check when milestone 03 is entered [y/) 1. fee Category and Amount: 3[ 2. rt t f ee Paid. Application may t>e processed fo Renewal License
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K0DIAK QLALITY CONTROL P. O. Box 3898 Ko(Wak, AK 898f5 (907) 400-4995 27 October 1992 Post Ir'WW lu transmittoi memu 7571 eeipp..
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Hs. Beth Frange
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M IfW'- " M @ebik UOHRC Region V dC. U }Gh) qc., Nuolear Hateriale safety Section 0+rt mdT 1450 Haria Lane ,,,, -. gg Walnut Creek, CA 94596-5368 b0 T7f 0M 'fW
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SUDJECT Transfer of nuclear densometers from Kodiak Testing Laboratories, Ino, to Kodiak Quality Control.
Hs. prangei I recently purchased certain assets of Kodiak Testing Laboratories, Inc., which I plan to use in a new business named Kodiak Quality Control. Included was a variety of materials testing equipment, including two- Troxler model 34112 nuclear densometers.
Kodiak Testing Laboratories (ETL) submitted an application dated 23 Septmeber 1992 to NRC for renewal of their materials license 850-23271-01. I submitted an application dated 22 October 1992 to HRC for a new materials license.
The purpose of my application is to enable me to take possession of the nuclear materials now in the custody of KTL. All my nuclear materials will come from KTL, with the possible future addition of new densometers from Troxler or Seaman. KTL will retain no nuclear materials.
Immanuel G. and Alice Berges, officers of KTL, intend to liquidate the stock of KTL and dissolve the corporation. KTL will then cease to exist. I. O. and Alice Berges have no plans to possess nuclear materials in the future. I have appended a copy of the purchase agreement executed between the Bergoes and me.
KTL recently received a lotter from Harnella Rodriguez informing them that the annual license fee has increased f rom $400 to S540, and stating that the license renewal application will lapse in 30 days it they do not provide the additional S140. The letter referred to control number 571697. - We would be very pleased if KTL's license renewal application were to lapse, provided NRC can issue a license to Kodiak Quality Control before KTL's present license lapses, and particularly if KTL could get their original S400 back. Could we perhaps call this a transter rather than two separate applications for-materials licenses? 5~7577
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' Ms. Seth 1992 27 October Prange - Nuclear Natarials safety 8ection !
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Page 2 * i I. don't-know really ha how much leeway you have regarding rees
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business, ppening and I am is that the 8stgees are getting out but what is , of the nuke
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they should not be getting required in.
It would seem reasonable that I natorials which they will to pay $540 tur a license for gives me a license. transfer to me just as soon as NRC : In any event I have included a check for $140 for my-license I application.
courts 90Ytificate,, I have as youalso requested. included a copy of my Troxler training " i you have questions, or if you need additional Please call or fex me if information. ,
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i L Mark Blakaslee, P.E., . Kodiak Quality Control owner-t
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. __ _., . _ _ _ __ _ _ _ _ _ _ _ __ . ._ . . __. _ _ _ . _ . _ _ _ . _ _ _ _ _ . _ _ _ . . _m . * . , . . , . ME1MORANDUM e Immanuel. O. and Alice Bergee, officers of KTL, -$ntend to liquidate the stock of XTL and dissolve the corporation.
. KTL will then cease tu exist. 2. G. and Altoo Berges have no plans to possess nuolear materials in the future.
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' Alice Bergeo d date f'
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. AQUALIFE ENGINEERING ,
P.O. Box 8994 Koolak, Alaske 99915 (90'f) 440 4998 Voloo & FAX 26 September 1992 PURCHASE AGREEMENT , AquaLife Engineering hereby offers to purchase eartain assets of Kodiak Testing Laboratories, Inc. This offer includes all materials testing equipment - and- supplies, accounts receivable - dated later than 16 September 1992, and the good reputation of the company. All stock, and any liabilities of the corporation (other than those incurred by AquaLife while operating the lab during 1992) remain the property and responsibility of I. G. and Alice Berget. The terms of sale are Es-follows.
1) Furchase price will be $18,000 plus 25% of the accounts receivable balance as of 16 8eptember 1992. 2. O. and Alice Bergee will collect the accounts receivable to 16 September 1992, and pay 75%, less qualifying expenses, to AquaLife per our' agreement of 6 May 1992. Payments will be made on
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the 15th of each month, or whenever the balmnee owed exceeds
$3000, whichever_is more frequent.
2) A down payment of $3000.00 will be made'when this agreement
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is comPlated.
3) Honthly payments of- 8600.00 will be made on the first day of f each month, July through December, 1993 through 1995.
4) A final balloon payment of_the remaining balance will be: made with the final monthly payment on 1 December 1995.
5) Lab equipment and lab product will be removed from their-current location no-lat'er-than 1 May.1993. No charges will be incurred =for storage of equipment at the present location.
6) AquaLife Engineering will immediately apply for a radioactive materials license ~from the NRC,-and will take possession of the nuclear densometers upon-receipt of the license.
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Purchase Agreement 26 September 1992 Page 2 of 2 7) i I. G. Bergee consents to provide field density and concrete testing as1992.
December required by clients from $ October through 31 the testing performed.Bergee will be compensated the full value of The above terms are accepted by the principals, as follows.
AqumL1:Ee IDngineering Agreeda N 71^ - ' Hark BjaXeslee, owner ' dnte Kodiak Testing Laboratories Agreed _ f. G.aelges w
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'date Agreed. 0 * _ M , _e m Alice Bergee
_ O 9 3o.92_ - date
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9 gON e 9CTRONIC LABORA70 b r~ f? f HEREBY CERTIFIES THAT
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gT HAS SUCCESSFULLY COMPLETED THE TROXLER ELECTRONIC LABORATOR2S, INC.
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@' % TRAINING COURSE FOR THE USE OF NUCLEAR TESTING EQUIPMENT. . , m: -[ : ~ :.
SUBJECTS INCLUDED IN THIS COURSE WERE AS FOLLOWS: E F -#
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Radiological Safety l g gii 1. Principles and practices of radwtion 5. Radioactivity measurement standardi~a sc-n
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i NUCLEAR REGULATORY COMMISSION wAsNINGToN, D.C. 30gus 00T 2 2 E Kodiak Testing Laboratories, Inc.
ATTN! Alice Berges, President P.O. Box 1945 Kodiak, AK 99615 Gentlement This refers to your letter dated September 23, 1992, for rwneWal of Materials License 50-23271-01. Your check No. 1420 ($400) in payment of annual fee Invoice AH07256 was received.
Your request is subject to a renewal fee of $540 as specified in fee category 3P of $170.31, 10 CFR 170, which went into effect August 24, 1992. A copy of the July 23, 1992, Faderal Racister notice regarding the revisions to the Commission's license and annual fee regulations (10 CFR 170 and 10 CFR 171) is enclosed.
Payment of the $$40 fee should be made to the U.S. Nuclear Regulatory Commission and mailed to the following address: U.S. Nuclear Regulatory Commission ATTH: J. Marnella Rodriguez License Fee and Debt Collection Branch, OC/DAF Hall Stop HNBB 4503 Washington, D.C. 20555 Your application will bo processed by the RV Licensing staff located at 1450 Maria Lane, suite 210, Walnut Creek, California 94596. The foe, however, is required prior to issuance of the renewal. When submitting the fee, please refer to CONTROL NUMBER 571697.
If we do not receive a reply from you within 30 oniendar days from the date of this letter, we shall assume that you do not wish to purnuo your application and will void this action.
Sincerely, $/A4<dLA-eJ f
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, Marne11a Rodr un i icense-Fee and Debt Collection Branch j Division of Accounting and Finance l Office of the Controller Enclosuret July 23, 1992, Federal Reaister notice ocs RV l l L t
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OCT 2 21992 (1W# '
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(1-ATTN: y Alice Bergee, President-P.O. Box 1945 l
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centlemen: 4M p M , c-) p* 7 k (, e f ')& This refers-to your letter dated September 23, 199 , for renewal ' c of Materials License 50-23271-01. Your check No 1420 ($400) in
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payment of annual fee Invoice A1107256 was rece ed.
Your request is subject to a renewal fee of $540 as specified in fee Category 3P of 5170.31, 10 CFR 170, w ich went into effect August 24, 1992. A copy of the July 23 1992, f.pderal Reaister notice regarding the revisions to the ommission's license-and annual fee regulations (10 CFR 170 a 10 CFR 171) is enclosed.
Payment of the $540 fee should be ade to the U.S. Nuclear Regulatory Commission and maile ._to the following address: U.S. Nuclear Regula ory Commission ATTN: J. Marnell Rodriguez License Fee and bt Collection Branch, OC/DAF Mail Stop MNBB 503 Washington, D . 20555 Your application will jbe processed by the RV Licensing staff located at 3450 Maria Lane, Suite 210, Walnut Creek, California 94596. The fee, ho/ever, is required prior to issuance of the renewal. When sub itting the fee, please refer to CONTROL NUMBER 571697.
If we do not re elve a reply from you within 30 calendar days from the date ,df this letter, we shall assume that you do not wish to purs year application and will void this action.
Sincerely, Sign 8d DY . y }pmsm R00'GucI J. Marnella Rodriguez s/ License Fee and Debt Collection Branch Division of Accounting and Finance Office of the Controller Enclosure: July 23,-1992, Federal Recister notice cc: .RV - RISTRLBUTION Pending Fee File,-OC/DAF R/F, LFDCB R/F (2), MAC#1 - A:\KTLI.TXT OFFICE: NAME:
$B8%w /h fB OC/L JMRoddiguez OC/LFDCb MMessier DATE: [/ O /o /SJ /// V /0/If///
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Kodiak Testing Laboratories, Inc. p,3 y . NOV 61992 t.
.ATTH: Alice Bergee, President- ' ' __} . P.O. Box 1945 Kodiak, AK 99615 p3 l,7l _n I.'; O 53 : L imm _
..j Gentlemen:
This refers to your letter dated September 23, 1992, for renewal of Materials License 50-23271-01. Your check No. 1420 ($400) in payment of annual fee Invcice AM07256 was received.
Your request is subject to a renewal fee of $540 as specified in fee Category 3P of $170.31, 10 CFR 170, which went into effect August 24, 1992. A copy of the July 23, 1992, Federal Reaister notice regarding the revisions to the commission's license and annual fee regulations (10 CFR 170 and 10 CFR 171) is enclosed.
Payment of the $540 fee should be made to the U.S. Nuclear Regulatory Commission and mailed to the following address: U.S. Nuclear Regulatory Commission ATTN: J. Marnella Rodriguez License Fee and Debt Collection Branch, OC/DAF Mail Stop MNBB 4503 Washington, D.C- 20555 Your application will be processed by the RV Licensing staff located at 1450 Maria Lane, Suite 210, Walnut Creek, California 94596. The fee, however, is required prior to issuance of the renewr.l. When submitting the fee, please refer to CONTROL NUMBER 571697.
If we do not receive a reply from you within 30 calendar days from the date of this letter, we shall assume that you do not wish to pursue your application and will void this action.
Sincerely, Signad D'l 3, pp,mpa RodrigucI J. Marnella Rodriguez License Fee and Debt Collection Branch Division of Accounting and Finance Office of the Controller Enclosure: July 23, 1992, Federal Reaister notice cc: RV
,, pISTRIBUTION Pending Fee File, OC/DAF R/F, L DCB R/F_(2), A LI.TXT \ gyl - MAC#ggg*'Ky?EOIU! '
OFFICE: RD B OC/LF B OC/LFD NAME: W JMRod;iguez MMessiet4 ll0l5I1; DATE: ,/ /o / SJ / /j 7 fo / y / - .'Ow .'
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THE MINIMAL INFORMATON REQUESTED FOR THIS CERTIFICATON DOES NOT CONSTITUTE AN INFORMATION COLLECTON'
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. AND, THEREFORE. DOES NOT REQUIRE OMB APPROVAL NJ.C FORM $24 U.S. NUCLEAR REGULATORY COMMISSION INVOCE NUMBER , i
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g AM07256-92 CERTIFICATION OF SMALL ENTITY STATUS FOR PURPOSES OF ANNUAL FEES WENSE NUMBER IMPOSED UNDER 10 CFR PART 171 see Instructions on rearse side.
50-232T1-01 Att etems MUST to completed-print or type. Incomplete Ibrms will be retumed.
NAME AND ADDRESS OF LCENSEE (as it appears on the ineke): KOLIAK TESTING LABOP.ATORIES, INf'. P. O. box 19h5 KODIAK, AK 99615 NOTE- See Instruction W. 2 on the reverse side - Check one box only.
1. BUSINESS OR NOT.FOR-PROFIT ORGANtZATION WITH MAXIMUM ANNUAL FEE PER LICENSED CATEGORY GROSS ANNUAL RECE! PTS OF: A $250,000 TO $3,5CO,000 $1,800 y B. LESS THAN $250,000 $ 400 j 2. PRIVATE PRACTCE PHYSICIAN WITH GROSS ANNUAL MAXIMUM ANNUAL FEE PER UCENSED CATEGORY RECElPTS OF: A $250.00010 $1,000,000 $1.800
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B. LESS THAN $250,000 $ 400 3 GO'4RNMENTAL JURISDCTON WITH A POPULATION OF: MAXIMUM ANNUAL FEE PER LICENSED CATEGORY A 20,000 TO 50,000 $1,800 ,
!
B. LESS THAN 20,000 $ 400 4. EDUCATIONAL INSTITUTON THAT IS SUPPORTED DY A .. QUAUFYING GOVERNMENTAL JURISDICTON WITH A MAXIMUM ANNUAL FEE PER LfCENSED CATEGORY POPULATON OF:
'A 20,000 TO 50,000 $1,800
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B. LESS THAN 20,000 $ 400 EDUCATONAL INSTITUTION THAT IS NOT STATE OR
- PUBLCLY SUPPORTED, AND HAS 500 OR LESS $1,800 - EMPLOYEES CERTIFICATION This certdication enust be signed by the owner of ttu entity named above or an omcial empowered to act on behan of the entity.
I certify that the above named NRC licensee qualifies as a small entity under the size standards established by the NRC for its licensees on November 6,1991, (56 FR 56671) and in accordance with Title 10, Code of Fsderal Regulations, Part 171, as cevised (56 FR 57587). The licensee qualifies as a small entity under the specific size standard indicated above.
WARNING: 18 U.S.C. Section 10ff., N4 of June 25,1948,62 Stat. 749, makes it a criminal offense to make a willfuffy tales statement or representation to any Department or A .ncy of the United States as to any matter within its jurisdiction. The submitta; of willful falso statements is punishable by fine or imprisonment. or both, and for purposes of this certi$ cation, may result in revocation or suspension of the license.
I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
TYPED OR PRINTED NAME AND TTTLE SIGNATURE DATE
n.x_ m rr, m anz @C, a _ p 17-32 _
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S., NUCLE AR REGUL ATORY' COMMISSION
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REO Ns 42 Annuai- Materials Fee InvoicRECEIVED
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10-CFR 171.16 N p e c.RC. . ,
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invoice Date Inv ice Number 0028888888=8 12 MP 30 P3:14 ._ ESRBB=255=E===
-08/24/1992 AM07256-92 KODIAK TESTING LABORATORIES, INC.
ATTENTION: RADIATION-SAFETYOFFICER-P.O. BOX 1945 KODIAK- AK 99615
***** Mark THIS COPY with'any billing address changes *****
License / Approval / Rogistration/ Code Annual Fee Surcharge Cortificate Number AA905 Category (s) Fee Amount Amount , ================== ===== =========== == ============== 50-23271-01 ANN 3P =========,====.00
$ 2 100 8 150.00
_______________ ______________ TOTAL: $ 2,100.00 4 150.00 TOTAL INVOICE: 4 2,250.00 ako-Checks Payable To:
====================== .S. Nuclear Regulatory Commission <=== 151s PO Box address 'I s .Jconse Fee.& Debt Collection Branch <=== iur receipt of payments 0 Box 954514 <=== 0.11y.
t. Louis, MO 63195-4514
.oras and conditions are-attached. Nonpayment of your annual fee ay result in the revocation of your license (s) in accordance with ho enforcement provisions of 10 CFR 171.23 of the Commission's.
ogulations.
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* * * PAYMENT C0PY *
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, ===> To ensure accurate credit, return this copy of the <=== ===> invoice with your payment.- Processing may-be <=== ===>-delayed if the invoice is:not included. <=== .
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Nuclese Materialc Safety Section : .
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U.S. Nuclear Regulatory Commission, Region V gg ' ~ ' # 1*150 Maria Lane ; . _ , p g. p Walnut Creek, CA 94596-5368 g ,. .
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PE: M a t e r '. p l License Renewal Fod i r.L Terting Laboratories. Inc., License 49 50-23271-01 Dear Sirs.
In rnsponse to the " Instructions for Preparation of Application for License benewal" supplied by your agency, I am enclosing copleu ott 1. Materia,la License # 50-23271-01 pages 1 througn "" da t ed October 6. 1Q87.
2. The Arplication for Material License dated August 17, 1987 which is attached to and made part of the Material License ** 50-23271-01.
3. A copy of Kodiak Testing Laboratories, Inc.'s letter of September 21, 1987 to Beth A. Riedlinger which is attached to and made part of the Material License # 50-23271-01.
Each of the above documents accurately represent the.
management control program, facilities, equipment, personnel, radiation safety procedures, waste disposal Procedures, location of use of flodiak Testing Laboratories, Inc. ett c eP t , as follows: , Application Attachment II, item 8. Add: Mark Blaleslee, Licensed Civil Engineer, has completed the
- Tronler Electronics Laboratories, Inc. Training course for ( the use of Nuclear Testing Equipment Certificate *:054105
(ct.r;> a t t ached ) and is authori::ed by the Safety Officer to operatu the devices containing radioactive material.
l APplicatton Attachment II, item 9. Amend " Storage" to: Page 1 of 3 l l 57/6f7 (S07)486-850S
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U.S. Nuclear Regulatory Commission, Region V September 23, 1992 Page 2 of 3 When not in-use the guage will be stored in a locked c3 binet, in a locked room with no outside access as per attached drawing on-Attachment III.
Application Attachment II, item 2. Amend "While in transtt" to: The gauge will be tran9 Ported to the site in the transport case, inside a locked box,. bolted to the bed of a pickup.
Attachment III, item A. SAFETY PROCEDURES, its 10 is amended as follows: Tronler Electronic Laboratcries. Inc.
11300 Sanders Drive. Suite 7 Rancho Cordova, CA 95742 Attachment III. item B. EMERGENCY PROCEDURES, 1. Accidents, stem d. is amended as follows: Region V, USNRC ' Office of Inspection t< Enf orcemen t 1990 N. California Blvd, Suite 202 Wa:Inut Creek, CA 94596 (301) 951-0550- Any Time Attachment IV, item 11, amend address to: Troxler International, Led.
3OOu- Cornwallis Rd. at Alexander Drive Researca Triangle Park, NC 27709 A11zother items include'd in.the APP lication for Materials-Lisence Renewal are-true and correct. Please issue-license s renewal and forward to: Kodiak Testing Laboratories, Inc., P. O. Box 1945, Kodiak, AK 99615
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U.S. Nuclear Regulatory Commission, Region V September 23, 1992 Page 3 of.3 If you have any questions regarding this application for Material License Renewal please phone (907) 486-6506 during regular business hours.
Sincerely, Alice Bergee Immanuel-G.-Bergee President Safety Officer AB cc: Material License File '
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September 21, 1987 Docket N. : 030-20439 Control M. : 70630-United States Nuclear Regulatory Commission, Region IV 1450' Maria Lane, Suite 210 Walnut Creek. CA 94596
- ATTN: Beth A. Riedlinger l Health Physicist (Licensing)
Nuclear Materials Safety Section
Dear Ms. Riedlinger,
In response to your letter of September 8, 1987 regarding the additional information requested to complete the review of our licenseing applicatton, the following should answer your questions: 1. The manufacturer and model number of the sealed source holders are Troxler 3411, there are two of these. They are manufactured by Troxler Electronic Laboratories, Inc., 3008 Cornwallis Rd. at Alexander Drive, Research Triangle Park, North Carolina 27709 The Sealed sources ares Cos'ium 137 Troxler #A-102112 Once source 8 mci (each) Americium 241 Troxler #A-102541 One soruce 40 mci (each) , 2. With regard to personnel monitoring devices, the name of the supplier is Radiation Detection Co., P. O. Box 1414, Sunnyvale, CA 94088-3414. The-type of devices used will be film badges and they-will be exchanged monthly.
3. Leak test as required will be performed every six months'
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by the radiation safety officer with the Troxler Model 3B80 Leak Test Kit.
Page 1 of 2
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United States September 21, 1987 Nuclear Regulatory commission 4. I spoke with Bob Thomas of your office regarding who to notify in the event of an emergency. He gave me the name and phone number of the person to contact in Alaska and advised he should be contacted also.
I am enclosing updated attachments I, IV and V with this additional information, to be attached to our original Application for Materials License. Please contact us as soon as possible if additional information is-requested.
Yours Truly, Alice Bergee Kodiak Testing Laboratories, Inc.
AB Page 2 of 2
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INSTfiUCTIONS: SEE THE APPROP46 ATE LICENSE APPLICATION GUIDE FOR DETAILEO INSTRUCTIONS 7OR COMPLE TING APPLICATION SEND TWO COPIES OF THE ENTIRE C097LETED APPL 1 CATION TO THE NRC OFFICE SPECIFIED BELOW.
$ 80t RAL AGl4Citt fit t AP941C ATION% RITM IF YOU Amt LOC AYtD IN U $ NUCLE Am *!GVL AtCav COvv ss:ON ILttNoit INO A N A Iowa. M6 CHIC A N. WINNISOT A. MissOVal. OMio. On Div'1 SON C 8 8 Lli C v C.t AND MATimeA L 1Af tTV. NW13 niSCON58N,$tNO ArettCATIONS TO DASHsNGTON OC PM66 V $ NuCLIa m alGULAf ont COWW15& ION, mtciON : :
&LL OTHt m et #$0NS F ett AP'LICATIONS Al FOLLowS,17 VOU A mt Maf ta:Ats LACE N5'NG 5tCTION LOCAft0IN 7M ADOstvtLT mOAD GLE N E LLYN, IL 6C137 CONNICTICUT OE L A ma nt DitT alCT OF COLUWSI A M AINE. M Am VL AkD.
MAESACHu%t TTl Nt * JI P$l v. hte YOR K.PE NNSVLV ANI A. mMOct ISLAND. ARK ANSAS COLOR ADO :DAMO E ANSAJ LOUISi AN A MONt&NA Int s m asm A, ca vemuCNT. 5tND AppLIC ATiONS TO Ntyv Mi a:CO NOmTM D As OT A Ca LA MOMA, $0VTM DanOT A,781A$ UT AM, Om WYOwho,8840 APf tiCATIONS 10 U S NUCL t A m atGUL A TCa v COVW:$3 ION. R EG ON I NUCLE Am Matt miat $tCTION B U S NUCLE AR af GUL Atomv cowwll'ON mtGIO4 ev 631# Ann avfNuf M Af t m AL m AOiATiON po'JT tCTION 5tCTION RING 08 PmV15e A. P A 19A06 sit a v &N 9( A2 A Omivt. Sutti 1000
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PutatO miCO SOUTM C anOtiNA f tNNt tse t, vimCiNtA, vinGIN isLANos. Om Al&5K A. Am:20N A CALIFORNta M AR All Niv&DA, On tGON W ASHINGTON nali VinGINSA.StND APPLiCAflONS TO ANO U S. TimmeTOmitt AND POS5815aONS 84 TMt pacific 54 NO APPLICATIONS
U S NUCLlan af GULATCav Covvi3SiON mtGtON il waf t mi AL R AOimtiON pmOf t CTION stCTIO's U S NUCLE Am mlGutATony COMwiss#0N mtGiON v tot W Amit TT A StatIT. 8viT E 2900 M Af t mi&L N ADia TION PmCTICTION SEC* TON
&TLANT A. GA 3GJ23 1450 U AmiA L ANI SUITE 210 WALNUT CattK CA 945M FIS10N1 LOC Af tD IN AGattWtNT ST Af tS SEND APPLIC ATIONS TO THE U 1 Nuckt AR mtOUL ATOmv COMMISSION ONLY IP TMtv vviSM TO POSSits AND ull LittNsto MAf talAL IN ST ATillsaJECT 10 u $ NUCLE AR mt GUL ATOmv COMMIE & ION JVaiSDiCTION TM $ 4 AN 4 *PL C AT QN FOm IC7een esaw ere nsem/ 2 N AME AND W AILING ADDat1S 08 AprLiCANT Owvoele Cooed A N4* LCEN18 1 Kodiak Testing Laboratories, Inc, e AvtNovtNT vo t:Ctsst Nuves Bor 1945 * ]: mtNan AL O eCINst Nuue'" - Kodiak, AK 99615
3.Ac:,ets: Es a-t at sCtN5to uAf tm1At wilt et u5to Om PcEt uto
/6 l'f A. Primary gauge storage at iden m ? 1 by 9d.e v odiak, Alaske B. Used at temporary job sites with m the ?+ rete at Alaska e Navt * 8 t a ;C'. * C 54 CONT ACit3 A&OUT TMt3 APPLIC A*lON TlittMON4 Nvv8tm Alice Bergee (9071486-6506 SVBY * *t"5 5 *-8 h ~e 11 ON t i e 11 APEm THE TvPt AND SCort OF INeomuaTION TO st PmovlOED i$ OtScmit t o IN TMt LiCINSI APpLIC ATION GuiOE s ma: :A;T',tva*ta et 4 * v4 ee .co. eae.w oamA+ 'wm. eas e mes=m em at a Pum*0stist FOm wMiCH LiCENsto wAYtme AL wiLL ei vsto.
e ** r.r i i . . w h ne.- r es, one time AttachTNent I Attarh*ent T T iN:s C. AL s; meseON$ SLt FOm maot ATION 5AF ETY PROGR AM AND TMtim Tae N.N 'a AND & iPImitNCE 9 TRAINING 50R INDiviOUALS WORKING tN Om 7mtOVtNTING mtSTmiCTED ARE AS httRrhVPnt T hYfRekPnnt TT
$ PACMTit $ ANO (OgifvtNT 10, R ADI ATION 5AFETY PmOGma u A*_tachrent II At+Nrhena* TTT ia.LictNsu ots,4. ,u n m m m an st .c t v nelNT AMOUNT m rx-y e T t, FEtCAftGomy P <Nnost o 5230.00 tJ <i2* *2A' ;N W ar se co+ >e ws e, ece,icenti THE APPLICANT uNot m1T ANDS TM A F ALL ST ATtutNis ANO mientsgNT A T CNS M ADt .N THis APPLIGATiON Am t i U Ni ,a;g*.gAedygagy T>t 448 CANY d.NO ANY 088ici AL I at CUTING THIS CERTt8 scatiON O s htM A. 06 THE APPLiC ANT. N AMED nN iTE W 2 Ctatif V TH AT TMSS AP'LICAfiON 11 P8t'A44* N CCN8 0R uivv WIT H T TLE 10. COOT OS F EDi n AL of GVL ATiON5 PamT$ 30. 37. 33. 34. 35. AN0 40 AND TM AT ALL .NsOmvAfiON CONT A,NEO Ma ntis, L5 tnt AND CO,8 AE CT TO THE gt1T 08 TMaim ENOWLEDGE ANO e tLit7 sk A E*dN 's 'd V ! C SECTION uce ACT 08 NNE 71 1948 67 $T AT '44 w Au nt IT A CalMiN AL 088tNSt to Mant A vetLLru(Lv patst STAf gutNT Om utpatstNT ATICC
'O ANT Ot* An've NT 04 AGENCY Cr T=t UNITED ST ATk3 A1 TO ANY W ATita ettarN ITS Jvmi$0iCTION
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5dGNA* dl - a P T + - NJ C5 8eCin T YPE D:Pm:NTED Navt TIT L 4 ATE Alice Bergcc President 8-17-87
.a s m wtaa,tccN M rave ! * a NWiliM O8 tv8. t Ort:5 f ate. fes a WOULD 10U 61 WiLLiNG TO sts*N ia COST INFOsw ATsCN Qa
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' , ^%. 3 g3gy,yy the agenew ** een6de Aser 9 9 ,,gy - Nwvet4C* SECS y3 vt3 NO FOR NRC USE ONLY TV'. * * 14 -siLCS Fit CattGCav CCvutNT3 AP*movtaev AW ' * * k t w ie CHtCA NLVeta OATE - -
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PRIVACY ACT STATEMENT Pursuant to 5 U.S.C. 552 ate)(3), enacted into law by section 3 of the Privacy Act of 1974 (Public Law 93 579), the follow-ing statement is furnished to individuals who supply information to the Nuclear Regulatory Commission on NRC Form 313. This information is maintained in a system of records designated as NRC 3 and described at 40 Federal Register 45334 (October 1,1975).
1. AUTHORITY: Sections 81 and 161(b) of the Atomic Energy Act of 1954, as amended (42 U.S.C. 2111 and 2201(b)). 2. PRINCIPAL PURPOSE (S): The information is evaluated by the NRC staff pursuant to the criteria set forth in 10 CFR Parts 30,32,33,34,35 and 40 to determine whether the application meets the requirements of the Atomic Energy Act of 1954, as amended, and the Commission's regulations, for the issuance of a radioactive material license or amendment thereof.
3. ROUTINE USES: The information may be (a) provided to State health departments for their information and use; and (t) povided to Federal, State, and local health officials and other persons in the event of incident or exposure, for the r informatton, investigation, and protection of the public health and safety. The information may also be dis-c!Med to appropriate Federal, State, and local agencies in the event that the information indicates a violation or potential ; vio.atico of law and in the course of an administrative or judicial proceeding. In addition, this information may be trans.
ferred to an appropriate Federal, State, or local agency to the extent relevant and necessary for an NRC decision or to an appropriate Federal agency to the extent relevant and necessary for that agency's decision about you.
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVID-ING INFORMATION: Disclosure of the requested information is voluntary, l' the requested information is not furn-ished, nowever, the app l! cation for radioactive material license, or amendment thereof, will not be processed. A request that information be held from public inspection must be in accordance with the provisions of 10 CFR 2.790. Withhold.
ing from public inspection shall not affect the right, if any, of persons properly and directly concerned need to inspect the document.
5. SYSTEM MANAGER (S) AND ADDRESS: U.S. Nuclear Regulatory Commission Director, Division of Fuel Cycle and Material Safety Office of Nuclear Material Safety and Safeguards Washington, D.C. 20555
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4.yj.ig' *- l TRAINING COURSC TOR TIIE USE- OF NUCI. EAR TESTING EQUIPMENT.
h& ' I'[" . 3h :, , SUBJECTS INCLUDED IN THIS COURSE WERE AS FOLLOWS: Radiological Safety - kr, (N, ' .
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TRAINING COURSE FOR THE USE OP NUCLEAR TESTING EQUIPMENT. $f.
- 4 . g[a! J SUBJECTS INCLUDED IN THIS COURSE WERE AS FOLLOWS: Ifh.yh.t .h.,} ; W.g f Radiological Safety g
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1. Principles and practices of radiation S. Radioactivity measurement standardization W %.'%. A,f%,;.$' j&
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the use and measurement of mdioact.ivi ty.
7. Procedurco for nuclear gauge stomge and transportation.
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Ql_; *{ 4. Biological effects 'of radiation. 8. Cencrat safety preca:stions.
. . s. /.].. '- (, ... .e4-QC. Cauge Opomtton ; ; >,.;
:. 1. Instruncnt theorg . 4. Field application f.5.-,
f(. ,}. 2. Operating procedures 5. Gauge calibration ,,Q, AQ. , C.i 3. Maintenanca (3, .y. ', j
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h. C / / 5/18/87 W. F. Troxler ' d.'.'t 01 & i 34n i r 7/{J971 ' ' J .L
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Reolaw' Testing Lacorateries.-Inc.
cJ Application for M a t e r i a .! License Attachment-1
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5. Radioactive Material s. Element and mass number Cesium 137 and Americtu.m 241 b. Chemical and/or pnysical form Sealed Source , c. Maximum amount which will_be possesed at any one time Cesium 137 - One source 8 mC1 (each ,
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Americium 241 - One source a0 mci teacn)
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4. Purposes for whlen licensed material will be usec Measure moisture and_denisty of construction - materials.
'. Inciv$ duals responsible for_ radiation safety' program and their training and experience.
Immanuel G. Bergee Troxter Electrontes Laboratories. Inc. Training Course for the use of Nuclear Testing Equipment. Certificate #19296
.I' Alice A. Bergee 7 Troxier Electronics Laboratories. Inc. Training Course for the use of Nuclear Testing Equipment. Certificate #19301 .
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Mod'iak' Testing L3toratories. Inc.
?' Application for-Material License ' Attachment 11 ITEMn i. Tryining for individuals working in-or f r equ e'r. t i n g restricted areas, it is not the intentien of Ecdiak Testing Laboratories. Inc. to hire employees, either to ecnauct-testing with the portable gauging devise, or have access to r e s '. r i c t e d . a r e a s . h: wever. if in the future amployees are hired they will be required tot 1. Complete the training program of sne device manuracturer.
2. Read and understand Nuclear Regulatory Commissien Regulations applicacle to portable gauging devices.
3. Commit to memory the safety and emergency-procedures as described in this application in section 10.
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4. Facil,ities and equipment. - Storage: When not in use the gauge will be-stered in the transport case. in a locked esonet. in a locked rcom with no outside access as per attached dra wir.g on Attachment !!!. While in transit: The gauge will be transported tc the site in the transport case, either-in the_ reat i of a locked station wagon or in-the bed of a pickup chained to mounted-rails.
At the-job site: The device will be under the constant surveillance and immediate control of one of-
:ne 'icensees. It will never be left unattended.
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' 7p' plica'. ion for Materials License
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KODIAK TESTING LABORATORIES. INC.
P. 0. Box 1945 Mediak, AK 99615 (?O7: 486-6506-RADIATION SAFETY PROGRAM A. SAFETY FROCEDURES 1. Do not operate or attempt to operate a gauge unless you r.s v e been authorized to do so.
1. Do nct attempt to repair, modify or open the' sealed source un er any circumstances.
3. Wear a film badge at all times while operating or ranrporting a gauge.
. Fellcw operating procedures, when uaing the gauge, in se:Oroance with'the Troxler instruction manual, the radiation montret regulations and this safety program.
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E. Keep unauthorized persons away from the gauge.
4. Do net leave the gauge unattended when in use or outside
:f the storage enclosure or locked vehicle.
'. Meep the gauge in the " SAFE" or storage position when net
:n use.
3. Se sure a.r the gauge is. locked-w'Ithin.an authori:ed ancl:sure (, g. closet, cabinet, vehicle, etc.) when it_is l not in use. Security against theLtheft'of a radioisotopefis or utmest importance.and must not be neglected. The storage
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enclosure must'be labeled'with a radiation warning sign bearing the symbol as described in 10 CFR-20.003 and tne wcres " CAUTION RADIOACTIVE MATERIALS".- 3 Gaugas-may only'be transported 1by autheri:ed personnel _:n arprovec v e h'i c l e s . The gauges may not be transported on1the
:: :nt or rear seats o: any vehicle. If a pickup trucu is ~
usse the geuges must be locked in an enc!osure (e.g.-cabinet.
, inipping case, etc.> and the enclosure tiec securely (e.g.
! chairec. bolted, etc.) to the-body of the truck in order te , prevent loss or-theit.
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10. Ensure-that the gauge-l's' leak tested st the4I1nterva'Is
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i n e ' w ' ye saople will os collected by the Radiation Safety
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test-measurement on the wipe sample w'ill be performed by
. ~ -Troxter Electronie Laboratories, Inc.
' P..O. Box 12057 ,s
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Research Triangle Park, NC 27709 11. When in douot, ask your Radiation Safety Officer.
E. EMERGENCY PROCEDURES
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1. Accidents a. In the event of possible damage to source or source control mechanism, the operator will keep unauthorized persons at least fifteen feet from the gauge and prevent removal of guage from the site until authorized by the Radiation Safety Officer or appropriate authority.
, b. If there is any possibility the source capsule might be ruptured, the location must be covered oy a sheet of material (plastic, tarp, etc), held cown by weights (rocks, bags of material.-etc.) to prevent scattering of radioactive material by the elements. . .; c '. The operator must then-immediately notify his/her Radiation Safety Officer of the incident and give an appraisal of the probable condition of the source.
c. The Radiation Sarety Officer will then immeciately notify the following authority who will provide instructions and assistance in accordance with the circumstances of the incident Region V,-USNRC Office of Inspection L Enforcement 1990 N. California Blvd., Suite 202 Walnut Creek, CA 94596 (415)a86-3141 -daytime, nights le holidays 2. Source stolen or lost.
a. The operator.must immediately notify local police or other law enforcement agency.within whose jurisdiction the incident occurred.
b. The operator must also notify his/her Radiatien Safety:Orf.icer who will notify the authority listed e in item'B-1-d above.
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1 ,C.. DUTIE5'0F THE RADIATION SAFETY 0FFICER- ' 1. Assure compliance with all pertinent parts of the Nuclear Regulatory" Commission's regulations. . ;-
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2. Assure compliance with the conditions in licensee's.
Radioactrive Materials License ano- amendments and above items given in this safety program. t
2. !!a i n t a i n t he following items in a radiation file and. keep availatle for inspection by controlling agency if-requested.
a. Current Radioactive Materials License.
< b. copies of license application, attachments and all pertinent correspondence referred to in the conditions of the license and amendments.
" c. Gauge Source Certificates issued with the Eauges by the man;facturer.
d. Film badge or TLD reports.
e. Leak test reports. _ r. Records concerning disposal, inventory and 1
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useage or sources, g. Copies of this safety program, h. A current copy of the controlling agency's regulations.
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Apoliesti:n for Materials License A . .s e ne.e n t 1V
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P. O. Box 12057 - Cornwallis Rd. at Alexander Dr.
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fer disposal.
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( 1 3 (t:c a aalrp,m 274 U.S. NUCLEA2 GEGULATO'.Y COMMIS$10N ##GE OP PAGES i . . .
MATERIALS LICENSE y Pursuant to the Atomic Energy Act of 1954, as amended, the Energy Reorganization Act of 1974 (Public 1.aw 93-438), and Title 10, g Code of Federal Regulations, Chapter I, Parts 30,31,32. 33,34,35,40 and 70, and in reliance on statements and representations p q heretofore made by the licensee, a license is hereby issued authorizing the licensee to receive, acquire, possess, and transfer byproduct, p i source, and special nuclear material designated below; to use such material for the purpose (s) and at the piace(s) designated below;to N I deliver or transfer such matenal to persons authorized to receive it in accordance with the regulations of the applicable Part(s). This k N license shall be deemed to contain the conditions specified in Section 183 of the Atomic Energy Act of 1954, as amended, and is ! subject to all applicable rules, regulations and orders of the Nuclear Regulatory Commission now or hereafter in effect and to any a conditions specified below. ' i ji ' ljcensee g 1-4 Kodiak Testing Laboratories, Inc. 3. License number 50-23271-01 4 pl F y<2. ._ __
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P.O. Box 1945 -* 4 *- - ,,. l Kodiak, Alaska 99615 4. E,xpiration date October 31, 1992 5 '~ 5. Docket or p 3 Reference No. 030-20439 p 4 6. Byproduct, source, and/or g, 7. Chemical and/or physical -J. Maximum amount hat licensee f
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A. ^ Not to exceed Il E g Q A. Cesium 137 - g
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10. Licensed material may be used at 1614 Mill BayTRoad, Kodiak, Alaska, and at W
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temporary job sites of the licensee anywhere in the United States where the D U. S. Nuclear Regulatory Commission maintains jurisdiction for regulating the use of licensed material, p}j E 11. Licensed material shall be used by, or under the supervision and in the physical F presence of, Alice Bergee, Immanuel Bergee, or individuals who have successfully (
, completed the manufacturer's training program for gauge users and who have been Fj [q designated by the Radiation Protection Officer, Immanuel Bergee. The licensee ;
shall maintain records of individuals designated as users.
) 12. Sealed sources containing licensed material shall not be opened. -
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,i h.3C2.,bh4A e r- U.S. NUCLEAR REoVLATORY COMMISSION PAGE OF 3 PAGES_ I i MI .
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Licen,e numbt ) i 50-23271-01 > l MATERIALS LICENSE oockeior nererenc number 8
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I SUPPLEMENT ARY SHEET 030-20439 i Y I > l 8 i > I > l CONDITIONS (continued) Nl l 13. A. The source (s) specified in Item (s) 7.A. and 7.B. shall be tested for leakage and/or contamination at intervals not to exceed 6 months. Any fL a i source received from another person which is not accompanied by a certificate H q indicating that a test was performed within 6 months before the transfer h l shall not be put into use until tested. [ l B. Any source in storage and not being used need not be tested. When the y q source is removed from storage for use or transfer to another person, it > q shall be tested before use or transfer. > q > The test shall be capable of detecting the presence of 0.005 microcurie of *
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l radioactive material on the test sample. If the test reveals the presence l g of 0.005 microcurie or more of removable contamination, the source shall be y q removed from service and decontaminated, repaired, or disposed of in 4 accordance with Comission regulations. A report shall be filed within 5 (>J 4 days of the date the leak test result is known with the U. S. Nuclear > 4 Regulatory Comission, Region V; Nuclear Materials Safety and Safeguards Branch; 1450 Maria Lane, Suite 210; Walnut Creek, California 94596. The
{ report shall specify the source involved, the test results, and corrective g
q action taken. Records of leak test results shall be kept in units of 4 microcuries and shall be maintained for inspection by the Comission.
4 Records may be disposed of following Comission inspection.
D. The licensee is authorized to collect leak test samples for analysis by p q Troxler Electronics, Inc or tests for leakage and/or contamination shall h' i q be performed by persons specifically licensed by the Comissior or an # q, Agreement State to perform such services. N The licensee shall conduct a physical inventory every six (6) months to account h
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for all sources and/or devices received and possessed under the license, p p g Records of the inventories shall be maintained for two (2) years from the date >i q of each inventory.
15. The licensee may transport licensed material in accordance with the provisions l4 of 10 CFR Part 71, " Packaging _ and Transportation of Radioactive Material".
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PAG {l , h l 45483 . License number R i 50-23271-01 N p . I MATERIALS LICENSE pg , , ,, g , ,,,, , ,,, i SUPPLEMENTARY SHEET 030-20439 k i > l P l P
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l , l (continued) t i 16. Except as specifically provided otherwise in this license, the licensee shall I conduct its program in acccrdance with the statements, representations, and 4 procedures contained in the documents including any enclosures, listed below.
The Nuclear Regulatory Comission's regulations shall govern unless the l statements, representations and procedures in the licensee's application and y correspondence are more restrictive than the regulations.
i A. Application dated August 17, 1987 j q B. Letter dated September 21, 1987 l
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F i >! d FOR THE U.S. NUCLEAR REGULATORY COMMISSION F Date Y By $7?f77.[$///lmNr,w Beth A. Riedlinger/ h h Health Physicist [ Licensing) p) p
4 Nuclear Materials Safety Section Region V l
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F[g*#j $ HEREBY CERTIFIES THAT c * 4 gi ;(\% **4pp MARK BLAKESLEE l,
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HAS SUCCESSFULLY COMPLETED THE TROXLER ELECTRONIC LABORATORIES, INC.
[k ~ TRAINING COURSE FOR TIIE USE OF NUCLEAR TESTING EQUIPMENT. =
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SUBJECTS INCLUDED IN Tills COURSE WERE AS FOLLOWS:
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%Q 1. Principles and practices of radiation 5. Radioactivity measurement standardization g = and monitoring techniques and (fQ ((flei,. -
3. Ics a'n'd b c c'f p c nucle,$.y _ fp C=='~; and%Ea ff. ProcTdurgs ar gaug rageyb . . .:;.9 8 tio
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! CERTIFICATE 0: 054105 ## - : $us."'"r"#"C#
CHRIS MORIE he%
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6/24/92 WILLIAM F. T ROXL ER = - 5 INSTRUCTOR DATE PRESIDENT f \ .
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l' KpntAK TESTING LABORATORIES INC.
P. o. 00X 1945 466-t506 M2'2
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08/24/1992 fy / p j#e AH07256-92 KODIAK TESTING LABORATORIES, INC.
ygrf " l ATTENTION: RADIATION SAFETY OFFICER
l P.O. BOX 1945
' KODIAK AK 99615 *****
Mark THIS COPY with any billing address changes ***** License / Approval / Registration / Code Annual Fee Surcha ge Certificate Number AA905 Category (s) Fee Amount Amount
================== ===== =========== =============== )
==============
50-23271-01 ANN 3P $ 2,100.00 $ 150.00
--------------- --------__---_
TOTAL: $ 2,100.00 $ 150.00 TOTAL INVOICE: $ 2,250.00 Make Checks Payable To:
======================= j U.S. Nuclear Regulatory Commission
<=== 1 Sis PO Box address is License Fee & Debt Collection Branch <=== ior receipt of payments PO Box 954514 < = = = o .1 1 y .
St. Louis, MD 63195-4514 ' l
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Terms and conditions are attached. Nonpayment of your annual fee 1 j 1: a y result in the revocation of your license (s)Jin acyrdance with the enforcement provisions of 10 CFR 171.23 of tT e Commission's 1 egulations.
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