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SOUTH CAROI.INA DEPARTMENT OF HEALTH & E}.TVIRONMENTALCONTROLBUREAU OF RADIOLOGICAL HEALTH

NqSTNUCTIONS OR PREPAMTION OFAPPLICATIONS OR MDIOACTIVE MATERIAL LICENSE

Gcncral nformatlon

An applicant or a "Radioactivc Matcrid Liccnsc," or rencwal f an cxistlng iccnsc, should omplctc hc application orm in dctail. .Rcncwalapplications hould contain complctc and up-to-datc nformation onccming hc pplicant'3 cumnt protram, ln submitting a rencwatapplication, ll itcms and subitcms n thc rencwal application orm must bc complctcd ntircly without rcfcrcnccs o prcviously submineddocumcnts. f your application and ptoccdurr! cmain unchrngcd, t will bc neccsssry o rc3ubmit complctc opy of thc prcvious spplicstlonmatcrials. Thc applicant should endeavor o cover his cntirc adioisotopc rograrn with onc application. Howcvcr, ep.ratc applicationr shouldbc submined or medical elctherapy nd gamma nadiotors, Supplcmcntal hcctr may bc appndcd whcn ncccssary o providc completcinformation. tcm l6 must bc complctcd n rll ap plications y pcnons of authority. Mcdical pplications houldbc signcd by thc hospitaladministrator nlcss hc applicatio n s for privrtc practicc. nd hen by the physician. Submission f an ncompletc pplication willoftcn rcsultin a delay n issuancc fthc liccnsc bccausc fthc conespondcncc ccessary o gbtain nformuion cqucstcd n thc application.

NOTE: In addition o the application orm, a liccnsing uidc s providcd which outlincs hc cssentlal nformation h.t is to bc submittd osupport he iccnsc application.

Onc copy of thc complctcd application orm, supplcmcntrl hccts, nd Supplcmcnt A - Human Usc if a mcdicat pplicrtion) hould bc acnt o:South CarolinaDcpartrncnt f Hcalth and Environmcntal onlrol, Burcau of RadiologicalHcalth,2600 Bull Strcct, Columbir, SC 29201.

Exolanation f Aoolication Form

Itcm No.

l. (a) The Applicant" is thc organization r pcrson cgally rcsponsiblc or posscrsion nd usc ofthe radioactivemarcrid spccificd nthc application.

2. The Department" is the dcpsrtment r similar subdivislon wherc thc radioactivematcrial will bc uscd.

3. Sclf+xplanatory

4. Thc "lndividual Uscr" s thc pcron cxpcricnccd n thc usc and safc handling of ndioisotopcs . f thc application s for'human tsc"thc ndividual uscr must be a physician iccnscd y thc Statc ofSouth Crrolina to dispcnsc rugs n the practice fmcdicinc andhavc cxtcnsivc cxpcricnce or cach proposcd linicalusc.

5. Sclf-cxplanatory.6. (a) List by namc cach adioisotogc csircd, uch as'Cerbon-!4', "Cobalt-50', ctc.

(b) List the chemical and/or physical orm or cach adioisotopc nd he quantity ofcach which hc applicant esires o possess tany onc timc. lf morc han onc chcmical r physical orm of a particular adioisotop s desired. scparatc osscssion imitshouldbcstatedforeachform. orcxamplc,anapplicantdcsiringtousctwochemicalormsoflodinc-l3lmustspccirybothforms and a posscssion imit for cach orm.

lodinc-13lodinc-l3

lodincIodinated uman cnrm Albumin

l0 millicuricsI millicuric

Ifthe radioactive atcrial s o bc obtained s a scalcd ourcc(s), pecify hc manufacturcr, odcl o. an d amount factivityin cach sealed ourcc.

Examplc: Cobalt.60; 3 Sealcd ourccs, 00millicurics ach, lso Corp.ModclZ-54, 30 0millicuries otal.

7. Statc hc u sc ofcach radioactivcmatcrial and chcmical orm spccificd n ltcms 6a and 5b.

8 -9 . Th ese i tcmsmu s tb cco mp le tcd fo rcach in d iv id u a lamcd in l tcm4 . fmo rc th an o n c in d iv id u a ls l i s tcd in l tcm4 .c lca r ly k cy th cnamc f cach ndividual o hivlrer cxpcricnce. thc radioisotopc s for "human use." o nol completc his tcm; complctcSupplcmcnt - Human se .

l0-16 Selt ' -erplanator.v.

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Applicationor Radioactlve aterial icenseBureau f Radiological ealth

ffiUCffONS: Cornplet tsms 1 through 16 l this s an nitialapplication. upplementary heets hall be usEd where appllcable' f application s

renewat, tems 1 thrcugh 16 must be completed ntirelywithout oferonces o previously ubmitted ocuments. f yout appllcatbn andpr,cedur

,emaln unatangeo, t dif be necassary o iesubmit a complete copy of the previous applbarion matarials. Mail one oopy b: Souh Cerolina Deparl'

rifnt ot freanrr nd Environmenret o;trot, Eureau of Radiological Health, 2600 Bull Street, Columbia, SC 29201. Upon aPPloval ol [ile eppllcation,

"ppn ."f willrecaive e State ol South Carolina Radioactive Materials Licensa ssued n accordanoo with !e gpnerel rsquhemfit! contahed in th

iJutr Carorina Department t Health and Environmentat Control, Regulation 1d1, Badioactive Materiats lide A)' and tte Atotnb Enargy and

Radiation ControlAct, Section 13'7'4o t. sog; ol the 1976 Code.

1. (a) NAlrEAt{DSTREETADDRESSOFAPPLICAT-lnstilution, irm, Persons, alc.

Telephone o. Area Code

(b) STREETADDRESS(ES) TwHlCl'l RADKIACIT\,EMATERIiALWILLBE USED (ildiftetent rcrn I (al. Indude a map lo thefacillty rom the noarest nlqpr inlerglste.

DEPARTMENT O USE MDIOACT]VEMATERIAL 3. PREVIOUS ICENSENUMBER(S). flhla b an applicatlon orBenewal of a license, please ndlcate hls dnd give tho number.

INDIVIDUALSEB(S).Neme and itleol inclivkiual(s) ho willuseor dlrgcty supeMsa use of radiraclive material. Givo tralning andexperience n ltems I and 9'

5. (a) MDIATIONPROTECnON OFFICER.Name ofperson desigrnatod as radiatbn protec{lon officer. Attaci reEum of hlsy'hetrdnhg and etpedence es h lleml 8. end 9.

(b) MAITIAGEMENTEPBESENTATIVE. atne d pcrson deCanatedas a managernent lntasl for this faclllty.

(a) RADIOACIIVEMAtrERtAL.oment and mass no. of each. (b) oHEMTCALNII|ORPHYSICAL OFMAr.lO IN(|MUM NUMBEOFMIIrcURIES OF EACHCHEMICALAI.IOrcRHYSICAL ORPCTSSESSED TANYONE TIME. f sealed source(g), so etatname ol malrufecturer. model m., no. ol soutcas and maximumacillvfiyper souse.

7. DESCRTBE URPOSE.FOBWHICHRAOTOACTTVEitATERtALWltl BE usED. Prwlb sffident dtail o allovrpotsnlial Pefsonnl ,(poeun o beevaluated. l radoac{ive material s in ttte form ol a saled 30rrro9, nct d3 ora make and modef nurnber of lh storag oontainer andor device nwhich the sourcc will be stored and/or usad. Attach extra thee|s if neo$8ary. '

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8. TRA|N|NG NDEXPEHTENCEFEACHNDIVIDUALAMEDN TEM ; Use upplementalsheelsl necessary)

TYPEOFTRAINING WHEFEIBAINED DURANONOFTMININGONTHEJOB

(Circle nswer)FomtA[@t Fs(Clrdcsnswer

a. Principles nd Practices fradialion protction.

Yes No Yes No

b. Radbac{vitYmeasuremsnteterdadization and monitoringtafinhues and instrumonls'

Yes No Yeg N

c. Mathmatics & calculalions basicb |he us and masutemnt ofradloac-llvlty.

Yeg No Yes No

d. Biological ffecls ot radialion. Yss No Yeg No

9. EXPERTENCE ITHRADIATIONActual se of radioisotopes r eguivalent xperierce')

lsotope MaximumAmount Where ExperianceWas Gained Duration f Experience Type ol Use

10. RADIATIoN ETECTIONNSTRUMENTSUse upplementralheets f necessary.)

Type of Instrumenls(tncludemake and modelnumber feach)

NumbrAvallabl Radiation etcted Seffillivity Rango(mR/}rr.)Window Thickness

(mg/cm2)Use Monitoring

Surveylng, Measurl

11 METFOD, REqJEItCy At{OSTANDARDS SEO NCALTBMTINGNSTRUMENTSSTEDAEOVE

12. FILMBAOGES,OOSIMETERS, NOBIO-ASSAY ROCEDURES SED. For ilmbadges, peo'tymethod ot celibraung nd processing, r namol suPPlier.)

NFORrrAIOr.l TOBESUBMITTED NADDffiOML SHEETS

13. FACILITIES ND EOUIPMENT. escribe eboratory acilities nd emote andling quipment, torago onlainers, hielding, um hoods, etc.Attach an explanatory ketch ol the acilities.

14 . BAD|ATIONPBOTECTIONPFOGRAM.Descrlb h6 radlatbn protection rogmm ncluding ontrol msasur68. f applicalion covers sealedsourcies, ubmit eak testing procdures where applicable, name, raining and experierre of person(s) o perform eak t93ts and tharrangmenB or performing nitlal adiation uryey, eMcing, maintenance nd repairof th sourca'

15. WASTEDISPOSAL.l a commercial aste disposal ervica s employed, pecily he name ol the company. Oherwise' submit a dtaileddescription of the methods which will be used for disposing of radbactive wasleg and estimates ol th tyPs and amount ol ec'tivily nvolved

16. THE AppLtcANT ANDA ty oFFtctAL exeorring his Ertificat3m behdl d lhe applicant naflEd h ltm t, cettity thet ulb appli:$m b

prepared n confomity with South Carolina Depa-riment l Health and Erwircnrnental onttol Rsgutatkns for Contrd of Fedialion and lhat atintormation contained herein, nclucting ny supplements ttachd hereto, e trus and @trost b U|e bst ol anl knowledge 8nd beliot.

DaIE: By:

DulyAuthorizecl anagement Representalive

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