columbus imaging associates, request for amendment to ... · robert a deweese, md radiation safety...
TRANSCRIPT
Casey Colleen
From Rhonda Lennon [rhondalennonyahoocom] Sent Thursday July 19 2012 tsectaPM To Casey C6l1een Cc William Breeden Subject License 13-26797-01 Attachments NRC FORM 314close out survey pdf
Colleen
Attached is a letter to tenninate our License 13-26797-01 along with NRC Fonn 314
If you have have any questions please feel free to contact myself or William Breeden
Thank you
Rhonda F Lennon Practice Manager Columbus Diagnostic Imaging 790 Creekview Drive Columbus IN 47201 812-373-2111
1
Columbus Diagnostic Imaging
July 29 2012
United States Nuclear Regulatory Commission Region III 2443 Warrenville Road Suite 210 lisle Il 60532-4352
RE Ucense Number 13-26797-01
Dear Colleen Carol Casey
This is a formal request to terminate our license 13-26797-01 Attached is a Certificate of Disposition of Materials along with the Close out survey completed on July 18 2012 by William KBreeden JII MS DABR
Please contact our Administrator Rhonda lennon at 812376-1000 for further clarification if you desire
ma~ Robert A DeWeese MD Radiation Safety Officer Columbus Imaging Associates dba Columbus Diagnostic Imaging
790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200 Fax (812) 376-6665middot wwwcolumbusimagingcom
--
APPROVED BY OMS NO 3150(1028 EXPIRES 101312013NRC FORM 314 US NUCLEAR REGULATORY COMMISSION (1)$2012) ES1imaIed bURIen per Ill$llOII$l 10 IIlIllPIY with lIIis ~ CCIIIecIioII fIIq 30 milUI8$0 CFfUO 380l() 40420)(1) This SIIbmittai is used by NRC as part 01 lilt basis to its deIemIimIIIIoII 111M lilt Iidy is70 38lilt) _72 5ltltk)15)lIl)
teIeased lor un~ed use SeIld _IllS mgllldrtg lIURIen esImIIIe 10 lilt IlIIonneIIon Servres Btanch (15 FS3) US NIICieIII Reg~ COIIIIIWIon WlIIIIIIIgbI DC 2055$-0001 or by inlemel e-mail 10 InIocoIIeclSResouneMgoy IIIICI 10 lilt DesI Ofbr 0IIke 01CERTIFICATE OF D1SPOSITION OF MATERIALS InUmation and RegWllOly AIIaits NEOB-I0202 (3150-0028) 0ftII 01 ManagemenI atIC BOOgeI WashnglCn DC 20503 If ameatI$ used 10 impose an IIIIDImIJIion coIecIIon does flO dl$pIay a ellJel1lly vetil OMS IlOtMlI nll1lbei lilt NRC IN) IlOl COnduct or spDflSQI IIIICI II person is IlOl mqutred 10 respond 1O111e InIormaIIon coIIectlcm
LICENSE NUMBER DOCKET NUMBERLICENSEE NAME AND AOORESS
13-26797-01Columbus Imaging Associates dba Columbus Diagnostic Imaging 790 Creekview Drive LICENSE EXPIRATION DATE Columbus Indiana 47201
A LICENSE STATUS (Check the appropriate box)D This license has expired o This license has not yet expired please terminate it
B DISPOSAL OF RADIOACTIVE MATERIAL (Check _ approprHIte boxes and complete as nee-aI) additional space is needed provide attachments)
The licensee Of any individual executing this certificate on behalf of the licensee certifies that
1 No radioactive materials have ever been procured or possessed by the licensee under this license0 2 All activities authorized by this license have ceased and all radioactive materials procured andor possessed by the licensee0
under this license number cited above have been disposed of in the following manner
0a Transfer of radioactive materials 10 the licensee listed below eckert and Ziegler Isotope Products Inc dba Isotope Products Laboratories California Lic I 509middot19 Cary Renquist RSO
as- ~~2SiQQ0b Disposal of radioactive materials
[] 1 Directty by the licensee
All radioactive waste that was being held for as decay-in storage bas been disposed ofproperly as it has been held for greater than) 0 halfmiddot lives and was indistinguishable from background exposure rate levels See attached log
o 2 By licensed disposal site
o 3 By waste contractor
Dc All radioactive materials have been removed such that any remaining residual radioactivity is within the limits of 10 CFR Part 20 Subpart E and is ALARA
C SURVEYS PERFORMED AND REPORTED o 1 A radiation survey was conducted by the licensee The survey confirms
o a the absence of licensed radioactive materials
Db that any remaining residual radioactivity is within the limits of 10 CFR 20 Subpart E and is ALARA
o 2 A copy of the radiation survey results
[lJ a is attached or b is not attached (ProVIde explanation) or c was towarded to NRC on ~-~ ~
DaleD 3 A radiation survey is not required as only sealed sources were ever possessed under this license and
o Ii The results of the latest leak test are attached andlor [lJ b No leaking sources have ever been identified
The person to be contacted regarding the information provided on this form TELEPHONE 11_l1N COlt1ftl 1EmiddotlIWLADDRaSSNAME
~TlE 812middot376-1000 rhondalcnnonyahoocomRhonda Lennon Practice Manager
Mild all Mute tonIIPcndo_ ~no this license 10
Rhonda lennon at address noted above
C CERTIFYING OFFICIAL I CERTIFY UNDER PENALTY OF PERmiddotIIlRLTUAT THE FOREGOING IS TRUE AND CORRECT
~~- ~~~-~~- IQA~~~middot--WARNING F~se STATEMENTS IN THIS CERTlFlCATE MAY BE SCJBJECT TO CIVIL AflBioR CRIMINAL PENALTIES NRC REGULATIONS REQUIRE TWAT SUBMISSIONS TO THE NRC BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECT 18 USC seCTION 1001 MAKES ITA CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTER WITHIN ITS JURISDICTION NRC FORiII314 (05-2012)
Clouse out survey for Columbus Imaging Associates dba Columbus Diagnostic Imaging
6182012 USNRC Materials License 13-26797-01
Location Location Description Exposure Rate (mRhr) Wipe activity(dpm100cmA 2)
1 Dose prep area 2 Dose calibrator 3 Rad waste bins (empty)
4 Seald Source box(empty) 5 patient injection area 6 gamma camera 7 computer console 8 hot lab door and handle
9 imaging room door and handle
10 hot lab floor
11 hot lab floor
12 hot lab floor
13 hot lab floor
14 hot la b floor 15 hot lab floor 16 imaging room floor 17 imaging room floor 18 imaging room floor
19 imaging room floor
20 imaging room floor 21 desk 22 hot lab counter
23 hot lab sink
24 sharps shielding box (empty)
002 002
002 002
002 001 002 002
002
002 002
001
002
002
002 002
002 001
002
002 002 002
002
001
421 421
421 421 403
403 403
18 15
27
29
44
44
32 33
27S 279
32
47
31 20 4
14 9
Wipe tests measured with a Capintec CAPRAC SIN 00658 last calibrated 4612 Exposure rate surveyed with Ludlum 14C SIN 101782 last calibrated 33012
Perfomed by William K Breeden III MS DABR
FA~75tfh~f( JlII (u J 5JJ((i C6gtve t1r1 1tilt t~ -1 vr 6wl rrlv() -b j)7a71 p PCP 0 shy
Medical Physics Survey Sealed Source Inventory
Facility Columbus Diagnostic Imaging Department Nuclear Medicine
Location Columbus Indiana Date July 18 2012
Nuclide
Cs-137
Cs-137
Cs-137
Cs-137
Co-57
1-----shy
Activity Date Model Serial No Type Location
RV-137shyDose Hot Lab
2198uCi 811197 559-162-7 Calibrator200V Vial
~r- shyRod Hot Lab
O1065uCi 811197 IPL 488-31-2
Button Ludlum Survey
10uCi 1295 None 4646 Meter
I I
Imiddot-~ -shy ~~~
Button Ludlum Survey
10 uCi 12195 None 4656 Meter
I ~
Flood Hot Lab 10mCi 9nlO8 BM01-10 BM011008220102
-I_-_0shyI
~~--
I
l-~- I
I
~-
1shy
~~~
- --~~ v_~
~-_
-=1
_ ~ ~~ L__ w_i
M_~ I
Present
No returned to
manufacturer No returned ~I
to manufacturer Yesexempt quantity to
be sold with camera
Yes exempt quantity to
be sold with camera
No returned to
manufacturer
I
I
I Comments Ambient Exposure Rate Survey of Sealed Sources ( Ludlum 14C SN141804 001 mRlhr)
Radiation Safety Officer
Provided by Advanced Medical Physics 16770 Cedar Creek Lane Inoblesville IN 46060middot 3172233022
i1J ( ~ J) 1)1shy
Bathroom0- ) IHot _ah
GJ I Ireg 15 i 7 I
(5)
c
-10
Lr~ Imaging
COLUMBUS DIAGNOSTIC IMAGING DAILY AREA SURVEYS
1 Dose Preparation
2 Dose Calibration J~ 3 Hot Trash cslfJ ) 4 Sealed Snurre Storage(tm ~ 5 Patient Injection Area 6 Gamma Camera 7 Computer Console
~ HJh~lPvl
[) 1m~5 () raquoJt ()o~r O-IS Hiab f$J( I-10 fin Jtj ~
(Zoo~fl~(
u- O~s0 -shy J L ~ltI ~1 C r1
MONTH YEAR
ITriaaer l evels-mRthr 20 20~10 05 10 HandsClothing Initials Comments
~ 1 2 6 7 8 1 ~ II J 1 ( t1- tt~ VIlJ
A
tl2 -w-- (L 0 ( 3 (J Jl 4 f 11 OWl ~ 5 I) r -0 1
6
7 8 9
10 ==t11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
jf =R311
__________ __ __
I I
I -r----~----------- shy
I I
I
I I
~~~~~6~~~--+----------~-
I I r-u=~-r-=middot-~=JiI-IImiddot----middotmiddot-middotmiddotmiddotmiddotr-middotmiddot-middot-middotmiddot--- --___+-__shy
NUCSl6AMMA ROOM
1--
i
bull ____laquo __bullbull___ I ___L
I I
II ~ ltgtlIe I I EGUIP I IBpoundJI I
i
I _l_____
~ I-Jltl
r
6
(J~Q
existing shelf
10
g
8
7
6
5
4
3
2
l
0-shy
PRELIMINARY PLANNfNG- ONLY
Wiscontit bull oquipmOllI 110 piiiCtcirti ~ Iiit
THIS LAYOUT WST BE APPROVED BEFORE RNAl llRAWlNGS CAN BE STARTED THANK yOU
PROJECT 1l11E
COLUMBUS DIAGNOSTIC IMAGING CUSTOMER PATNUCLEAR ROOM - MILLENIUM MG GE Project cqulppllat AII n- _ 1M atot laquoyeniIor 1 _ lhltIICOLUMBUS INDIANA Monager td~ ~ 01 -- II CW-rInstalrotion PATE P Iot h ~ rcIII ~ _ t ~SCHEME NO081NAQ80 DRAWH BY TlO DAli 07-22-~
Radioactive Wastl And Disposal Record
Policy and Procedure 1 Seal and slore radioactive waste containers behind adequate shielding 2 Indicate Container 10 andor Conlents (ie Hot Trash Sharps etc) 3 Radioactive waste should be held for at least 10 half-lives of the longest-lived radIoisOtope to be disposed 4 Monitor background and surface with a GM 5uNay Meter on its most sensitive scale without shielding prior to
disposal 5 Waste may be disp~d of if activity Is indistinguIshable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash
Survey Meter Code Brand Model Serial Number
1 1_ tI-~ ILLfVl Lle I L 11Ct- 2 rtrfl IUn ll(r Il ) 7)-)
0Lj 3$YJ
last AsS2V DJte of Waste to La lJisposed Isotope to be
of Dis osed of ~1l~~1~~~ 1 C-
o7h6 I~) o~ ~ j I S-ltC lt1A
~8u~Hit5Sltq~W ) 7 jj-) iiWif( r 9q ~~~IEP1fisect ~84~~ ~dJili(5)i-)Jamp --=T~Y 1Jifll-)~ltilli~~ ~lltY ~~iLl ~ r ))RT=_L 2 ~~LL~~Li2 L ~~ laquo44
-~hO~ - 1iI~l7-~pL-r~-h7 ~2 I-l-h 1~)1] r- I ---shy I~I P - -- v- -shy r-~--- I - ---~~
(Providcd by A~edMedical Physics 16771Hi rak Lanemiddot NoblesviIleIN 46060middot 3172n3022
Radioactive Materials Shipment Ret l and Return Container Survey RecOImiddotd
Instruments Usedor SurllJsAction le~eIs Tile Radiation Safety Of11Cer should be immediately Dotilied when radiatioll or cootamination levels to which personnel DeteclorMeier No Make amp Model Serial No
Efficiencymay be exposed elteed tbe rollowing levels
Area
Restricted
Radiation Survey Conmlnatioll Surveys
50 mRlhr lOOODPMI10Ocm 2 2
BKG Cpm I Initials
Report Date Apri122 2012
Facility Columbus Diagnostic Imaging Columbus IN
State License Number Not Supplied USNRC License Number 13-24706-01
$ogrce Identification
Radionuc6de Cobalt-57 Calibrated Activity Date 090708 Calibrated Activity lOmCi Manufacturer Not Supplied Setia1 Number BM01-10 Model Number BMOl1008220102 Source Description Flood Source
Assay Results Counting Efficiency 0762 cpmdptn 1691543 cpmuCi MDA 102 dpm 78 cpm 000005 uCi Background time ofassay 351 cpm)
Grosscpm PtyWipe 347
Instrument used fot Analysis Ludlum Well Counter MN 2200 SIN 198663
Analysis Results Source is not leaking at this time
Removable contamination is lt0005 uCi
Next Leak Test Due
LeakTest Performed By
Analysis Performed By
IpoundI~ I Radiation Safety Officer (signature)
Report Date
Facility
State License Number USNRC License Number
Source Ideptification
Radionuclide Calibrated Activity Date Cahbrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
April 22 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137 080197 2198 uCi IPL 559-1627 RV-137-200V Dose CaliJIrator Vial Soutce
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm 000013 uCi 351
Grosscpm DryWtpe 347
Instrument used for Analysis Ludlum Well Counter MN2200 SIN PR 198663
Analysis Results Source is not leaking at this time Removable contamination is lt0005 uCi
Next Leak Test Due
Leak Test Pedormed By
Analysis Performed By
Officer (signature)
Columbus Diagnostic Imaging
July 29 2012
United States Nuclear Regulatory Commission Region III 2443 Warrenville Road Suite 210 lisle Il 60532-4352
RE Ucense Number 13-26797-01
Dear Colleen Carol Casey
This is a formal request to terminate our license 13-26797-01 Attached is a Certificate of Disposition of Materials along with the Close out survey completed on July 18 2012 by William KBreeden JII MS DABR
Please contact our Administrator Rhonda lennon at 812376-1000 for further clarification if you desire
ma~ Robert A DeWeese MD Radiation Safety Officer Columbus Imaging Associates dba Columbus Diagnostic Imaging
790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200 Fax (812) 376-6665middot wwwcolumbusimagingcom
--
APPROVED BY OMS NO 3150(1028 EXPIRES 101312013NRC FORM 314 US NUCLEAR REGULATORY COMMISSION (1)$2012) ES1imaIed bURIen per Ill$llOII$l 10 IIlIllPIY with lIIis ~ CCIIIecIioII fIIq 30 milUI8$0 CFfUO 380l() 40420)(1) This SIIbmittai is used by NRC as part 01 lilt basis to its deIemIimIIIIoII 111M lilt Iidy is70 38lilt) _72 5ltltk)15)lIl)
teIeased lor un~ed use SeIld _IllS mgllldrtg lIURIen esImIIIe 10 lilt IlIIonneIIon Servres Btanch (15 FS3) US NIICieIII Reg~ COIIIIIWIon WlIIIIIIIgbI DC 2055$-0001 or by inlemel e-mail 10 InIocoIIeclSResouneMgoy IIIICI 10 lilt DesI Ofbr 0IIke 01CERTIFICATE OF D1SPOSITION OF MATERIALS InUmation and RegWllOly AIIaits NEOB-I0202 (3150-0028) 0ftII 01 ManagemenI atIC BOOgeI WashnglCn DC 20503 If ameatI$ used 10 impose an IIIIDImIJIion coIecIIon does flO dl$pIay a ellJel1lly vetil OMS IlOtMlI nll1lbei lilt NRC IN) IlOl COnduct or spDflSQI IIIICI II person is IlOl mqutred 10 respond 1O111e InIormaIIon coIIectlcm
LICENSE NUMBER DOCKET NUMBERLICENSEE NAME AND AOORESS
13-26797-01Columbus Imaging Associates dba Columbus Diagnostic Imaging 790 Creekview Drive LICENSE EXPIRATION DATE Columbus Indiana 47201
A LICENSE STATUS (Check the appropriate box)D This license has expired o This license has not yet expired please terminate it
B DISPOSAL OF RADIOACTIVE MATERIAL (Check _ approprHIte boxes and complete as nee-aI) additional space is needed provide attachments)
The licensee Of any individual executing this certificate on behalf of the licensee certifies that
1 No radioactive materials have ever been procured or possessed by the licensee under this license0 2 All activities authorized by this license have ceased and all radioactive materials procured andor possessed by the licensee0
under this license number cited above have been disposed of in the following manner
0a Transfer of radioactive materials 10 the licensee listed below eckert and Ziegler Isotope Products Inc dba Isotope Products Laboratories California Lic I 509middot19 Cary Renquist RSO
as- ~~2SiQQ0b Disposal of radioactive materials
[] 1 Directty by the licensee
All radioactive waste that was being held for as decay-in storage bas been disposed ofproperly as it has been held for greater than) 0 halfmiddot lives and was indistinguishable from background exposure rate levels See attached log
o 2 By licensed disposal site
o 3 By waste contractor
Dc All radioactive materials have been removed such that any remaining residual radioactivity is within the limits of 10 CFR Part 20 Subpart E and is ALARA
C SURVEYS PERFORMED AND REPORTED o 1 A radiation survey was conducted by the licensee The survey confirms
o a the absence of licensed radioactive materials
Db that any remaining residual radioactivity is within the limits of 10 CFR 20 Subpart E and is ALARA
o 2 A copy of the radiation survey results
[lJ a is attached or b is not attached (ProVIde explanation) or c was towarded to NRC on ~-~ ~
DaleD 3 A radiation survey is not required as only sealed sources were ever possessed under this license and
o Ii The results of the latest leak test are attached andlor [lJ b No leaking sources have ever been identified
The person to be contacted regarding the information provided on this form TELEPHONE 11_l1N COlt1ftl 1EmiddotlIWLADDRaSSNAME
~TlE 812middot376-1000 rhondalcnnonyahoocomRhonda Lennon Practice Manager
Mild all Mute tonIIPcndo_ ~no this license 10
Rhonda lennon at address noted above
C CERTIFYING OFFICIAL I CERTIFY UNDER PENALTY OF PERmiddotIIlRLTUAT THE FOREGOING IS TRUE AND CORRECT
~~- ~~~-~~- IQA~~~middot--WARNING F~se STATEMENTS IN THIS CERTlFlCATE MAY BE SCJBJECT TO CIVIL AflBioR CRIMINAL PENALTIES NRC REGULATIONS REQUIRE TWAT SUBMISSIONS TO THE NRC BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECT 18 USC seCTION 1001 MAKES ITA CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTER WITHIN ITS JURISDICTION NRC FORiII314 (05-2012)
Clouse out survey for Columbus Imaging Associates dba Columbus Diagnostic Imaging
6182012 USNRC Materials License 13-26797-01
Location Location Description Exposure Rate (mRhr) Wipe activity(dpm100cmA 2)
1 Dose prep area 2 Dose calibrator 3 Rad waste bins (empty)
4 Seald Source box(empty) 5 patient injection area 6 gamma camera 7 computer console 8 hot lab door and handle
9 imaging room door and handle
10 hot lab floor
11 hot lab floor
12 hot lab floor
13 hot lab floor
14 hot la b floor 15 hot lab floor 16 imaging room floor 17 imaging room floor 18 imaging room floor
19 imaging room floor
20 imaging room floor 21 desk 22 hot lab counter
23 hot lab sink
24 sharps shielding box (empty)
002 002
002 002
002 001 002 002
002
002 002
001
002
002
002 002
002 001
002
002 002 002
002
001
421 421
421 421 403
403 403
18 15
27
29
44
44
32 33
27S 279
32
47
31 20 4
14 9
Wipe tests measured with a Capintec CAPRAC SIN 00658 last calibrated 4612 Exposure rate surveyed with Ludlum 14C SIN 101782 last calibrated 33012
Perfomed by William K Breeden III MS DABR
FA~75tfh~f( JlII (u J 5JJ((i C6gtve t1r1 1tilt t~ -1 vr 6wl rrlv() -b j)7a71 p PCP 0 shy
Medical Physics Survey Sealed Source Inventory
Facility Columbus Diagnostic Imaging Department Nuclear Medicine
Location Columbus Indiana Date July 18 2012
Nuclide
Cs-137
Cs-137
Cs-137
Cs-137
Co-57
1-----shy
Activity Date Model Serial No Type Location
RV-137shyDose Hot Lab
2198uCi 811197 559-162-7 Calibrator200V Vial
~r- shyRod Hot Lab
O1065uCi 811197 IPL 488-31-2
Button Ludlum Survey
10uCi 1295 None 4646 Meter
I I
Imiddot-~ -shy ~~~
Button Ludlum Survey
10 uCi 12195 None 4656 Meter
I ~
Flood Hot Lab 10mCi 9nlO8 BM01-10 BM011008220102
-I_-_0shyI
~~--
I
l-~- I
I
~-
1shy
~~~
- --~~ v_~
~-_
-=1
_ ~ ~~ L__ w_i
M_~ I
Present
No returned to
manufacturer No returned ~I
to manufacturer Yesexempt quantity to
be sold with camera
Yes exempt quantity to
be sold with camera
No returned to
manufacturer
I
I
I Comments Ambient Exposure Rate Survey of Sealed Sources ( Ludlum 14C SN141804 001 mRlhr)
Radiation Safety Officer
Provided by Advanced Medical Physics 16770 Cedar Creek Lane Inoblesville IN 46060middot 3172233022
i1J ( ~ J) 1)1shy
Bathroom0- ) IHot _ah
GJ I Ireg 15 i 7 I
(5)
c
-10
Lr~ Imaging
COLUMBUS DIAGNOSTIC IMAGING DAILY AREA SURVEYS
1 Dose Preparation
2 Dose Calibration J~ 3 Hot Trash cslfJ ) 4 Sealed Snurre Storage(tm ~ 5 Patient Injection Area 6 Gamma Camera 7 Computer Console
~ HJh~lPvl
[) 1m~5 () raquoJt ()o~r O-IS Hiab f$J( I-10 fin Jtj ~
(Zoo~fl~(
u- O~s0 -shy J L ~ltI ~1 C r1
MONTH YEAR
ITriaaer l evels-mRthr 20 20~10 05 10 HandsClothing Initials Comments
~ 1 2 6 7 8 1 ~ II J 1 ( t1- tt~ VIlJ
A
tl2 -w-- (L 0 ( 3 (J Jl 4 f 11 OWl ~ 5 I) r -0 1
6
7 8 9
10 ==t11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
jf =R311
__________ __ __
I I
I -r----~----------- shy
I I
I
I I
~~~~~6~~~--+----------~-
I I r-u=~-r-=middot-~=JiI-IImiddot----middotmiddot-middotmiddotmiddotmiddotr-middotmiddot-middot-middotmiddot--- --___+-__shy
NUCSl6AMMA ROOM
1--
i
bull ____laquo __bullbull___ I ___L
I I
II ~ ltgtlIe I I EGUIP I IBpoundJI I
i
I _l_____
~ I-Jltl
r
6
(J~Q
existing shelf
10
g
8
7
6
5
4
3
2
l
0-shy
PRELIMINARY PLANNfNG- ONLY
Wiscontit bull oquipmOllI 110 piiiCtcirti ~ Iiit
THIS LAYOUT WST BE APPROVED BEFORE RNAl llRAWlNGS CAN BE STARTED THANK yOU
PROJECT 1l11E
COLUMBUS DIAGNOSTIC IMAGING CUSTOMER PATNUCLEAR ROOM - MILLENIUM MG GE Project cqulppllat AII n- _ 1M atot laquoyeniIor 1 _ lhltIICOLUMBUS INDIANA Monager td~ ~ 01 -- II CW-rInstalrotion PATE P Iot h ~ rcIII ~ _ t ~SCHEME NO081NAQ80 DRAWH BY TlO DAli 07-22-~
Radioactive Wastl And Disposal Record
Policy and Procedure 1 Seal and slore radioactive waste containers behind adequate shielding 2 Indicate Container 10 andor Conlents (ie Hot Trash Sharps etc) 3 Radioactive waste should be held for at least 10 half-lives of the longest-lived radIoisOtope to be disposed 4 Monitor background and surface with a GM 5uNay Meter on its most sensitive scale without shielding prior to
disposal 5 Waste may be disp~d of if activity Is indistinguIshable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash
Survey Meter Code Brand Model Serial Number
1 1_ tI-~ ILLfVl Lle I L 11Ct- 2 rtrfl IUn ll(r Il ) 7)-)
0Lj 3$YJ
last AsS2V DJte of Waste to La lJisposed Isotope to be
of Dis osed of ~1l~~1~~~ 1 C-
o7h6 I~) o~ ~ j I S-ltC lt1A
~8u~Hit5Sltq~W ) 7 jj-) iiWif( r 9q ~~~IEP1fisect ~84~~ ~dJili(5)i-)Jamp --=T~Y 1Jifll-)~ltilli~~ ~lltY ~~iLl ~ r ))RT=_L 2 ~~LL~~Li2 L ~~ laquo44
-~hO~ - 1iI~l7-~pL-r~-h7 ~2 I-l-h 1~)1] r- I ---shy I~I P - -- v- -shy r-~--- I - ---~~
(Providcd by A~edMedical Physics 16771Hi rak Lanemiddot NoblesviIleIN 46060middot 3172n3022
Radioactive Materials Shipment Ret l and Return Container Survey RecOImiddotd
Instruments Usedor SurllJsAction le~eIs Tile Radiation Safety Of11Cer should be immediately Dotilied when radiatioll or cootamination levels to which personnel DeteclorMeier No Make amp Model Serial No
Efficiencymay be exposed elteed tbe rollowing levels
Area
Restricted
Radiation Survey Conmlnatioll Surveys
50 mRlhr lOOODPMI10Ocm 2 2
BKG Cpm I Initials
Report Date Apri122 2012
Facility Columbus Diagnostic Imaging Columbus IN
State License Number Not Supplied USNRC License Number 13-24706-01
$ogrce Identification
Radionuc6de Cobalt-57 Calibrated Activity Date 090708 Calibrated Activity lOmCi Manufacturer Not Supplied Setia1 Number BM01-10 Model Number BMOl1008220102 Source Description Flood Source
Assay Results Counting Efficiency 0762 cpmdptn 1691543 cpmuCi MDA 102 dpm 78 cpm 000005 uCi Background time ofassay 351 cpm)
Grosscpm PtyWipe 347
Instrument used fot Analysis Ludlum Well Counter MN 2200 SIN 198663
Analysis Results Source is not leaking at this time
Removable contamination is lt0005 uCi
Next Leak Test Due
LeakTest Performed By
Analysis Performed By
IpoundI~ I Radiation Safety Officer (signature)
Report Date
Facility
State License Number USNRC License Number
Source Ideptification
Radionuclide Calibrated Activity Date Cahbrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
April 22 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137 080197 2198 uCi IPL 559-1627 RV-137-200V Dose CaliJIrator Vial Soutce
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm 000013 uCi 351
Grosscpm DryWtpe 347
Instrument used for Analysis Ludlum Well Counter MN2200 SIN PR 198663
Analysis Results Source is not leaking at this time Removable contamination is lt0005 uCi
Next Leak Test Due
Leak Test Pedormed By
Analysis Performed By
Officer (signature)
--
APPROVED BY OMS NO 3150(1028 EXPIRES 101312013NRC FORM 314 US NUCLEAR REGULATORY COMMISSION (1)$2012) ES1imaIed bURIen per Ill$llOII$l 10 IIlIllPIY with lIIis ~ CCIIIecIioII fIIq 30 milUI8$0 CFfUO 380l() 40420)(1) This SIIbmittai is used by NRC as part 01 lilt basis to its deIemIimIIIIoII 111M lilt Iidy is70 38lilt) _72 5ltltk)15)lIl)
teIeased lor un~ed use SeIld _IllS mgllldrtg lIURIen esImIIIe 10 lilt IlIIonneIIon Servres Btanch (15 FS3) US NIICieIII Reg~ COIIIIIWIon WlIIIIIIIgbI DC 2055$-0001 or by inlemel e-mail 10 InIocoIIeclSResouneMgoy IIIICI 10 lilt DesI Ofbr 0IIke 01CERTIFICATE OF D1SPOSITION OF MATERIALS InUmation and RegWllOly AIIaits NEOB-I0202 (3150-0028) 0ftII 01 ManagemenI atIC BOOgeI WashnglCn DC 20503 If ameatI$ used 10 impose an IIIIDImIJIion coIecIIon does flO dl$pIay a ellJel1lly vetil OMS IlOtMlI nll1lbei lilt NRC IN) IlOl COnduct or spDflSQI IIIICI II person is IlOl mqutred 10 respond 1O111e InIormaIIon coIIectlcm
LICENSE NUMBER DOCKET NUMBERLICENSEE NAME AND AOORESS
13-26797-01Columbus Imaging Associates dba Columbus Diagnostic Imaging 790 Creekview Drive LICENSE EXPIRATION DATE Columbus Indiana 47201
A LICENSE STATUS (Check the appropriate box)D This license has expired o This license has not yet expired please terminate it
B DISPOSAL OF RADIOACTIVE MATERIAL (Check _ approprHIte boxes and complete as nee-aI) additional space is needed provide attachments)
The licensee Of any individual executing this certificate on behalf of the licensee certifies that
1 No radioactive materials have ever been procured or possessed by the licensee under this license0 2 All activities authorized by this license have ceased and all radioactive materials procured andor possessed by the licensee0
under this license number cited above have been disposed of in the following manner
0a Transfer of radioactive materials 10 the licensee listed below eckert and Ziegler Isotope Products Inc dba Isotope Products Laboratories California Lic I 509middot19 Cary Renquist RSO
as- ~~2SiQQ0b Disposal of radioactive materials
[] 1 Directty by the licensee
All radioactive waste that was being held for as decay-in storage bas been disposed ofproperly as it has been held for greater than) 0 halfmiddot lives and was indistinguishable from background exposure rate levels See attached log
o 2 By licensed disposal site
o 3 By waste contractor
Dc All radioactive materials have been removed such that any remaining residual radioactivity is within the limits of 10 CFR Part 20 Subpart E and is ALARA
C SURVEYS PERFORMED AND REPORTED o 1 A radiation survey was conducted by the licensee The survey confirms
o a the absence of licensed radioactive materials
Db that any remaining residual radioactivity is within the limits of 10 CFR 20 Subpart E and is ALARA
o 2 A copy of the radiation survey results
[lJ a is attached or b is not attached (ProVIde explanation) or c was towarded to NRC on ~-~ ~
DaleD 3 A radiation survey is not required as only sealed sources were ever possessed under this license and
o Ii The results of the latest leak test are attached andlor [lJ b No leaking sources have ever been identified
The person to be contacted regarding the information provided on this form TELEPHONE 11_l1N COlt1ftl 1EmiddotlIWLADDRaSSNAME
~TlE 812middot376-1000 rhondalcnnonyahoocomRhonda Lennon Practice Manager
Mild all Mute tonIIPcndo_ ~no this license 10
Rhonda lennon at address noted above
C CERTIFYING OFFICIAL I CERTIFY UNDER PENALTY OF PERmiddotIIlRLTUAT THE FOREGOING IS TRUE AND CORRECT
~~- ~~~-~~- IQA~~~middot--WARNING F~se STATEMENTS IN THIS CERTlFlCATE MAY BE SCJBJECT TO CIVIL AflBioR CRIMINAL PENALTIES NRC REGULATIONS REQUIRE TWAT SUBMISSIONS TO THE NRC BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECT 18 USC seCTION 1001 MAKES ITA CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTER WITHIN ITS JURISDICTION NRC FORiII314 (05-2012)
Clouse out survey for Columbus Imaging Associates dba Columbus Diagnostic Imaging
6182012 USNRC Materials License 13-26797-01
Location Location Description Exposure Rate (mRhr) Wipe activity(dpm100cmA 2)
1 Dose prep area 2 Dose calibrator 3 Rad waste bins (empty)
4 Seald Source box(empty) 5 patient injection area 6 gamma camera 7 computer console 8 hot lab door and handle
9 imaging room door and handle
10 hot lab floor
11 hot lab floor
12 hot lab floor
13 hot lab floor
14 hot la b floor 15 hot lab floor 16 imaging room floor 17 imaging room floor 18 imaging room floor
19 imaging room floor
20 imaging room floor 21 desk 22 hot lab counter
23 hot lab sink
24 sharps shielding box (empty)
002 002
002 002
002 001 002 002
002
002 002
001
002
002
002 002
002 001
002
002 002 002
002
001
421 421
421 421 403
403 403
18 15
27
29
44
44
32 33
27S 279
32
47
31 20 4
14 9
Wipe tests measured with a Capintec CAPRAC SIN 00658 last calibrated 4612 Exposure rate surveyed with Ludlum 14C SIN 101782 last calibrated 33012
Perfomed by William K Breeden III MS DABR
FA~75tfh~f( JlII (u J 5JJ((i C6gtve t1r1 1tilt t~ -1 vr 6wl rrlv() -b j)7a71 p PCP 0 shy
Medical Physics Survey Sealed Source Inventory
Facility Columbus Diagnostic Imaging Department Nuclear Medicine
Location Columbus Indiana Date July 18 2012
Nuclide
Cs-137
Cs-137
Cs-137
Cs-137
Co-57
1-----shy
Activity Date Model Serial No Type Location
RV-137shyDose Hot Lab
2198uCi 811197 559-162-7 Calibrator200V Vial
~r- shyRod Hot Lab
O1065uCi 811197 IPL 488-31-2
Button Ludlum Survey
10uCi 1295 None 4646 Meter
I I
Imiddot-~ -shy ~~~
Button Ludlum Survey
10 uCi 12195 None 4656 Meter
I ~
Flood Hot Lab 10mCi 9nlO8 BM01-10 BM011008220102
-I_-_0shyI
~~--
I
l-~- I
I
~-
1shy
~~~
- --~~ v_~
~-_
-=1
_ ~ ~~ L__ w_i
M_~ I
Present
No returned to
manufacturer No returned ~I
to manufacturer Yesexempt quantity to
be sold with camera
Yes exempt quantity to
be sold with camera
No returned to
manufacturer
I
I
I Comments Ambient Exposure Rate Survey of Sealed Sources ( Ludlum 14C SN141804 001 mRlhr)
Radiation Safety Officer
Provided by Advanced Medical Physics 16770 Cedar Creek Lane Inoblesville IN 46060middot 3172233022
i1J ( ~ J) 1)1shy
Bathroom0- ) IHot _ah
GJ I Ireg 15 i 7 I
(5)
c
-10
Lr~ Imaging
COLUMBUS DIAGNOSTIC IMAGING DAILY AREA SURVEYS
1 Dose Preparation
2 Dose Calibration J~ 3 Hot Trash cslfJ ) 4 Sealed Snurre Storage(tm ~ 5 Patient Injection Area 6 Gamma Camera 7 Computer Console
~ HJh~lPvl
[) 1m~5 () raquoJt ()o~r O-IS Hiab f$J( I-10 fin Jtj ~
(Zoo~fl~(
u- O~s0 -shy J L ~ltI ~1 C r1
MONTH YEAR
ITriaaer l evels-mRthr 20 20~10 05 10 HandsClothing Initials Comments
~ 1 2 6 7 8 1 ~ II J 1 ( t1- tt~ VIlJ
A
tl2 -w-- (L 0 ( 3 (J Jl 4 f 11 OWl ~ 5 I) r -0 1
6
7 8 9
10 ==t11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
jf =R311
__________ __ __
I I
I -r----~----------- shy
I I
I
I I
~~~~~6~~~--+----------~-
I I r-u=~-r-=middot-~=JiI-IImiddot----middotmiddot-middotmiddotmiddotmiddotr-middotmiddot-middot-middotmiddot--- --___+-__shy
NUCSl6AMMA ROOM
1--
i
bull ____laquo __bullbull___ I ___L
I I
II ~ ltgtlIe I I EGUIP I IBpoundJI I
i
I _l_____
~ I-Jltl
r
6
(J~Q
existing shelf
10
g
8
7
6
5
4
3
2
l
0-shy
PRELIMINARY PLANNfNG- ONLY
Wiscontit bull oquipmOllI 110 piiiCtcirti ~ Iiit
THIS LAYOUT WST BE APPROVED BEFORE RNAl llRAWlNGS CAN BE STARTED THANK yOU
PROJECT 1l11E
COLUMBUS DIAGNOSTIC IMAGING CUSTOMER PATNUCLEAR ROOM - MILLENIUM MG GE Project cqulppllat AII n- _ 1M atot laquoyeniIor 1 _ lhltIICOLUMBUS INDIANA Monager td~ ~ 01 -- II CW-rInstalrotion PATE P Iot h ~ rcIII ~ _ t ~SCHEME NO081NAQ80 DRAWH BY TlO DAli 07-22-~
Radioactive Wastl And Disposal Record
Policy and Procedure 1 Seal and slore radioactive waste containers behind adequate shielding 2 Indicate Container 10 andor Conlents (ie Hot Trash Sharps etc) 3 Radioactive waste should be held for at least 10 half-lives of the longest-lived radIoisOtope to be disposed 4 Monitor background and surface with a GM 5uNay Meter on its most sensitive scale without shielding prior to
disposal 5 Waste may be disp~d of if activity Is indistinguIshable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash
Survey Meter Code Brand Model Serial Number
1 1_ tI-~ ILLfVl Lle I L 11Ct- 2 rtrfl IUn ll(r Il ) 7)-)
0Lj 3$YJ
last AsS2V DJte of Waste to La lJisposed Isotope to be
of Dis osed of ~1l~~1~~~ 1 C-
o7h6 I~) o~ ~ j I S-ltC lt1A
~8u~Hit5Sltq~W ) 7 jj-) iiWif( r 9q ~~~IEP1fisect ~84~~ ~dJili(5)i-)Jamp --=T~Y 1Jifll-)~ltilli~~ ~lltY ~~iLl ~ r ))RT=_L 2 ~~LL~~Li2 L ~~ laquo44
-~hO~ - 1iI~l7-~pL-r~-h7 ~2 I-l-h 1~)1] r- I ---shy I~I P - -- v- -shy r-~--- I - ---~~
(Providcd by A~edMedical Physics 16771Hi rak Lanemiddot NoblesviIleIN 46060middot 3172n3022
Radioactive Materials Shipment Ret l and Return Container Survey RecOImiddotd
Instruments Usedor SurllJsAction le~eIs Tile Radiation Safety Of11Cer should be immediately Dotilied when radiatioll or cootamination levels to which personnel DeteclorMeier No Make amp Model Serial No
Efficiencymay be exposed elteed tbe rollowing levels
Area
Restricted
Radiation Survey Conmlnatioll Surveys
50 mRlhr lOOODPMI10Ocm 2 2
BKG Cpm I Initials
Report Date Apri122 2012
Facility Columbus Diagnostic Imaging Columbus IN
State License Number Not Supplied USNRC License Number 13-24706-01
$ogrce Identification
Radionuc6de Cobalt-57 Calibrated Activity Date 090708 Calibrated Activity lOmCi Manufacturer Not Supplied Setia1 Number BM01-10 Model Number BMOl1008220102 Source Description Flood Source
Assay Results Counting Efficiency 0762 cpmdptn 1691543 cpmuCi MDA 102 dpm 78 cpm 000005 uCi Background time ofassay 351 cpm)
Grosscpm PtyWipe 347
Instrument used fot Analysis Ludlum Well Counter MN 2200 SIN 198663
Analysis Results Source is not leaking at this time
Removable contamination is lt0005 uCi
Next Leak Test Due
LeakTest Performed By
Analysis Performed By
IpoundI~ I Radiation Safety Officer (signature)
Report Date
Facility
State License Number USNRC License Number
Source Ideptification
Radionuclide Calibrated Activity Date Cahbrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
April 22 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137 080197 2198 uCi IPL 559-1627 RV-137-200V Dose CaliJIrator Vial Soutce
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm 000013 uCi 351
Grosscpm DryWtpe 347
Instrument used for Analysis Ludlum Well Counter MN2200 SIN PR 198663
Analysis Results Source is not leaking at this time Removable contamination is lt0005 uCi
Next Leak Test Due
Leak Test Pedormed By
Analysis Performed By
Officer (signature)
Clouse out survey for Columbus Imaging Associates dba Columbus Diagnostic Imaging
6182012 USNRC Materials License 13-26797-01
Location Location Description Exposure Rate (mRhr) Wipe activity(dpm100cmA 2)
1 Dose prep area 2 Dose calibrator 3 Rad waste bins (empty)
4 Seald Source box(empty) 5 patient injection area 6 gamma camera 7 computer console 8 hot lab door and handle
9 imaging room door and handle
10 hot lab floor
11 hot lab floor
12 hot lab floor
13 hot lab floor
14 hot la b floor 15 hot lab floor 16 imaging room floor 17 imaging room floor 18 imaging room floor
19 imaging room floor
20 imaging room floor 21 desk 22 hot lab counter
23 hot lab sink
24 sharps shielding box (empty)
002 002
002 002
002 001 002 002
002
002 002
001
002
002
002 002
002 001
002
002 002 002
002
001
421 421
421 421 403
403 403
18 15
27
29
44
44
32 33
27S 279
32
47
31 20 4
14 9
Wipe tests measured with a Capintec CAPRAC SIN 00658 last calibrated 4612 Exposure rate surveyed with Ludlum 14C SIN 101782 last calibrated 33012
Perfomed by William K Breeden III MS DABR
FA~75tfh~f( JlII (u J 5JJ((i C6gtve t1r1 1tilt t~ -1 vr 6wl rrlv() -b j)7a71 p PCP 0 shy
Medical Physics Survey Sealed Source Inventory
Facility Columbus Diagnostic Imaging Department Nuclear Medicine
Location Columbus Indiana Date July 18 2012
Nuclide
Cs-137
Cs-137
Cs-137
Cs-137
Co-57
1-----shy
Activity Date Model Serial No Type Location
RV-137shyDose Hot Lab
2198uCi 811197 559-162-7 Calibrator200V Vial
~r- shyRod Hot Lab
O1065uCi 811197 IPL 488-31-2
Button Ludlum Survey
10uCi 1295 None 4646 Meter
I I
Imiddot-~ -shy ~~~
Button Ludlum Survey
10 uCi 12195 None 4656 Meter
I ~
Flood Hot Lab 10mCi 9nlO8 BM01-10 BM011008220102
-I_-_0shyI
~~--
I
l-~- I
I
~-
1shy
~~~
- --~~ v_~
~-_
-=1
_ ~ ~~ L__ w_i
M_~ I
Present
No returned to
manufacturer No returned ~I
to manufacturer Yesexempt quantity to
be sold with camera
Yes exempt quantity to
be sold with camera
No returned to
manufacturer
I
I
I Comments Ambient Exposure Rate Survey of Sealed Sources ( Ludlum 14C SN141804 001 mRlhr)
Radiation Safety Officer
Provided by Advanced Medical Physics 16770 Cedar Creek Lane Inoblesville IN 46060middot 3172233022
i1J ( ~ J) 1)1shy
Bathroom0- ) IHot _ah
GJ I Ireg 15 i 7 I
(5)
c
-10
Lr~ Imaging
COLUMBUS DIAGNOSTIC IMAGING DAILY AREA SURVEYS
1 Dose Preparation
2 Dose Calibration J~ 3 Hot Trash cslfJ ) 4 Sealed Snurre Storage(tm ~ 5 Patient Injection Area 6 Gamma Camera 7 Computer Console
~ HJh~lPvl
[) 1m~5 () raquoJt ()o~r O-IS Hiab f$J( I-10 fin Jtj ~
(Zoo~fl~(
u- O~s0 -shy J L ~ltI ~1 C r1
MONTH YEAR
ITriaaer l evels-mRthr 20 20~10 05 10 HandsClothing Initials Comments
~ 1 2 6 7 8 1 ~ II J 1 ( t1- tt~ VIlJ
A
tl2 -w-- (L 0 ( 3 (J Jl 4 f 11 OWl ~ 5 I) r -0 1
6
7 8 9
10 ==t11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
jf =R311
__________ __ __
I I
I -r----~----------- shy
I I
I
I I
~~~~~6~~~--+----------~-
I I r-u=~-r-=middot-~=JiI-IImiddot----middotmiddot-middotmiddotmiddotmiddotr-middotmiddot-middot-middotmiddot--- --___+-__shy
NUCSl6AMMA ROOM
1--
i
bull ____laquo __bullbull___ I ___L
I I
II ~ ltgtlIe I I EGUIP I IBpoundJI I
i
I _l_____
~ I-Jltl
r
6
(J~Q
existing shelf
10
g
8
7
6
5
4
3
2
l
0-shy
PRELIMINARY PLANNfNG- ONLY
Wiscontit bull oquipmOllI 110 piiiCtcirti ~ Iiit
THIS LAYOUT WST BE APPROVED BEFORE RNAl llRAWlNGS CAN BE STARTED THANK yOU
PROJECT 1l11E
COLUMBUS DIAGNOSTIC IMAGING CUSTOMER PATNUCLEAR ROOM - MILLENIUM MG GE Project cqulppllat AII n- _ 1M atot laquoyeniIor 1 _ lhltIICOLUMBUS INDIANA Monager td~ ~ 01 -- II CW-rInstalrotion PATE P Iot h ~ rcIII ~ _ t ~SCHEME NO081NAQ80 DRAWH BY TlO DAli 07-22-~
Radioactive Wastl And Disposal Record
Policy and Procedure 1 Seal and slore radioactive waste containers behind adequate shielding 2 Indicate Container 10 andor Conlents (ie Hot Trash Sharps etc) 3 Radioactive waste should be held for at least 10 half-lives of the longest-lived radIoisOtope to be disposed 4 Monitor background and surface with a GM 5uNay Meter on its most sensitive scale without shielding prior to
disposal 5 Waste may be disp~d of if activity Is indistinguIshable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash
Survey Meter Code Brand Model Serial Number
1 1_ tI-~ ILLfVl Lle I L 11Ct- 2 rtrfl IUn ll(r Il ) 7)-)
0Lj 3$YJ
last AsS2V DJte of Waste to La lJisposed Isotope to be
of Dis osed of ~1l~~1~~~ 1 C-
o7h6 I~) o~ ~ j I S-ltC lt1A
~8u~Hit5Sltq~W ) 7 jj-) iiWif( r 9q ~~~IEP1fisect ~84~~ ~dJili(5)i-)Jamp --=T~Y 1Jifll-)~ltilli~~ ~lltY ~~iLl ~ r ))RT=_L 2 ~~LL~~Li2 L ~~ laquo44
-~hO~ - 1iI~l7-~pL-r~-h7 ~2 I-l-h 1~)1] r- I ---shy I~I P - -- v- -shy r-~--- I - ---~~
(Providcd by A~edMedical Physics 16771Hi rak Lanemiddot NoblesviIleIN 46060middot 3172n3022
Radioactive Materials Shipment Ret l and Return Container Survey RecOImiddotd
Instruments Usedor SurllJsAction le~eIs Tile Radiation Safety Of11Cer should be immediately Dotilied when radiatioll or cootamination levels to which personnel DeteclorMeier No Make amp Model Serial No
Efficiencymay be exposed elteed tbe rollowing levels
Area
Restricted
Radiation Survey Conmlnatioll Surveys
50 mRlhr lOOODPMI10Ocm 2 2
BKG Cpm I Initials
Report Date Apri122 2012
Facility Columbus Diagnostic Imaging Columbus IN
State License Number Not Supplied USNRC License Number 13-24706-01
$ogrce Identification
Radionuc6de Cobalt-57 Calibrated Activity Date 090708 Calibrated Activity lOmCi Manufacturer Not Supplied Setia1 Number BM01-10 Model Number BMOl1008220102 Source Description Flood Source
Assay Results Counting Efficiency 0762 cpmdptn 1691543 cpmuCi MDA 102 dpm 78 cpm 000005 uCi Background time ofassay 351 cpm)
Grosscpm PtyWipe 347
Instrument used fot Analysis Ludlum Well Counter MN 2200 SIN 198663
Analysis Results Source is not leaking at this time
Removable contamination is lt0005 uCi
Next Leak Test Due
LeakTest Performed By
Analysis Performed By
IpoundI~ I Radiation Safety Officer (signature)
Report Date
Facility
State License Number USNRC License Number
Source Ideptification
Radionuclide Calibrated Activity Date Cahbrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
April 22 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137 080197 2198 uCi IPL 559-1627 RV-137-200V Dose CaliJIrator Vial Soutce
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm 000013 uCi 351
Grosscpm DryWtpe 347
Instrument used for Analysis Ludlum Well Counter MN2200 SIN PR 198663
Analysis Results Source is not leaking at this time Removable contamination is lt0005 uCi
Next Leak Test Due
Leak Test Pedormed By
Analysis Performed By
Officer (signature)
Medical Physics Survey Sealed Source Inventory
Facility Columbus Diagnostic Imaging Department Nuclear Medicine
Location Columbus Indiana Date July 18 2012
Nuclide
Cs-137
Cs-137
Cs-137
Cs-137
Co-57
1-----shy
Activity Date Model Serial No Type Location
RV-137shyDose Hot Lab
2198uCi 811197 559-162-7 Calibrator200V Vial
~r- shyRod Hot Lab
O1065uCi 811197 IPL 488-31-2
Button Ludlum Survey
10uCi 1295 None 4646 Meter
I I
Imiddot-~ -shy ~~~
Button Ludlum Survey
10 uCi 12195 None 4656 Meter
I ~
Flood Hot Lab 10mCi 9nlO8 BM01-10 BM011008220102
-I_-_0shyI
~~--
I
l-~- I
I
~-
1shy
~~~
- --~~ v_~
~-_
-=1
_ ~ ~~ L__ w_i
M_~ I
Present
No returned to
manufacturer No returned ~I
to manufacturer Yesexempt quantity to
be sold with camera
Yes exempt quantity to
be sold with camera
No returned to
manufacturer
I
I
I Comments Ambient Exposure Rate Survey of Sealed Sources ( Ludlum 14C SN141804 001 mRlhr)
Radiation Safety Officer
Provided by Advanced Medical Physics 16770 Cedar Creek Lane Inoblesville IN 46060middot 3172233022
i1J ( ~ J) 1)1shy
Bathroom0- ) IHot _ah
GJ I Ireg 15 i 7 I
(5)
c
-10
Lr~ Imaging
COLUMBUS DIAGNOSTIC IMAGING DAILY AREA SURVEYS
1 Dose Preparation
2 Dose Calibration J~ 3 Hot Trash cslfJ ) 4 Sealed Snurre Storage(tm ~ 5 Patient Injection Area 6 Gamma Camera 7 Computer Console
~ HJh~lPvl
[) 1m~5 () raquoJt ()o~r O-IS Hiab f$J( I-10 fin Jtj ~
(Zoo~fl~(
u- O~s0 -shy J L ~ltI ~1 C r1
MONTH YEAR
ITriaaer l evels-mRthr 20 20~10 05 10 HandsClothing Initials Comments
~ 1 2 6 7 8 1 ~ II J 1 ( t1- tt~ VIlJ
A
tl2 -w-- (L 0 ( 3 (J Jl 4 f 11 OWl ~ 5 I) r -0 1
6
7 8 9
10 ==t11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
jf =R311
__________ __ __
I I
I -r----~----------- shy
I I
I
I I
~~~~~6~~~--+----------~-
I I r-u=~-r-=middot-~=JiI-IImiddot----middotmiddot-middotmiddotmiddotmiddotr-middotmiddot-middot-middotmiddot--- --___+-__shy
NUCSl6AMMA ROOM
1--
i
bull ____laquo __bullbull___ I ___L
I I
II ~ ltgtlIe I I EGUIP I IBpoundJI I
i
I _l_____
~ I-Jltl
r
6
(J~Q
existing shelf
10
g
8
7
6
5
4
3
2
l
0-shy
PRELIMINARY PLANNfNG- ONLY
Wiscontit bull oquipmOllI 110 piiiCtcirti ~ Iiit
THIS LAYOUT WST BE APPROVED BEFORE RNAl llRAWlNGS CAN BE STARTED THANK yOU
PROJECT 1l11E
COLUMBUS DIAGNOSTIC IMAGING CUSTOMER PATNUCLEAR ROOM - MILLENIUM MG GE Project cqulppllat AII n- _ 1M atot laquoyeniIor 1 _ lhltIICOLUMBUS INDIANA Monager td~ ~ 01 -- II CW-rInstalrotion PATE P Iot h ~ rcIII ~ _ t ~SCHEME NO081NAQ80 DRAWH BY TlO DAli 07-22-~
Radioactive Wastl And Disposal Record
Policy and Procedure 1 Seal and slore radioactive waste containers behind adequate shielding 2 Indicate Container 10 andor Conlents (ie Hot Trash Sharps etc) 3 Radioactive waste should be held for at least 10 half-lives of the longest-lived radIoisOtope to be disposed 4 Monitor background and surface with a GM 5uNay Meter on its most sensitive scale without shielding prior to
disposal 5 Waste may be disp~d of if activity Is indistinguIshable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash
Survey Meter Code Brand Model Serial Number
1 1_ tI-~ ILLfVl Lle I L 11Ct- 2 rtrfl IUn ll(r Il ) 7)-)
0Lj 3$YJ
last AsS2V DJte of Waste to La lJisposed Isotope to be
of Dis osed of ~1l~~1~~~ 1 C-
o7h6 I~) o~ ~ j I S-ltC lt1A
~8u~Hit5Sltq~W ) 7 jj-) iiWif( r 9q ~~~IEP1fisect ~84~~ ~dJili(5)i-)Jamp --=T~Y 1Jifll-)~ltilli~~ ~lltY ~~iLl ~ r ))RT=_L 2 ~~LL~~Li2 L ~~ laquo44
-~hO~ - 1iI~l7-~pL-r~-h7 ~2 I-l-h 1~)1] r- I ---shy I~I P - -- v- -shy r-~--- I - ---~~
(Providcd by A~edMedical Physics 16771Hi rak Lanemiddot NoblesviIleIN 46060middot 3172n3022
Radioactive Materials Shipment Ret l and Return Container Survey RecOImiddotd
Instruments Usedor SurllJsAction le~eIs Tile Radiation Safety Of11Cer should be immediately Dotilied when radiatioll or cootamination levels to which personnel DeteclorMeier No Make amp Model Serial No
Efficiencymay be exposed elteed tbe rollowing levels
Area
Restricted
Radiation Survey Conmlnatioll Surveys
50 mRlhr lOOODPMI10Ocm 2 2
BKG Cpm I Initials
Report Date Apri122 2012
Facility Columbus Diagnostic Imaging Columbus IN
State License Number Not Supplied USNRC License Number 13-24706-01
$ogrce Identification
Radionuc6de Cobalt-57 Calibrated Activity Date 090708 Calibrated Activity lOmCi Manufacturer Not Supplied Setia1 Number BM01-10 Model Number BMOl1008220102 Source Description Flood Source
Assay Results Counting Efficiency 0762 cpmdptn 1691543 cpmuCi MDA 102 dpm 78 cpm 000005 uCi Background time ofassay 351 cpm)
Grosscpm PtyWipe 347
Instrument used fot Analysis Ludlum Well Counter MN 2200 SIN 198663
Analysis Results Source is not leaking at this time
Removable contamination is lt0005 uCi
Next Leak Test Due
LeakTest Performed By
Analysis Performed By
IpoundI~ I Radiation Safety Officer (signature)
Report Date
Facility
State License Number USNRC License Number
Source Ideptification
Radionuclide Calibrated Activity Date Cahbrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
April 22 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137 080197 2198 uCi IPL 559-1627 RV-137-200V Dose CaliJIrator Vial Soutce
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm 000013 uCi 351
Grosscpm DryWtpe 347
Instrument used for Analysis Ludlum Well Counter MN2200 SIN PR 198663
Analysis Results Source is not leaking at this time Removable contamination is lt0005 uCi
Next Leak Test Due
Leak Test Pedormed By
Analysis Performed By
Officer (signature)
i1J ( ~ J) 1)1shy
Bathroom0- ) IHot _ah
GJ I Ireg 15 i 7 I
(5)
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Lr~ Imaging
COLUMBUS DIAGNOSTIC IMAGING DAILY AREA SURVEYS
1 Dose Preparation
2 Dose Calibration J~ 3 Hot Trash cslfJ ) 4 Sealed Snurre Storage(tm ~ 5 Patient Injection Area 6 Gamma Camera 7 Computer Console
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[) 1m~5 () raquoJt ()o~r O-IS Hiab f$J( I-10 fin Jtj ~
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MONTH YEAR
ITriaaer l evels-mRthr 20 20~10 05 10 HandsClothing Initials Comments
~ 1 2 6 7 8 1 ~ II J 1 ( t1- tt~ VIlJ
A
tl2 -w-- (L 0 ( 3 (J Jl 4 f 11 OWl ~ 5 I) r -0 1
6
7 8 9
10 ==t11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
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__________ __ __
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NUCSl6AMMA ROOM
1--
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bull ____laquo __bullbull___ I ___L
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II ~ ltgtlIe I I EGUIP I IBpoundJI I
i
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~ I-Jltl
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6
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existing shelf
10
g
8
7
6
5
4
3
2
l
0-shy
PRELIMINARY PLANNfNG- ONLY
Wiscontit bull oquipmOllI 110 piiiCtcirti ~ Iiit
THIS LAYOUT WST BE APPROVED BEFORE RNAl llRAWlNGS CAN BE STARTED THANK yOU
PROJECT 1l11E
COLUMBUS DIAGNOSTIC IMAGING CUSTOMER PATNUCLEAR ROOM - MILLENIUM MG GE Project cqulppllat AII n- _ 1M atot laquoyeniIor 1 _ lhltIICOLUMBUS INDIANA Monager td~ ~ 01 -- II CW-rInstalrotion PATE P Iot h ~ rcIII ~ _ t ~SCHEME NO081NAQ80 DRAWH BY TlO DAli 07-22-~
Radioactive Wastl And Disposal Record
Policy and Procedure 1 Seal and slore radioactive waste containers behind adequate shielding 2 Indicate Container 10 andor Conlents (ie Hot Trash Sharps etc) 3 Radioactive waste should be held for at least 10 half-lives of the longest-lived radIoisOtope to be disposed 4 Monitor background and surface with a GM 5uNay Meter on its most sensitive scale without shielding prior to
disposal 5 Waste may be disp~d of if activity Is indistinguIshable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash
Survey Meter Code Brand Model Serial Number
1 1_ tI-~ ILLfVl Lle I L 11Ct- 2 rtrfl IUn ll(r Il ) 7)-)
0Lj 3$YJ
last AsS2V DJte of Waste to La lJisposed Isotope to be
of Dis osed of ~1l~~1~~~ 1 C-
o7h6 I~) o~ ~ j I S-ltC lt1A
~8u~Hit5Sltq~W ) 7 jj-) iiWif( r 9q ~~~IEP1fisect ~84~~ ~dJili(5)i-)Jamp --=T~Y 1Jifll-)~ltilli~~ ~lltY ~~iLl ~ r ))RT=_L 2 ~~LL~~Li2 L ~~ laquo44
-~hO~ - 1iI~l7-~pL-r~-h7 ~2 I-l-h 1~)1] r- I ---shy I~I P - -- v- -shy r-~--- I - ---~~
(Providcd by A~edMedical Physics 16771Hi rak Lanemiddot NoblesviIleIN 46060middot 3172n3022
Radioactive Materials Shipment Ret l and Return Container Survey RecOImiddotd
Instruments Usedor SurllJsAction le~eIs Tile Radiation Safety Of11Cer should be immediately Dotilied when radiatioll or cootamination levels to which personnel DeteclorMeier No Make amp Model Serial No
Efficiencymay be exposed elteed tbe rollowing levels
Area
Restricted
Radiation Survey Conmlnatioll Surveys
50 mRlhr lOOODPMI10Ocm 2 2
BKG Cpm I Initials
Report Date Apri122 2012
Facility Columbus Diagnostic Imaging Columbus IN
State License Number Not Supplied USNRC License Number 13-24706-01
$ogrce Identification
Radionuc6de Cobalt-57 Calibrated Activity Date 090708 Calibrated Activity lOmCi Manufacturer Not Supplied Setia1 Number BM01-10 Model Number BMOl1008220102 Source Description Flood Source
Assay Results Counting Efficiency 0762 cpmdptn 1691543 cpmuCi MDA 102 dpm 78 cpm 000005 uCi Background time ofassay 351 cpm)
Grosscpm PtyWipe 347
Instrument used fot Analysis Ludlum Well Counter MN 2200 SIN 198663
Analysis Results Source is not leaking at this time
Removable contamination is lt0005 uCi
Next Leak Test Due
LeakTest Performed By
Analysis Performed By
IpoundI~ I Radiation Safety Officer (signature)
Report Date
Facility
State License Number USNRC License Number
Source Ideptification
Radionuclide Calibrated Activity Date Cahbrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
April 22 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137 080197 2198 uCi IPL 559-1627 RV-137-200V Dose CaliJIrator Vial Soutce
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm 000013 uCi 351
Grosscpm DryWtpe 347
Instrument used for Analysis Ludlum Well Counter MN2200 SIN PR 198663
Analysis Results Source is not leaking at this time Removable contamination is lt0005 uCi
Next Leak Test Due
Leak Test Pedormed By
Analysis Performed By
Officer (signature)
__________ __ __
I I
I -r----~----------- shy
I I
I
I I
~~~~~6~~~--+----------~-
I I r-u=~-r-=middot-~=JiI-IImiddot----middotmiddot-middotmiddotmiddotmiddotr-middotmiddot-middot-middotmiddot--- --___+-__shy
NUCSl6AMMA ROOM
1--
i
bull ____laquo __bullbull___ I ___L
I I
II ~ ltgtlIe I I EGUIP I IBpoundJI I
i
I _l_____
~ I-Jltl
r
6
(J~Q
existing shelf
10
g
8
7
6
5
4
3
2
l
0-shy
PRELIMINARY PLANNfNG- ONLY
Wiscontit bull oquipmOllI 110 piiiCtcirti ~ Iiit
THIS LAYOUT WST BE APPROVED BEFORE RNAl llRAWlNGS CAN BE STARTED THANK yOU
PROJECT 1l11E
COLUMBUS DIAGNOSTIC IMAGING CUSTOMER PATNUCLEAR ROOM - MILLENIUM MG GE Project cqulppllat AII n- _ 1M atot laquoyeniIor 1 _ lhltIICOLUMBUS INDIANA Monager td~ ~ 01 -- II CW-rInstalrotion PATE P Iot h ~ rcIII ~ _ t ~SCHEME NO081NAQ80 DRAWH BY TlO DAli 07-22-~
Radioactive Wastl And Disposal Record
Policy and Procedure 1 Seal and slore radioactive waste containers behind adequate shielding 2 Indicate Container 10 andor Conlents (ie Hot Trash Sharps etc) 3 Radioactive waste should be held for at least 10 half-lives of the longest-lived radIoisOtope to be disposed 4 Monitor background and surface with a GM 5uNay Meter on its most sensitive scale without shielding prior to
disposal 5 Waste may be disp~d of if activity Is indistinguIshable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash
Survey Meter Code Brand Model Serial Number
1 1_ tI-~ ILLfVl Lle I L 11Ct- 2 rtrfl IUn ll(r Il ) 7)-)
0Lj 3$YJ
last AsS2V DJte of Waste to La lJisposed Isotope to be
of Dis osed of ~1l~~1~~~ 1 C-
o7h6 I~) o~ ~ j I S-ltC lt1A
~8u~Hit5Sltq~W ) 7 jj-) iiWif( r 9q ~~~IEP1fisect ~84~~ ~dJili(5)i-)Jamp --=T~Y 1Jifll-)~ltilli~~ ~lltY ~~iLl ~ r ))RT=_L 2 ~~LL~~Li2 L ~~ laquo44
-~hO~ - 1iI~l7-~pL-r~-h7 ~2 I-l-h 1~)1] r- I ---shy I~I P - -- v- -shy r-~--- I - ---~~
(Providcd by A~edMedical Physics 16771Hi rak Lanemiddot NoblesviIleIN 46060middot 3172n3022
Radioactive Materials Shipment Ret l and Return Container Survey RecOImiddotd
Instruments Usedor SurllJsAction le~eIs Tile Radiation Safety Of11Cer should be immediately Dotilied when radiatioll or cootamination levels to which personnel DeteclorMeier No Make amp Model Serial No
Efficiencymay be exposed elteed tbe rollowing levels
Area
Restricted
Radiation Survey Conmlnatioll Surveys
50 mRlhr lOOODPMI10Ocm 2 2
BKG Cpm I Initials
Report Date Apri122 2012
Facility Columbus Diagnostic Imaging Columbus IN
State License Number Not Supplied USNRC License Number 13-24706-01
$ogrce Identification
Radionuc6de Cobalt-57 Calibrated Activity Date 090708 Calibrated Activity lOmCi Manufacturer Not Supplied Setia1 Number BM01-10 Model Number BMOl1008220102 Source Description Flood Source
Assay Results Counting Efficiency 0762 cpmdptn 1691543 cpmuCi MDA 102 dpm 78 cpm 000005 uCi Background time ofassay 351 cpm)
Grosscpm PtyWipe 347
Instrument used fot Analysis Ludlum Well Counter MN 2200 SIN 198663
Analysis Results Source is not leaking at this time
Removable contamination is lt0005 uCi
Next Leak Test Due
LeakTest Performed By
Analysis Performed By
IpoundI~ I Radiation Safety Officer (signature)
Report Date
Facility
State License Number USNRC License Number
Source Ideptification
Radionuclide Calibrated Activity Date Cahbrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
April 22 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137 080197 2198 uCi IPL 559-1627 RV-137-200V Dose CaliJIrator Vial Soutce
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm 000013 uCi 351
Grosscpm DryWtpe 347
Instrument used for Analysis Ludlum Well Counter MN2200 SIN PR 198663
Analysis Results Source is not leaking at this time Removable contamination is lt0005 uCi
Next Leak Test Due
Leak Test Pedormed By
Analysis Performed By
Officer (signature)
~ I-Jltl
r
6
(J~Q
existing shelf
10
g
8
7
6
5
4
3
2
l
0-shy
PRELIMINARY PLANNfNG- ONLY
Wiscontit bull oquipmOllI 110 piiiCtcirti ~ Iiit
THIS LAYOUT WST BE APPROVED BEFORE RNAl llRAWlNGS CAN BE STARTED THANK yOU
PROJECT 1l11E
COLUMBUS DIAGNOSTIC IMAGING CUSTOMER PATNUCLEAR ROOM - MILLENIUM MG GE Project cqulppllat AII n- _ 1M atot laquoyeniIor 1 _ lhltIICOLUMBUS INDIANA Monager td~ ~ 01 -- II CW-rInstalrotion PATE P Iot h ~ rcIII ~ _ t ~SCHEME NO081NAQ80 DRAWH BY TlO DAli 07-22-~
Radioactive Wastl And Disposal Record
Policy and Procedure 1 Seal and slore radioactive waste containers behind adequate shielding 2 Indicate Container 10 andor Conlents (ie Hot Trash Sharps etc) 3 Radioactive waste should be held for at least 10 half-lives of the longest-lived radIoisOtope to be disposed 4 Monitor background and surface with a GM 5uNay Meter on its most sensitive scale without shielding prior to
disposal 5 Waste may be disp~d of if activity Is indistinguIshable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash
Survey Meter Code Brand Model Serial Number
1 1_ tI-~ ILLfVl Lle I L 11Ct- 2 rtrfl IUn ll(r Il ) 7)-)
0Lj 3$YJ
last AsS2V DJte of Waste to La lJisposed Isotope to be
of Dis osed of ~1l~~1~~~ 1 C-
o7h6 I~) o~ ~ j I S-ltC lt1A
~8u~Hit5Sltq~W ) 7 jj-) iiWif( r 9q ~~~IEP1fisect ~84~~ ~dJili(5)i-)Jamp --=T~Y 1Jifll-)~ltilli~~ ~lltY ~~iLl ~ r ))RT=_L 2 ~~LL~~Li2 L ~~ laquo44
-~hO~ - 1iI~l7-~pL-r~-h7 ~2 I-l-h 1~)1] r- I ---shy I~I P - -- v- -shy r-~--- I - ---~~
(Providcd by A~edMedical Physics 16771Hi rak Lanemiddot NoblesviIleIN 46060middot 3172n3022
Radioactive Materials Shipment Ret l and Return Container Survey RecOImiddotd
Instruments Usedor SurllJsAction le~eIs Tile Radiation Safety Of11Cer should be immediately Dotilied when radiatioll or cootamination levels to which personnel DeteclorMeier No Make amp Model Serial No
Efficiencymay be exposed elteed tbe rollowing levels
Area
Restricted
Radiation Survey Conmlnatioll Surveys
50 mRlhr lOOODPMI10Ocm 2 2
BKG Cpm I Initials
Report Date Apri122 2012
Facility Columbus Diagnostic Imaging Columbus IN
State License Number Not Supplied USNRC License Number 13-24706-01
$ogrce Identification
Radionuc6de Cobalt-57 Calibrated Activity Date 090708 Calibrated Activity lOmCi Manufacturer Not Supplied Setia1 Number BM01-10 Model Number BMOl1008220102 Source Description Flood Source
Assay Results Counting Efficiency 0762 cpmdptn 1691543 cpmuCi MDA 102 dpm 78 cpm 000005 uCi Background time ofassay 351 cpm)
Grosscpm PtyWipe 347
Instrument used fot Analysis Ludlum Well Counter MN 2200 SIN 198663
Analysis Results Source is not leaking at this time
Removable contamination is lt0005 uCi
Next Leak Test Due
LeakTest Performed By
Analysis Performed By
IpoundI~ I Radiation Safety Officer (signature)
Report Date
Facility
State License Number USNRC License Number
Source Ideptification
Radionuclide Calibrated Activity Date Cahbrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
April 22 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137 080197 2198 uCi IPL 559-1627 RV-137-200V Dose CaliJIrator Vial Soutce
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm 000013 uCi 351
Grosscpm DryWtpe 347
Instrument used for Analysis Ludlum Well Counter MN2200 SIN PR 198663
Analysis Results Source is not leaking at this time Removable contamination is lt0005 uCi
Next Leak Test Due
Leak Test Pedormed By
Analysis Performed By
Officer (signature)
Radioactive Wastl And Disposal Record
Policy and Procedure 1 Seal and slore radioactive waste containers behind adequate shielding 2 Indicate Container 10 andor Conlents (ie Hot Trash Sharps etc) 3 Radioactive waste should be held for at least 10 half-lives of the longest-lived radIoisOtope to be disposed 4 Monitor background and surface with a GM 5uNay Meter on its most sensitive scale without shielding prior to
disposal 5 Waste may be disp~d of if activity Is indistinguIshable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash
Survey Meter Code Brand Model Serial Number
1 1_ tI-~ ILLfVl Lle I L 11Ct- 2 rtrfl IUn ll(r Il ) 7)-)
0Lj 3$YJ
last AsS2V DJte of Waste to La lJisposed Isotope to be
of Dis osed of ~1l~~1~~~ 1 C-
o7h6 I~) o~ ~ j I S-ltC lt1A
~8u~Hit5Sltq~W ) 7 jj-) iiWif( r 9q ~~~IEP1fisect ~84~~ ~dJili(5)i-)Jamp --=T~Y 1Jifll-)~ltilli~~ ~lltY ~~iLl ~ r ))RT=_L 2 ~~LL~~Li2 L ~~ laquo44
-~hO~ - 1iI~l7-~pL-r~-h7 ~2 I-l-h 1~)1] r- I ---shy I~I P - -- v- -shy r-~--- I - ---~~
(Providcd by A~edMedical Physics 16771Hi rak Lanemiddot NoblesviIleIN 46060middot 3172n3022
Radioactive Materials Shipment Ret l and Return Container Survey RecOImiddotd
Instruments Usedor SurllJsAction le~eIs Tile Radiation Safety Of11Cer should be immediately Dotilied when radiatioll or cootamination levels to which personnel DeteclorMeier No Make amp Model Serial No
Efficiencymay be exposed elteed tbe rollowing levels
Area
Restricted
Radiation Survey Conmlnatioll Surveys
50 mRlhr lOOODPMI10Ocm 2 2
BKG Cpm I Initials
Report Date Apri122 2012
Facility Columbus Diagnostic Imaging Columbus IN
State License Number Not Supplied USNRC License Number 13-24706-01
$ogrce Identification
Radionuc6de Cobalt-57 Calibrated Activity Date 090708 Calibrated Activity lOmCi Manufacturer Not Supplied Setia1 Number BM01-10 Model Number BMOl1008220102 Source Description Flood Source
Assay Results Counting Efficiency 0762 cpmdptn 1691543 cpmuCi MDA 102 dpm 78 cpm 000005 uCi Background time ofassay 351 cpm)
Grosscpm PtyWipe 347
Instrument used fot Analysis Ludlum Well Counter MN 2200 SIN 198663
Analysis Results Source is not leaking at this time
Removable contamination is lt0005 uCi
Next Leak Test Due
LeakTest Performed By
Analysis Performed By
IpoundI~ I Radiation Safety Officer (signature)
Report Date
Facility
State License Number USNRC License Number
Source Ideptification
Radionuclide Calibrated Activity Date Cahbrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
April 22 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137 080197 2198 uCi IPL 559-1627 RV-137-200V Dose CaliJIrator Vial Soutce
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm 000013 uCi 351
Grosscpm DryWtpe 347
Instrument used for Analysis Ludlum Well Counter MN2200 SIN PR 198663
Analysis Results Source is not leaking at this time Removable contamination is lt0005 uCi
Next Leak Test Due
Leak Test Pedormed By
Analysis Performed By
Officer (signature)
Radioactive Materials Shipment Ret l and Return Container Survey RecOImiddotd
Instruments Usedor SurllJsAction le~eIs Tile Radiation Safety Of11Cer should be immediately Dotilied when radiatioll or cootamination levels to which personnel DeteclorMeier No Make amp Model Serial No
Efficiencymay be exposed elteed tbe rollowing levels
Area
Restricted
Radiation Survey Conmlnatioll Surveys
50 mRlhr lOOODPMI10Ocm 2 2
BKG Cpm I Initials
Report Date Apri122 2012
Facility Columbus Diagnostic Imaging Columbus IN
State License Number Not Supplied USNRC License Number 13-24706-01
$ogrce Identification
Radionuc6de Cobalt-57 Calibrated Activity Date 090708 Calibrated Activity lOmCi Manufacturer Not Supplied Setia1 Number BM01-10 Model Number BMOl1008220102 Source Description Flood Source
Assay Results Counting Efficiency 0762 cpmdptn 1691543 cpmuCi MDA 102 dpm 78 cpm 000005 uCi Background time ofassay 351 cpm)
Grosscpm PtyWipe 347
Instrument used fot Analysis Ludlum Well Counter MN 2200 SIN 198663
Analysis Results Source is not leaking at this time
Removable contamination is lt0005 uCi
Next Leak Test Due
LeakTest Performed By
Analysis Performed By
IpoundI~ I Radiation Safety Officer (signature)
Report Date
Facility
State License Number USNRC License Number
Source Ideptification
Radionuclide Calibrated Activity Date Cahbrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
April 22 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137 080197 2198 uCi IPL 559-1627 RV-137-200V Dose CaliJIrator Vial Soutce
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm 000013 uCi 351
Grosscpm DryWtpe 347
Instrument used for Analysis Ludlum Well Counter MN2200 SIN PR 198663
Analysis Results Source is not leaking at this time Removable contamination is lt0005 uCi
Next Leak Test Due
Leak Test Pedormed By
Analysis Performed By
Officer (signature)
Report Date Apri122 2012
Facility Columbus Diagnostic Imaging Columbus IN
State License Number Not Supplied USNRC License Number 13-24706-01
$ogrce Identification
Radionuc6de Cobalt-57 Calibrated Activity Date 090708 Calibrated Activity lOmCi Manufacturer Not Supplied Setia1 Number BM01-10 Model Number BMOl1008220102 Source Description Flood Source
Assay Results Counting Efficiency 0762 cpmdptn 1691543 cpmuCi MDA 102 dpm 78 cpm 000005 uCi Background time ofassay 351 cpm)
Grosscpm PtyWipe 347
Instrument used fot Analysis Ludlum Well Counter MN 2200 SIN 198663
Analysis Results Source is not leaking at this time
Removable contamination is lt0005 uCi
Next Leak Test Due
LeakTest Performed By
Analysis Performed By
IpoundI~ I Radiation Safety Officer (signature)
Report Date
Facility
State License Number USNRC License Number
Source Ideptification
Radionuclide Calibrated Activity Date Cahbrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
April 22 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137 080197 2198 uCi IPL 559-1627 RV-137-200V Dose CaliJIrator Vial Soutce
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm 000013 uCi 351
Grosscpm DryWtpe 347
Instrument used for Analysis Ludlum Well Counter MN2200 SIN PR 198663
Analysis Results Source is not leaking at this time Removable contamination is lt0005 uCi
Next Leak Test Due
Leak Test Pedormed By
Analysis Performed By
Officer (signature)
Report Date
Facility
State License Number USNRC License Number
Source Ideptification
Radionuclide Calibrated Activity Date Cahbrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
April 22 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137 080197 2198 uCi IPL 559-1627 RV-137-200V Dose CaliJIrator Vial Soutce
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm 000013 uCi 351
Grosscpm DryWtpe 347
Instrument used for Analysis Ludlum Well Counter MN2200 SIN PR 198663
Analysis Results Source is not leaking at this time Removable contamination is lt0005 uCi
Next Leak Test Due
Leak Test Pedormed By
Analysis Performed By
Officer (signature)