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] Z Z Z Z Z Z Z $ ~ ~ ~ ~ P , ~ ! . " " ( J J J J " l x G 6 B N! $ " $ l r! Z J J r! @ Z Z J J " @ @ @ H Z J Z J ~ ~ Z Z Z Z @ @ ~ ] 8 Z Z J , ~ ~ x X This checklist is for applicants using DOH Form DH 1054 to apply for or renew a category 3L(I) radioactive materials license authorizing possession and use of portable gauging devices. DOH Regulatory Guide 1.10 provides detailed instructions for preparing the application. Appendices, exhibits and supplements referenced below are found in the guide, which is available on the Internet at or by calling the FL BRC (850/245-4545).
U.S. DOT regulations (49 CFR) are available on the Internet at .
To prevent the potential for identity theft, never submit documentation that lists individuals social security numbers or birth dates.
CHECK WHEN ADDRESSEDAPPLICATION ITEMNOTES(1.a.Name/Mailing Address Unless applying as an individual, list the business name registered with the FL Div. of Corporations; name registration may be verified by phone (850/488-9000) or online at ; if doing business as (d/b/a) a fictitious name, add d/b/a Fictictitious Name
Under Mailing Address, list address to be used for license-related correspondence(1.b.Location of Useand/or StorageFor location of use, list temporary job sites; for location of storage, list the street address of the permanent facility where gauges will be stored & where records will be available for inspection; if gauges will also be stored overnight at temporary job sites, add & at temporary job sites; 64E-5.208(2), .213(5)(2.License Category/FeeThe license category is 3L(I); a non-refundable application fee ($605 as of 3/01) is required for new license applications; there is no fee for license renewal applications; annual/reclamation fees ($1,014.30 as of 3/01) are due within 60 days of license issuance & annually thereafter; 64E-5.204(3.Purpose of ApplicationCheck the appropriate box; if applying to renew a license, list the license number(4.Individual UsersList the name of the RSO & all authorized users (AUs) individuals trained to use or supervise the use of portable gauges; 64E-5.208(2)(5.Rad. Safety Officer (RSO)List the name of the RSO (must be an AU); 64E-5.208(2), .1305(1)(6.Training and Experiencein Radiation SafetyEnclose relevant documentation on training for the RSO & each AU (i.e., training certificates, not resumes); min. of 8 hrs training covering 64E-5.1307(1) subjects; if training provided by a third party, it may be necessary to submit a separate record of training on in-house O&E procedures; a description of experience not required unless seeking approval to be an instructor for in-house training; 64E-5.208(1), .1305, .1307(7.Radioactive MaterialList the element, source manufacturer & model no., maximum activity for each source & no. of sources requested; 64E-5.208(2)(8.UseList the manufacturer, model no. & intended use for each device, & brief description of the intended use(s); 64E-5.208(2)(9.Radiation DetectionInstrumentsA survey meter is not typically required, but if used, list the manufacturer, model no., detection capability & range of each instrument; 64E-5.208(2)
If using a survey meter, confirm access to an equivalent backup instrument when the primary meter is unavailable due to calibration or repair; 64E-5.208(2)(10.Calibration of RadiationDetection InstrumentsIf applicable, list the name, license no. & address of the instrument calibration vendor (may include option of using other licensed vendors) & confirm annual calibration frequency; if seeking to conduct in-house calibrations, submit detailed procedures (additional guidance is available from the FL BRC); 64E-5.208(2), .314
CHECK WHEN ADDRESSEDAPPLICATION ITEMNOTES(11.Personnel Monitoring(PM) DevicesList the type of whole body PM badge (e.g., FB, OSLD, TLD) used, the supplier, & exchange frequency (at least quarterly); if using gauges containing Am-241 sources, PM badges must be capable of detecting neutrons; a list of approved suppliers is available from the FL BRC; 64E-5.208(2), .314., .31564E-5.208(2), .314., .315(12.Facilities & EquipmentSubmit a diagram of the permanent facility showing the gauge storage location & all adjacent areas; indicate the storage areas proximity to work stations (see Exhibit A for a sample facility diagram); 64E-5.208(2)
Describe the gauge storage area (e.g., cabinet, locker, closet) demonstrates adequate capacity for max. no. of gauges authorized by license; 64E-5.208(2)
Describe security at the perm. facility to prevent access to stored gauges (minimum of 2 locks between the gauge & the public); 64E-5.208(2), .320, .131113.Rad. Protection Program64E-5. 208(2), .303(A.Member of Public(MOP) Dose StudyRefer to Appendix A for guidance; 64E-5.208(2), .303, .313
New license applicants: submit procedures for demonstrating compliance with MOP dose limits (< 2 mrem in any 1 hr in unrestricted areas, < 100 mrem/yr)
Renewals: submit completed study demonstrating compliance with public dose limits(B.ALARA PolicySubmit policy describing management's commitment to ALARA principles & to performance of an annual rad. protection program review/ALARA audit; App. B is a model ALARA policy; Ex. F is a model audit form; 64E-5.208(2), .303C.Radiation Safety Officer64E-5.208(2), .1305((1)RSO DutiesDescribe the RSOs duties, equivalent to the duties listed in 64E-5.1305(3); App. C is a model procedure; Supplement B is model RSO administrative procedures((2)Notification of RSO ChangeSubmit a statement confirming that written notification will be submitted to the BRC within 30 days of a change of RSO or other safety positions (App. C includes this commitment); 64E-5.213(7)D.Radiation SafetyTraining ProgramSubmit a program that addresses all training components described below; App. D is a model program; 64E-5.208(2), .1307(2); .1312, .1313, .1501, .1502, 49 CFR((1)Instructions to WorkersDescribe how Instructions to Workers (radiation awareness) training will be provided to occupational radiation workers per 64E-5.902((2)AU TrainingDescribe how AU training will be provided to all gauge operators per 64E-5.1307 & .1312 [min. of 8 hrs. formal training covering .1307(1) subjects]; identify any third parties used to provide rad. safety training
If seeking to conduct AU training in-house, describe the proposed course per 64E-5.1307(2), including instructor qualifications, course description, method of testing (w/ sample exam) & retesting; Sup. D is a model training course outline((3)Hazmat Employee& Driver TrainingDescribe hazmat employee & driver training provided to satisfy 49 CFR 172 & 177.816; training may be done in-house or by third parties, & may be part of rad. awareness/AU training; address record-keeping requirements per 49 CFR 172.704(E.PM ProgramSubmit instructions for administration of the PM program; App. E is a model procedure; 64E-5.208(2), .315, .339, .903, .1302
CHECK WHEN ADDRESSEDAPPLICATION ITEMNOTES13.Rad. Protection Program(contd.)(F.Operating & Emergency (O&E) ProceduresApp. F provides model O&E procedures; 64E-5.208(2), .1302(1)Procedure Availability Refer to Sec. II of App. F; 64E-5.208(2), .1302((i)O&E ProceduresProvide instructions to have a copy of the O&E procedures accompany portable gauges at all times((ii)Gauge ManualsProvide a commitment to maintain copies of the manufacturers operation/mainte-nance manuals for each gauge model authorized by the license on file for reference((2)PM ProceduresSubmit instructions for use of PM badges; Sec. III of App. F is a model procedure; 64E-5.303(2), .1302(1)((3)General Rules of UseSec. IV of App. F provides model procedures; 64E-5.208(2), .303(2), .1302(1)((i)ALARA PrinciplesProvide instructions on proper handling & use of gauges to minimize exposures((ii)PrecautionsProvide instructions to: (a) use gauges in accordance w/ manufacturers instructions; (b) not open/remove sources from source holders; (c) prohibit contact with or direct viewing of source rod or placement of hands, etc. in radiation field((iii)Radiation SurveysProvide instructions to have the RSO arrange for a survey to be performed if damage to a gauge is suspected((4)SecurityProvide instructions on securing gauges to prevent unauthorized access, including a commitment to maintain direct surveillance when not in storage, & to provide two locks between a stored gauge & the public; refer to Sec. V of App. F for model procedures & Ex. C for a model utilization log (recommended for users of multiple gauges); 64E-5.320, .321, .1302(3); .1311((5)TransportationProvide instructions for safe transport of gauges per U.S. DOT regs (inspection, packaging, marking, labeling, blocking & bracing, security, shipping papers, emergency response information (ERI), etc.; Sec. VI of App. F is a model procedure; Ex. D-1 & Ex. D-2 are model shipping papers; Ex. E is a model ERI sheet; Sup. C provides guidance on SI units; 64E-5.321, .1311, .1302(5), .1501, .1502; 49 CFR((6)Routine MaintenanceProvide instructions to: (a) restrict performance of routine gauge maintenance & cleaning to AUs in accordance w/ manufacturers instructions; & (b) prohibit non-routine gauge maintenance or repair requiring removal of the source/source rod;Sec. VII of App. F is a model procedure; 64E-5.208(2)((7)PostingProvide instructions to address posting requirements specified in 64E-5 Parts III, IX & XIII; Sec. VIII of App. F is a model procedure; 64E-5.208(2), .323, .901, .1302((8)Ordering, Receiving, Opening & ShippingProvide instructions for preparation & handling of incoming & outgoing gauge shipments; App. H is a model procedure; 64E-5.208(2), .327, .1501, .1502, 49 CFR((9)Special Proceduresfor Depth ProbesIf requesting authorization for depth probes (gauges capable of extending to depths > 3'), include O&E procedures providing instructions specific to those gauges (e.g., CPN Model 501, 503, Troxler Model 4300 Series); 64E-5.208(8), .212(2), .1302
CHECK WHEN ADDRESSEDAPPLICATION ITEMNOTES13.Rad. Protection Program(contd.)(G.Emergency ProceduresProvide instructions for handling gauge loss, theft or damage; include emergency notification numbers for the RSO & FL BRC; App. G is a model procedure; 64E-5.208(2), .1302, 49 CFR 173.1435H.Leak Testing (LT)App. I is a model procedure; 64E-5.208(2), .1303((1)LT Kit & VendorList: (a) manufacturer name & model no. of LT kit used, & (b) name & license no. of vendor contracted to perform LT sample analysis (may include option of using other licensed vendors)((2)LT ProcedureProvide instructions for: (a) the interval LTs will be performed (6/12 months) & (b) collecting LT samples(I.InventorySubmit procedure for performance of semiannual physical inventories, including sample inventory form; App. J provides a model procedure; Ex. B is a model inventory form; 64E-5.208(2), .1304(J.Record Retention ProcedureSubmit procedure addressing record-keeping requirements specified in 64E-5;App. L is a model procedure; 64E-5.208(2), .1302
Provide commitment to maintain on file, for at least 1 year after the last shipment, copies of the testing methods & results for each Type A package in use (contact gauge manufacturers for the documentation); 64E-5.1502(2), 49 CFR 173.415(a)(14.Waste DisposalSubmit procedure with a commitment that gauges will be transferred only to licensed recipients (e.g., manufacturer, waste broker); App. K is a model procedure; 64E-5.208(2), Part III, .1302(15.CertificateHave application signed & dated by a certifying official a person authorized to make legally binding statements on behalf of the applicant; e.g., president, CEO, etc.
Notes:
Radioactive Materials License Application Checklist
FLORIDA DOH BUREAU OF RADIATION CONTROL (BRC)
RADIOACTIVE MATERIALS LICENSE APPLICATION CHECKLIST
PG Supplement A License Application ChecklistPage PAGE \* MERGEFORMAT 4 of 4
FLORIDA DOH BUREAU OF RADIATION CONTROL (BRC)
PORTABLE GAUGE LICENSE APPLICATION CHECKLIST
PG Supplement A License Application ChecklistPage PAGE \* MERGEFORMAT 4 of 4
PG Supplement A License Application ChecklistPage 4 of 4PG Sup. A.doc 12/12/00 Ver.3
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