ࡱ > { } | 7 !+ bjbjUU x 7| 7| [% l 6 6 6 6 6 6 6 $ Z P F $ j < Z ? n > S6 U6 U6 U6 B 6 T : T ?? $ ,A LC l c? 6 & & & c? 6 6 x? & . 6 6 S6 & S6 @ 7. 6 6 0 p>yZ T j / 0 D ? 0 ? / C C 0 Z Z 6 6 6 6 Notes: This checklist is for applicants using DOH Form DH-1054 to apply for or renew a license for the following use categories:1A 1C, 2A 2C, 3A, 3B, 3F(1) 3F(3), 3G, 3H, 3I(1), 3I(2), 3J, 3K, 3L(2), 3L(3), 3L(5), 3M(1), 3N, 3O, 3P, or 6. Refer to section 64E-5.204, Fla. Admin. Code, for a list of license categories. If additional assistance is needed, call the BRC at (850) 245-4545 or access the BRC website at .
The U.S. Nuclear Regulatory Commissions NUREG-1556 series of technical reports (Consolidated Guidance About Materials Licenses) provide licensing guidance for many of the activities categorized above. The documents are available on the Internet at .
U.S. Dept. of Transportation regulations (49 CFR) are available at .
CHECK OFF IF ADDRESSEDAPPLICATION ITEMNOTES(1.a.Name/Mailing AddressUnless application is for an individual, list the business name registered with the FL Div. of Corporations; verify name registration by phone (850/488-9000) or online at
If doing business under a fictitious name, verify the names registration & include it in Item 1 as a d/b/a name; if fictitious name is not registered, include it in Item 2
List the mailing address for license-related correspondence(1.b.Location of Useand/or StorageList the street address where RAM will be used & stored, & where records will be available for inspection; 64E-5.208(2), .213(5)
Indicate if temporary job sites will be used as storage locations(2.License Category/FeeList appropriate license category & application fee; there is no fee for license renewal applications
Annual/reclamation fees are due within 60 days of license issuance and annually thereafter (an invoice for the fees is included w/ the new license); 64E-5.204(3.Purpose of ApplicationCheck appropriate box; if applying to renew a license, list the license no.(4.Individual UsersList all authorized users (AUs), including the RSO; a minimum of two AUs is required for fixed devices; 64E-5.208(2), .1313(4)(5.Rad. Safety Officer (RSO)List the name of the RSO (must be an AU); 64E-5.208(2)(6.Training and Experiencein Radiation SafetyEnclose relevant documentation on the rad. safety training/experience for the RSO & each authorized user; 64E-5.208(1), .1305, .1307(7.Radioactive Material (RAM)List the element/source model no. & maximum activity for each source(8.UseList the manufacturer, model no. & intended use for each source/device(*Current RAM InventoryFor renewal applications, include current inventory of all RAM, including exempt, generally licensed (GL) & specifically licensed (SL) sources/devices & indicate their status (exempt, GL or SL); 64E-5.208(2)(9.Radiation DetectionInstrumentsIf applicable, list the manufacturer, model no., detection capability, range & probe specifications (if equipped w/ probe) of each instrument; 64E-5.208(2) .1314, .1318
Confirm access to an equivalent backup instrument when the primary meter is out due to calibration or repair; 64E-5.208(2), .1314, .1318(10.Calibration of RadiationDetection InstrumentsIf applicable, list the name & address of the instrument calibration vendor (may include option of using other licensed vendors) & confirm annual calibration frequency; if conducting in-house cal., submit procedures; 64E-5.208(2), .314
CHECK OFF IF ADDRESSEDAPPLICATION ITEMNOTES(11.Personnel Monitoring(PM) DevicesExternal PM required unless able to demonstrate that workers are unlikely to exceed 500 mrem/yr TEDE; if applicable, list PM badge type (FB/OSLD/TLD), supplier & exchange frequency (monthly/bimonthly/quarterly); 64E-5.208(2), .314, .315(1)
Internal PM required for users of I-125, I-131, H-3, U-234, U-235 or U-238 per64E-5.1310(3); also required for users of unsealed sources of RAM unless able to demonstrate workers are unlikely to exceed 10% of applicable ALIs; if applicable, describe internal PM method (e.g., bioassays); 64E-5.208(2), .307, .315(2), .1310(3)(12.Facilities & EquipmentAnnotated facility diagram shows RAM use/storage locations, access pts., adjacent areas, proximity to occupied work stations, no. of stories to bldg.; 64E-5.208(2)
Description of storage container; 64E-5.208(2)
Description of security measures in place to prevent access; 64E-5.320, .321
Description of safety equipment; 64E-5.208(2)
Description of posting; 64E-5.323, .90113.Rad. Protection ProgramDescription of program addressing below items; 64E-5.303(A.Member of Public (MOP)Dose StudyNew applicant: procedures for demonstrating compliance w/ MOP dose limits
License renewal: submit MOP study; 64E-5.208(2), .313(B.ALARA PolicyPolicy describes a) management's commitment to ALARA philosophy, &b) commitment to perform an annual ALARA/rad. protection program review;model ALARA policy available from BRC; 64E-5.208(2), .303C.Radiation Safety Officer((1)RSO DutiesDescription of RSO duties equivalent to the duties listed in 64E-5.1305((2)Change of RSO NotificationStatement confirming that written notification will be given to BRC within 30 days of a change of RSO or other safety positions; 64E-5.213(7)(D.Radiation SafetyTraining ProgramTraining program addresses:
Instructions to workers/radiation awareness training per 64E-5.902
AU training per 64E-5.1307, .1312 & .1313 (as applicable)
Hazmat employee training per 49 CFR 172 Subpart H & driver training per 49 CFR 177.816 (as applicable)
If requesting authorization to conduct an in-house training program, submit a detailed description per 64E-5.1307(2); .208(2), .1307, .1312, .1313(E.Operating ProceduresProcedures address all applicable components listed below; 64E-5.208(2), .1302
Procedures include commitment that users are instructed in/have access to all procedures/manuals for each type of RAM; 64E-5.208(2), .1302
If applicable, procedures for transporting RAM to temporary job sites; .208(2)((1)Personnel Monitoring(PM) ProceduresExternal PM: Instructions on proper use: only use assigned PM badge, always wear badge when handling RAM, do not expose badge to excessive heat/light/chemicals/ moisture, promptly return for exchange when due; use of spare badges; dealing w/ lost/damaged badges; PM records (DH-1622 & DH-1623 or equivalent forms; annual/termination reports); 64E-5.208(2), Part III, .1302(4), .1310(1)
Internal PM: procedures address 64E-5.307 requirements; .208(2), .307, .1310(3)
CHECK OFF IF ADDRESSEDAPPLICATION ITEMNOTES13.E.Operating Procedures(contd.)((2)General Safety Rules(unsealed RAM)Procedures describe safety precautions for routine RAM use, applicable to requested authorizations; 64E-5.208(2), .1316
Procedures address storage & control of volatile & gaseous RAM per 64E-5.1317((3)Posting ProceduresProcedures address posting requirements specified in 64E-5 Parts III, IX & XIII; 64E-5.208(2), .323, .901, .1302((4)Security ProceduresProcedures address RAM security, including security at temporary job sites & overnight storage (as applicable); 64E-5.320, .321, .1311((5)Contamination Control& Survey Procedures(unsealed RAM)Procedures address 64E-5.1319 requirements; establish action levels & wipe/ survey procedures (instruments/locations/frequency/records), including 4 meter checks prior to use: inspection, cal., battery and rad. response; 64E-5.208(2), .314(1) & (2), .1319((6)Respiratory Prot. Pro.Procedures address RP requirements in 64E-5.319 to limit RAM intake; .208(2)((7)RAM Ordering, Receiving,Opening & Shipping Pro.Instructions for preparation/handling of incoming & outgoing RAM shipments; 64E-5.208(2), .327, .1501, .1502, 49 CFR(F.Emergency ProceduresInstructions for response to RAM loss, theft or damage; include emergency notification numbers (RSO, BRC); 64E-5.208(2), .1302(G.Leak Testing (LT)Procedures (sealed sources)Instructions for collecting LT samples; performed only by AUs; state interval tests will be performed (6/12/36 months); list manufacturer name & model no. of LT kit used; list vendor contracted to analyze LT samples (may include option of using other licensed vendors); if LT analysis conducted in-house, detailed procedures required; 64E-5.208(2), .1303(H.Inventory ProceduresProcedures address performance of physical inventories, describe inv. frequency (6/12 months) & record-keeping; include sample inventory form (model form available from the BRC); 64E-5.208(2), .1304(I.Record RetentionProceduresProcedures address record-keeping requirements; 64E-5.208(2), .1302
If applicable, include a 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 manufacturers for documentation); 64E-5.1502(2), 49 CFR 173.415(a)(14.Waste DisposalProcedures address RAM disposal, with commitment that RAM will be transferred only to licensed recipients; 64E-5.208(2), .328
For unsealed RAM, address decay-in-storage, sewer disposal & LLRW shipments as applicable; 64E-5 Part III, .1302
For LLRW, include commitment to notify BRC no less than 48 hrs. before shipment to treatment/storage/disposal facility per 64E-5.1508(15.CertificateApplication signed & dated by a certifying official (person authorized to make legally binding statements on behalf of the applicant)
Radioactive Materials License Application Checklist
FLORIDA DOH BUREAU OF RADIATION CONTROL (BRC)
RADIOACTIVE MATERIAL LICENSE APPLICATION CHECKLIST
Page 2 of 3
FLORIDA DOH BUREAU OF RADIATION CONTROL (BRC)
RADIOACTIVE MATERIAL LICENSE APPLICATION CHECKLIST
Page 1 of 3
FLORIDA DOH BUREAU OF RADIATION CONTROL (BRC)
RADIOACTIVE MATERIAL LICENSE APPLICATION CHECKLIST
Page PAGE \* MERGEFORMAT 3 of 3Rad. Material.doc Ver. 15 11/29/01
~ ` a D
E
'
/
7
?
$ j l m n U W X Y | $ % >*CJ CJ
j o5CJ 5CJ
5>*CJ 5CJ 5CJ >* W
~
$
$If a$ $:$If ]^:a$ $ $If ]^a$ $
&