Livingston HealthCare II" II"fl ll "f ,",IJI I/ ll ll il ilil '-'Ii '"

Jacque li ne D. Cook, Senior Ilcalth Physicist Division of Nuclear Materials Safety Nuclear M <l tcria ls Sa fety Branch R 6 t 2 E. Lamar Blvd. , Suite 400 A rlington. T X 760 11

Dear Ms. Cooke,

Li vingston ]-lealthCarc Nucl ear Medicine 504 South 13 lh Street Livingston, MT 59047 January 26, 20 12

I am writing 10 in J(lrIn yo u Ihal Li vi ngston Memorial Hos pital as slaled on our Materia ls I ,iccnsc number 25-27450-0 1 is undergoing a na ille change to I ,ivingstoll IlcalthCarc. Our mldress and all other infi:mmll ion are unchanged.

Please in foflll lll c if there is any other information [ need to provide for yo u.

Thank y<l U.

Sincerely,

'u~!L ,. t Y~'1-Yu.o·l. C. till T l3eth Lamphear, CNMT Nuclear Medi cine Department Email add ress: bcth. lam phcar@ li vingstonhealthcarc.org

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FEB ~ 03~2012(FRI) 10:55 LHH INS BI LLING

Llce n :;"- -* dS-J7450-01

Dodcdil> 030 -3J9<.17

(FRX)40G 823 0280

Change of Control and/or Change of Ownership (includes Change of Name)

P. 002/004

10 CFR 30.34(b} states that "no license Issued or granted pursuant 10 the regulatlons ... nor any right under a license shall be transferred, assigned or in any manner disposed of, either voluntarily Or involuntarily, directly or Indirectly. through transfer 01 control of any license to any person, unless the Commission shall ••• find that the transfer is in accordance with the provisions of the Act and shall give its consent in writing. Although not specifically addressed by 10 CFR 30.34, licensees undergoing a name c:hange may also be affected by this regulation.

Control over licensed activities can be construed as the authority to decide when and how a license (licensed material and/or activities) will be used. A change of ownership may be an example of a chango of control. The central Issue is whether the authority over the license has changed. In 011 cases, determining whether a change of control has taken place or whether a change is in name only Is the Commission's responsibility.

Licensees must notify the Commission when they are undergoing a possible change of control and/Qr a change of name. While this notification Is not required within a certain time frame, NRC needs adequate time to review the submittal to ensure that1he transfer is in accordance wrth the regulations.

In order to proeess your request for a change of control/ownership and/or a name change, the Information on the following pages Is required. Our fax number Is (817) 860·8263 or (817) 860-8188. If you have <lny questions regarding our discussion or this fax, please contact: me. When responding to this fax, please include the license, docket, and mail control numbers, located at the top of this page as well as the following pages. Thank you.

1Il5 7 6 c 6

FEB-Ol-20 12I FRI I 10,55 LMH INS BILLING IFAX I'O' B2l '2B'

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Informa.tion Required fOr Change of Control and/or Change of Ownership (to include a name chcnge)

Source: NUREG-1556. Volume 15

PI@ase provide the following information concerning ehanges of control (transferor and/or transferee, as appropriate). If any Items are not applicable, so state.

1. Provide a complete description of the transaction (I.e., transfer of stocks or assets, or merger). Indicate whether the name has changed and include 1he new name. Include the name and telephone number of a licensee contact who NRC may contact if more

P. 003/004

information is needed.

A. Description of the transaction:

RECEIVED

FEB - 3 2012

B. [ ] No name change DNMS

tjl New name of licensed organi"""0n:_L~i-"il"'-'()':;5:l'S"-,1-o=h.!..--,H,-,-,,,-,=,,a.,-,·l,-,+--,h-,-,C=,""'-'-Y..::"-=-

C. Q<1 No change in contact

[ 1 New contact ________________ _

[ 1 New telephone numbe" ______________ _

2. Da5Cribe any changes in personnel or duties that relate to the licensed program. Include training and experience for new personnel.

A. [)C No changes In personnel having control over licensed activities.

[ ] Changes is personnel having control over licensed activities (e.g. officers of a corporation):

B. o<l No changes in personnel named in the license.

[ ] Changes in personnel named in the license (e.g. RSO. AUs) -include training, experience and responsibilities:

3. Describe, in detail, any changes in the organization, location. facilities. eqUipment or procedures that relate to the licensed program.

[ 1 Organization: [ 1 Equipment:

[ 1 location: ( J Procedures;

[ 1 Facility: t)<{ NOI applicable

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4. Describe the status of the surveillance progam (Le., surveys, wipe tests, quality control) at the present time and the expected status at the time that control Is to be transferred.

A. Description of the status of all surveillance program:

Ctp +0 ~ <t te.-

6. Surveillance Items & Records: calibrations. leak tests, surveys, inventories, and accountabifity requitements will be current at the time of transfer

[ 1 Yas [ 1 No (explain) tV 0 + \'"" noS k t" 0 F CO n +rO I 5. Confirm that all records concerning the safe and effective decommissioning of the facility

will be transferred to the transferee or to N AC, as appropriate. These records include documentation of surveys of ambient radiation levels and fixed andlor removable contamination, including methods and sensitivity.

Records transferred to: ( J New licensee [ 1 NRC for license termination [)iNO! applioable

6. Confirm that the transferee will abide by all constraints, conditions, requirements and commitments of the transferor or that the transferee will submit a complete description of the proposed licensed program.

____ --,= = __ -,.,-,-_ _____ wiJI abide by all constraints, conditions, (rran:tJare!l campanyJ

requirements and commitments of _ ______ =====,,-_____ _ (Irn~faror ccmPllny)

SiOr<l!.tumrrJllo TRlnsJorOQ alllelal

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OR

SlgnllMomdl! Tlf1n~leror Olfldnl

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[ ] Description' of proposed licensed program from transferee attached (with signature)

OR

f>{Not applicable (name change only)

Certifying Officer - Signature Date

Certifying Officer - Typed name and title

"

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'I Uvit1g~on , ' HealthCare

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DNMS LiviDgstoll, MT 59041 'oJ 2, -b <./ c;..3 ,(;'!~ (qD~) 0 ' , ',

DATE: ~ I ~ II l. TO: CO (ice .....

COMPANY: /IJ Q C.

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TOTAL PAGES SENT (Including <;ovcr sheet):' 4

Ass is -I-a. ... t

, Utile render of this transmis:;ioo is not the intended rec::ipi~t, you arc hereby notified tll:lt any dil:CWiOIlo, dwtributioll. or copyins ofthht commu.,iQtioll U Itrictly prohibited.

IC you recdVlld tbis ccmmunic.,tilJn in c .. .'1'O:, pil:lUc notify Wi imm"edintt;!y.

Thank you for your cooperation.

.' , .

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Livlng5ton

HealthCare 504 South 13th St reet

liv.ng\ton, MT ~904 7 -J798

A(Jdr .. ~', Servlu.' R('que~ lf'd

Roldan, Lizette

From: Sent : To: Subject:

Attachments:

Docket No. License No. Control No.

030-32948 25-27450-01 576666

Dear Ms. Lamphear,

Dear Mr. Cargill :

Roldan, Lizette Tuesday, February 28, 2012 9: 1 0 AM 'beth .Ia mphear@livingstonhealthcare.org ' REQUEST FOR ADDITIONAL INFORMATION REGARDING LICENSE AMENDMENT CONTROL 576666 Livingston Memorial - name change. pdf

This is in reference to your letter received February 3, 2012 requesting to amend Nuclear Regulatory Commission License Number 25-27450-01. In order to continue our review, we need the following additional information:

1. Please have management sign and date the attached page 2 you faxed to the NRC on February 3 certifying the name change only request.

Current NRC regulations and guidance are induded on the NRC's website at www.nrc.gov; select Nuclear Materials; Medical, Academic, and Industrial Uses of Nuclear Material; then Regulations, Guidance, and Communications. You may also obtain these documents by contacting the Government Printing Office (GPO) to ll-free at 1-866-512-1800. The GPO is open from 7:00 a.m. to 6:30 p.m. EST, Monday through Friday (except Federal holidays).

We will continue our review upon receipt of this information . Please reply to my attention and refer to Mail Control No. 576866. You may attach your response as a PDF document via e-mail , orfax it to 817-200-1188. If you have any technical questions regarding this deficiency letter, please call me at (817) 200-1596.

If we do not receive a reply from you by March 9, 2012 we will assume that you do not wish to pursue your amendment request.

Sincerely,

Lizette Roldim-Otero, Ph.D. Hea lth Physicist

U.s. Nuclear Regulatory Comm ission

1600 E. Lamar Blvd . Arlington, TX 760 11 -4511 Office: 817-200- ] 596 r d X' 817 -200-1188

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/1, ~! LJving~ton '

SlM-IHealthCare

Livingston, MT 59047 (406) 222-5093

(406) 222-5099 fax

FAX COVER SHEET

TO: Li :Le+t-e. Ro Ida VJ

COMPANY: /j , s NRC.

FAX NUMBER: 8 I 7 - ;;JoO - I I P8' FROM: Be..~ L"0"phE9r, CJVrYl~(

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MESSAGE:

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," ."" IV\ CV'" t y U0t " B ~ t-1-:J "" " " !he mformanon contain-cd in this faC.!i imile messa e' '. ,-' . ' Intended so lely for the individual or en"tl"ty , gb IS pnvllI:gl'\d and conCidential inforination', ' nameu il aye, '

If the reader ofth" " """ , IS ansmlsslOn IS not the intended ," dlseusRion, distribution, or ropyiag fth. ,rec~p.e?t, you are hereby notified that any o IS COl1UllUnLeatJQn IS strictly prohibited,

Ji you received this co '" mmUOI,eatJOfI LO error, plll~se notify us imIll"cdiatcly,

Thank you for your cooperation.

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Information Requ ired for Change of Control and/or Change of Ownership (to include a name change)

Source: NUREG-1556, Volume 15

Please provide the following information concern ing changes of control (transferor andlor transferee, as appropriate). If any items are not applicable, so state.

1. Provide a complete description of the transaction (Le., transfer of stocks or assets, or merger). Indicate whether the name has c hanged and include the new name. Include the name and telephone number of a licensee contact who NRC may contact if more information is needed.

A. -Description of the transaction: nO. vYle.. c,hO-Yl 3e..

I' U 11 2/ (J [I J

B. [ ] No name change I

ljJ New name of licensed Organization:_L=i--,V-,i-C",",.'l+S=+'=o",--,-H,-,-"-= "-"I",+-,h,-,-,C,,,k,,-,-,,-'''-=-'_

C. ~ No change in contact

[ 1 New contact:

[ ] New telephone number: ________________ _

2. Describe any changes in personnel or duties that relate to the licensed program. training and experience for new personnel.

A. [)6 No changes in personnel having control over licensed activities.

I I

Include

[ 1 Changes is personnel having control over licensed activities (e.g. officers of a corporation):

B. rX1 No changes in personnel named in the license.

r ] Changes in personnel named in the license (e.g. RSQ, AUs) - include t rain,ng,

experience and responsibilities: l'

3. Describe, in detail, any changes in the organization, location, facilities, equipment r procedures that relate to the licensed program.

[ ] Organization: [ } Equipment:

[ 1 Location: [ J Procedures:

[ } Facility: t>4 Not applicable

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4. Describe the status of the surveillance pro gam (Le., surveys, wipe tests, quality control) at the present time and the expected status at the time that control is to be transferred.

A. Description of the status of all surveillance program:

(;lp hJ c\ "Je..,

B. Surveillance Items & Records: calibrations, leak tests, surveys, inventories, and accountability requirements will be current at the t ime of transfer

[ I Yes

5. Confinn that aU records concerning the safe and effective decommissioning of the facility will be transferred to the transferee or to NRC, as appropriate. These records include documentation of surveys of ambi'ent radiation levels and fixed andlor removable contamination, including methods and sensitivity.

Records transferred to: ( ] New licensee [ J NRC for license termination ['>iNot applicable

6. Confirm that the transferee will abide by all constraints, conditions, reqUirements and commitments of the transferor or that the transferee will submit a complete description of the proposed licensed program.

_____ -;:::===== ________ will abide by all constraints, condition::;, Ilransferco company)

requirements and commitments of --------;o==::-::==c-----~ (Ir<lns/erer company)

Signatura/Tille Tran::;fltree Olnclill

OR

Slgnaturen1Ue Transferor Olllcia!

dale

[ J Description of proposed licensed program from transferee attached (with signature)

OR

t:x{Not applicable (name change only)

de'rtif'ying Officer· 'Signature

Lilli f} / . (?ae., IrrM~ Ina /)JOJJa.q.£lv Certifying Officer - Typed name and [tle/ I

FEB - G 2012 This.is to_a;;:know\edgB the reGcipl of your leUer/application dated

FEB ;s 2012 . and to in!orm you that the initial proce~si ng. DATE

which inCludes ,In adminis trative rev iew, has been performed,

o

There were no administrative omissions. Your applicatIon will be assigned \0 a technical reviewer. Please note thallhe technical review may idnn1ity additional omissions or reQui re additional informatlon_

Ploaso pmvido to this oflice WiUlIll 30 da~ at YOUI receipt 01 this card :

The aCllon you requested is normally processed within q 0 days.

o A copy of your action has been lorwardod to our Ucense Fee & Accoullls Receivable Branch, who wilt contact you separately it there is a lee issue involved.

. 11576866 YO\Jr acliOfl has been assioned Mall Control Number ;".;;;;;;;;:;;;:;;;,-;;:;;; .. ;-_. When calling to ,nqulro about thiS action, please ~('r to this ma,1 con trol number Youmayc;;!lt mo at 8178608103 / ,

NRC rOOM S3? (illY)

(tG-2OOG)

['"r"'· " J<" I' I " 7 't . . I J c: 1---t~A.----I , ' lJ.~

¥Censlng Ass,st~nt

BETWEEN:

Accounts Receivable/Payable

and Regional licensing Branches

[ FOR ARPB USE J

INFORMATION FROM l TS

Program Code 02121 Status Code Pending Amendment

Fee Category: 7C Exp . Date. 03l31f2013

Fee Comments: Decom Fin Assur Reqd: N

License Fee Worksheet - License Fee Transmittal

A. REGION

1. APPLICATION ATTACHED

AppticanUlicensee:

Received Date:

Docket Number:

Mail Conlrol Number:

license Number:

Action Type:

2. FEE ATTACHED

Amount:

Check No.:

3. COMMENTS !

LIVINGSTON MEMORIAL HOSPITAL

0210312012 3032948

576866

25-27450-0 1

Amendment

/ /

Signed :

Dale:

B. LICENSE FEE MANAGEMENT BRANCH (Check when mit(lstone 031$ entered

t . Fee Category and Amount:

2. Cooed Fee Paid. Applic.a tion may be processed for:

Amendmenl:

Renewal:

License:

3, QTHER _ _ _______ ___ _

Signed:

Dale: