ii$(). certificate i:r mlinagemp.rlt in · u.s. nrc region i attn: elizabeth ullrich 2100...
TRANSCRIPT
la
EXPIRES 11JJ112013US NUClpoundAR REGULATORY COMMISSKlN APlftoVED BY OMS NO 31SQOO~ estmjjlOO cultlcn pf~ 10 wmlll willllhs mandslOly ~1lII01 ~uesl O mimJlls This sutrnmsl is USId b) NRC a pM lll1he lJllls fur il$ 41l1rrimliorgt lhiit he released ref ulltl~ II$() Slrd COIlIlllllIlgt 1I1ril1J boolm iil8Mlli ll1la SeMOO$ ampfilii (rmiddot5 gt53) US Nudeat RegulalJrt CemtnlSSIelR IX 2U6551~Ol Ir by iltmet e-mail oliTfoc1ildlR~go~ jjn~ II) Hl OIfioo ofCERTIFICATE OF DISPOSITION OF MATERIALS 1nI~~n ~rld fllJgUl4Iif) MI$ NIilOOgt1l202 1315QOO21l) 0IfDl rA MlInagemprlt lIil lloJd(jt1 lIigthnJrm DC 2000) 11 lT11lllnr ulllld In imp111 9r i~h(lli tdilldlrm doe rol (l1gt bull rurrently llIid OMB crolra _ber the NFl (IV ~I roneoo (T SPllflt and s parson Is nQ Illlftcent 1(1 re$j7m to IIl) r~linr~
OOCKpoundT NIJM8ERLICENSEE NAME AND AOO~ESS
00-708Bi()R~li)l Inc 5 Science Park at Yale New Haven CI 0651 t August 11 2017
LICENSE NUMBER
A LICENSE STATUS C~k the appropriate box)
This license has expired 0 This l~nse has not yet expired please terminate it
B OjSPOSAl OF RADIOACTNE MATERIAL (Checf the SpptfJprlfJW bOlffiS and compJeti as necessary If adrJitkmaJ sjR1e is needed provide IJUflchmenrs)
The licensee or any individual executing this certificate on behalf 01 the licensee certifies that
1 No radioactive materials have ever been procured Of possessed by the licensee under this license
2 AJI activities authorized by this license have ceased and all radioactive materials procured andor DogtsessE~ by the licensee under this license number cited above have ooen disposed of iii the foRowing marmeL
B Transfer of radioactive materials to the ifoonsee listed below
Dipcgtsai of radioactive materials
1 Directly by the licensee
2 By nceflsed disposal site
o 3 By waste contractor
Chase Environmental Group (nc
c All radioactive materials have been removed such that any remaining residual radiollLtivity is wlthin the limits of 10 CFR Part 20 Subpart E and is ALARA
C SURVEYS PERFORMED AND REPORTED
o 1 A ra(jiatioo survey wall conducted by the licensee The SUVflY confirms
a the absence of licensed radioactive materials
b thaI any ~mainlng residual radiltlactivity is within the limis of 10 CFR 20 Subpal1 E and is ALARA
2 A copy of the radiation survey results
o a is attached or 0 b is not attached Pro~de explanatio1) or C was forwarded to NRC on
3 A radiation survey is not required as only sealed sources were ever ~JOltsessed under this license and
a The results of the laleslleak test are attached andfol D b No sources have ever been identified
The person to be contactedreg~rding the infonnalion provided on this form KMIE E lLEfHONE (~M~ AI$~) [MAlL M)i)HtiS5
ipmkarzl[l)gmaiLcomIzabcia Puskart Radiation Safety Oftlcr tS601231-7S0R ~llll Mum ()()If~Wlln(dlOO I~jlll jtll toi Ii lo
Ronald W Lennox clo OiL Medjcal Partners lQ55 W$hington Blvd StltHnford CT ()6901
C CERTIFYING OFF I CERTIFY UNOER PENALTY OF PERJURY lHA1THE FOREl101MG TRUE AND CORREcT
IAL
I I 5IGNgtTUFE ~
ARMING FALSE STATEMENTS IN THI8 CeRTlFtCATE MAY Be SUBJICT 10 eML ANDOR nONS REQUIRE THAT USMIS~0ft8 TO TKE NRC BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPeCT HI UAC l OFFENSE TO MAKE A LFULlYFALSE STATEMENT OR REPRESENTATION TO ANY OEPARllitENT M AGeNCY OF THE UMTEtI STATES AS TO ANY filA TIER WIDlIN ITS JURISDICTION_
S g0 J5 if NMSSRGN1 MITERIALS-002
Bio bullbullbull Reli~i
5 Science Park at Yale bull New Haven CT 06511 Tel (203) 785-9282 bull Fax (203) 785-8058
January 22 2012
US NRC Region I Attn Elizabeth Ullrich 2100 Renaissance Boulevard Renaissance Park King of Prussia P A 19406 610-337-5000
Re BioRelix 5 Science Park NRC License No 06-31263-01 CT DEEP Permit No 01576 New Haven CT 06511
Introduction The purpose of this document is to provide details and supporting information for the terminating the radiation use license for BioRelix Inc located at 5 Science Park New Haven Connecticut The information is presented to satisfy the US Nuclear Regulatory Commission in the license termination
On October 112012 a final shipment of three drums containing all remaining radioactive materials was shipped under uniform low-level radioactive waste manifest A copy of the manifest is enclosed
On October 15 2012 a survey was conducted in the laboratories of BioRelix for the purpose of termination of the companys radioactive use license The permit for radiation use at BioRelix had been issued for the use of P32 P33 H3 S35 and 1125 Survey was performed by
Safdoc Systems LLC Kenneth S Weinberg PhD 20 Thompson Court Stoughton MA 02072 SafdocSysaolcom PhoneFax 7813413893
A survey of all the equipment hoods benches and sinks in the following rooms 309 316 318 319 321 was conducted A sketch showing the radioactive use locations and sample locations is enclosed The survey included Room 309 that had previously been used to store radioactive waste for disposal
An initial survey was conducted using a handheld Geiger-Muller with a pancake probe (Ludlum Measurements Inc Model 3 SN 244273 and pancake probe Model 44-9 SN PR257735 both calibrated on May 21 2012) The areas were slowly scanned so that
each location had a two second observation interval No radioactivity was detected to have been present To further characterize any potential residual radioactivity wipe samples were collected A total of74 wipe samples as well as field blanks and quality assurance and quality control (QAlQC) samples were counted in a scintillation counter (PerkinElmer TriCarb 2900TR SN 432701 calibrated October 2012) Each wipe sample covered an area of 100 cm2 were counted for one minute Since the presence of residual H3 cannot be determined using the GM tube the use of wipe samples will confirm the absence of this isotope as well as the absence of any beta particles from the other isotopes used in the laboratory The scintillation counter results are enclosed
Observations Samples 72 through 74 represent the control and QAIQC samples The results of all wipe samples except for sample No 39 were consistent as the background samples Sample No39 was collected from inside of a piece of equipment in Room 319 on Bench 12 This sample was several orders of magnitude higher than all of the other samples collected On October 182012 the equipment was sampled a second time The second sample event included a control sample and two samples from within the equipment The results of the second samples found count levels consistent with background A copy of the results is enclosed
Results A total of72 wipe samples each covering 100 cm2 three field blanks and QAlQC samples were analyzed in a PerkinElmer TriCarb 2900TR scintillation counter (SN 432701 calibrated October 2012) All results on a first run of samples fell within the range of background as shown by the controls and QAlQC samples One sample No39 was found to be above background The sample location No 39 was sampled again splitting the area in half and the results demonstrated that the equipment met the criteria ofcleanliness as demonstrated by a reading consistent with background similar to the previous 69 samples collected in the BioRelix laboratories To reiterate NUREG 1570 NUREG 1757 Consolidated NMSS Decommissioning Guidance Vol 2 and Subpart E of 10 CFR Part 20 was consulted in evaluating this data and it was established that the wipe samples values were below screening values for building surface contamination for betagamma emitters However because ofthe nature of the isotopes used and the failure to detect any removable H3 there was no rational for the use ofadditional techniques for characterization such as a proportional counter to further evaluate the area The results of the surveys for removable contamination fixed surface contamination and radiation dose rates qualify the facilities for release for unrestricted use per 10 CFR 20 subpart E Radiological Criteria for License Termination and the Nuclear Regulatory Commission (NRC) document entitled Guidelines for Decontamination of Facilities and Equipment Prior to Release for Unrestricted Use Table 1 A copy of the signed CT DEEP Radioactive Materials and Industrial X-Ray Device Registration (termination) form is enclosed
Respectfully Submitted
---r- 1rY~ (hlt- f- -c v
Izabela J Puskarz Radiation Safety Officer BioRelix Inc
Enclosures cc CT DEEP - Central Pennit Processing Unit Attn Andrew Zwick 79 Elm Street Hartford CT 06106 860-424-3035
gt
tlRCFCfIIlUgt40 15 ftPP=R-HNoEAM) FACILITY EHPIgtat II) lit IMC t5QJUrKlS4M PAGef_l~ 8~tI~
ae~QoupInI NtA MMfOIIWM~ OF _1~ (IJoo _ _ DIfI
UNIFORM LOW-LEVl5L 1WlI0ACnVE 1145cWaaenscn Court XI~ - --1-JIG~ WASTEMANlFSST L4IiIlyeniIeKY 40299 -shy ~(amp) ro-201~middot28S
SliIlPlMG PNa it---~ ~ -_ ~_WtJlY_ ~ t_~_E~_~
T-KY(l(G112 rroxCO Inc RiCkLcw 8OC-424-Q300 COCTACT 1aIAItflltt 109 F1intRoad IT~ Nlimber(1Dcbde _ COde)
~ Janet eater BliS25G4593 Oak RidQe IN3183O 886-4S2-S532 CHEMTREC IB~ NAUENJOAI)f)RESS reAI[)~
-~--DaSeo
Ilf~WC~ III01IIUIIIIlERCII iSJ Transpollaltln Co tnc NJD0716299i5
xJ YES _1OIlH1IID 3 PO Boic i 69shy lIH_ampWE 10Qetilication NO TIIS_ Woortsawn NJ 0SEl9S 1011112012 ~~___Dl___W-C~
lIIIPIonCI [ lYES m_JiIWIIIR CCNTAC1 lEllPHOIElII ~~_~~~Ml - [X J NO Kevln Elder 866-169-2741 __~~__~-n___
---shy ~~t~ OiltTE -l)~~~~ TITIE tIPJE CU-flttshy bull Ggt~ r~I~ (C-lt-t2
1fl1amp DEPMJIEN QIl_A11ltlfI~ i2 110 I~ 5 II 11 -shy 1IIlD ~_~___UIID_
DotWlil -shy ~- - TOTAlPAC~ IJiWSCO _ _Of -It__ - ~1aIM _1laIleS IICTIIffi IN UBq CtiOCSS m3 -UN2910 Ratlloadive material ~ package- IJIA NIA SoJidIOxfde H--3 P-32 P-33 536E+02 NlA D212 To-CT-E-1~-eD4
limited quantity ofmalEftal T
On~ drum with DAW far dlsllO$al UN2910 RadioacWe materia~ exceptied package- NtA NlA SOlidOxide H--3 P-32 P-33 S~E+02 NfA 1)212 TO-CT-amp12-005 limiied qlisnlity of mafamprilaJ 7
One dlllOl wlth CAW dlarps foe disposalINon oar Regltlated Material NlA NlA liquidlOraquoie P-32 7nE+OO NlA 0114 lO--L$-E-12e06
One drum wittt ampQUeolS$ lIalAd l1on-haz ISV fer dIsc )Sal ~ -
GElMratar CeTtificatioo Satement tnre cansituenl$ of1t1e Waste mafifested herein are 1rnown to tile getlererlor Theft are no EPA ReM patboael1icor o1iIer hazards pmenhlUlElrthan those specilleally listed on the Foms541
1p~q ez S~ ~ PrlJ1tnams ---shy ___~natutle __ ___ _ _ _
OOIgtlSIGNEE QRI(JI1tW MUST ACCOMPAlNWASTE IN rWINlm
~_1lOtoIIoI_
INU_
srewNUClEAAIlATlORlAl(a _ - -shyUNIFORM LOWEVEL RADIOACTIVE -shy _Ill
_ lJ2S3shy t U-235 Pu TOTAl TQ2012286
WASTe MANIFEST 3 0538 no ta-COtnA1tIERANOWA$IEDESCRrFTlON PAGE 1 OF I PAGiSrm
ACiTMlY SOORCpound SHfPfER WM AU1-UOIlIleS T lRInJIpound T Co14 I Tc4 I-m Im Chase E~v GrDUJ)
1085+03 MflQ TS61E+02f NP I NIP NIP NIP fsitFPElR 10 KJbllBER 290E+01 mCl 1976amp001 1 NJA
DlSPOSAL()OHAIIampOEBCRIPTlON ~I5SCaJPTlO~ 1OR5Itf WASTETlPE 1N00NTJiIIMSR shySccmAIIIER ~ 1 II
s_ shy ~IIS9CIIIPT1OH ~~- 161Ia~_
~ -shy -shy -shy - n_ ~ shy - ~---- shy- _M - lIId - shy - - - p-----shy -shy-shy 1t (m3) - 11shy -shy - _-r - --shy _ ~~ tkrl~ shy - - IIoo_ Em --shy 11 01 Nuclrae MBa mCI
_0 TO-Cfe12-604 0212 lt5(10 lt361amp6 lt367E-5 39 l212 jeD OxidaINP NP K-S 242aQ2 Gs~E+OD NfA
1159 Pa2 18QE+02 486E+OD
4G F-33 1tgtlE+a2 3tItaOl
P~t1claJ 53SE+02 1A5E+01TQCT-E-12-605 4 0212 lt500 lt3S1E-S lt367amp0 39 0212 100 NP fiS 24~ eB3E+OO NfA1159
Jt f32 1a1E+02 4IIBEoo p~ 114EltfOli 301E+C0
~1ltane1Cllil1 s3tJE+02 ~ TQlSE-12-606 A of14 0$00 lt367E-6 lt3amp75-$ 2559 0114 100 0lddeNP If P-S2 771E+OO 210amp011159 3 ~I Water IIOn-haz lJN Pa~tofal 777E+W 2fQen1
yen p 10P
~1__~_lltIt_
~---tWA__ ____shy -__shyI-o__n____
JItshy ~- _shy r--~1-s----_~11~1 ~1t---_lII__ p_ ~~ --shy shy ~ shy~ --shy ~ -_ 0shy pshy trt c~ t-Dd -shy - _shy shy DO_10- _-shy _shy -shy ~-
- - lItIIIR1rDr
01 __ -~-- shy ta-shy _JrIIII --_ ia2-1IojI -shy _1 -shy shyDIItiur shy 1--shy --- ~ ~ -shy IIshy shy~~clhll - 10- __ --shy ~- ~HIDOI _ T~U -shy-- _shy shy ~~- ~0IIMtt ~1It11or bull ~_T 1t~3130 ~IItIIIIdttIQ
Ir __ _ - -shy ~~
1J __
_shy
I i I
~ t3
0 d gt
I m ~
I i ~ g
2 I ~ g I s
q
~ 8 0 d
S 12
I II ~ ~ sect
I d
II ~ I t
Ii If
id i ampII 0
-I I ~
I ti IIi
lot I ~~ Ii II~I II I i
I~ ti 1l
101 i g If
T ~ fO
I i I ~ I~b
I I 11lt[ i
8~
~ I~i 0
~ ~ I 101 i I
IIi I pIi ~ I II II
Si I I i ci ~ = ~ - i
sect iI I ~ -IL fa
II IB i
It II
I
Key 309 B
~ ~ (fJ Olraquo
0 ampJS3 rTl1j
l -Z n rTl
r~ flkr (fJraquorTl 5 n
9 m
T ~1middot~~~~~~Imiddot~112Bmiddotmiddot3119~~ili1()middotBmiddot3119~i9iBI3i119Il8filiBmiddot31111i9~BI7B1i3iic1li9I~Iii-nuiigiiii1Iii19IIl5IBmiddot3~191~B4IBmiddot3i1ii19~B~3iBi3middot19IBili2BIllli311l9il1H~IOoi~i51i111middotIIBi)iIiI2RmiddotlI3231nmfuge iyen8 319W 319Microwave r- I I I
I 319BIOA I ~ 3215BLA 321BRA ~
1319B12A I 319B9A 3191l8A 319~7A 319116A 319B5A 319B4A 319B3A 319B2A319Sdnti amp I ~ 319B105 1319B9EI 319S~aker I U 319825J L321S~bull
I 321SA
1 bull ( l
~ ~ ~31amps(f) - ~~-JCit)
csect) e e reg etr)-~I J
(sectV ~
Hlt shy ~r Mtl~1 It~ -
JnA T1+ +rV+ oAr j Ii 8 el L (amp aor ~J U I 309BSC
Figure 1 Site Plan BioRelix
5 Science Park 3rd Floor New Haven CT
TRIUMVIRATE TRIUMVIRATE ENVIRONMENTAL INC
ENViRONMENTAL 200 Inner Belt Road Somerville MA 02143
(800) 966-9282 Fax (617) 628-8099
gt
1 UZlpound bull Ji
e LJ
rreg ~9 middotu
J J e
6
~ l nr Z 3 r l
~
( ~ e
e E
~ ~ ~i
0 1 rTl
l r rTl shy
Assay Definition-
Assay Description Wipe Test
Assay Type CPM Report Name Report1 Output Data Path CPackardTricarbResultswipe testwipe test20121015 1702 Raw Results Path CPackardTricarbResu1tswipe testwipe test20l21015 170220121015 1702results Comma-Delimited File Name CPackardTricarbResultswipe testwipe test201210 02Report1csv Assay File Name CPackardTriCarbAssayswipe testlsa
Count Conditions-
Nuclide 3H-14C-32P Quench Indicator tSIE External Std Terminator (sec) 05 2s Pre-Count Delay (min) 000
Quench Set na Count Time (min) 100 Count Mode Normal Assay Count Cycles 1 Sample Count 1 VialsSamp1e 1 Calculate Reference Off
Background Subtract Off Low CPM Threshold Off 2 Sigma Terminator Off
Regions LL UL A 00 120 B 120 1560 C 1560 17000
Count Corrections-
Static Controller On Luminescence Correction Off Colored na Heterogeneity Monitor na Coincidence Time (nsec) 18 Delay Before Burst (nsec) 75
Half Life-
Half Life Correction Off Regions Half Life Units Reference Date Reference Time A B
C
Cycle 1 Results S Count Time CPMA MESSAGES CPMB CPMC
1 1 00 20 14 7 2 1 00 18 7 4 3 1 00 20 14 2 4 1 00 18 12 7
5
10
15
20
25
30
35
40
45
50
55
60
1 00 14 l7 8 6 1 00 11 15 6 7 1 00 17 23 11 8 1 00 18 10 3 9 100 23 13 4
1 00 l3 20 5 11 1 00 12 8 8 12 1 00 15 11 6 l3 1 00 17 l7 6 14 1 00 14 l7 7
1 00 16 11 9 16 1 00 12 11 7 l7 100 19 15 5 18 1 00 20 11 12 19 1 00 19 12 10
1 00 12 14 10 21 1 00 16 15 5 22 1 00 12 8 12 23 1 00 19 18 12 24 1 00 5 l7 5
1 00 19 12 5 26 1 00 20 13 6 27 1 00 l7 14 9 28 100 16 17 6 29 1 00 19 9 3
1 00 25 13 6 31 1 00 14 13 5 32 1 00 14 7 5 33 1 00 9 20 6 34 1 00 13 9 10
1 00 20 28 8 36 100 31 24 10 37 1 00 19 20 5 38 1 00 19 11 9 39 1 00 568 l7 8
1 00 16 10 7 41 1 00 15 8 9 42 1 00 30 13 6 43 1 00 18 12 8 44 1 00 11 13 11
1 00 19 12 12 46 100 11 13 7 47 1 00 13 16 10 48 1 00 23 14 7 49 1 00 12 11 3
1 00 14 13 6 51 1 00 15 21 4 52 1 00 15 18 8 53 1 00 18 12 3 54 1 00 16 11 9
1 00 23 9 9 56 1 00 l7 11 6 57 1 00 21 23 4 58 1 00 15 13 10 59 100 15 11 6
1 00 11 20 10 61 1 00 23 7 8
62 1 00 63 1 00 64 1 00 65 1 00 66 1 00 67 1 00 68 1 00 69 1 00 70 1 00 71 1 00 72 1 00 73 1 00 74 1 00
19 25 20 11 25 13 18 13 27 22 17 20 19
12 5 12 4
9 3 13 4
7 7 17 5 12 14
7 9 12 9 17 7 19 5 12 4 19 4
Assay Definition-
Assay Description Wipe Test
Assay Type CPM Report Name Reportl Output Data Path CPackardTricarbResultswipe testwipe test20121018 1436 Raw Results Path CPackardTricarbResultswipe testwipe test20121018 143620121018 1436results Comma-Delimited File Name CPackardTricarbResultswipe testwipe test20121018 436Reportlcsv Assay File Name CPackardTriCarbAssayswipe testlsa
Count Conditions-
Nuclide 3H-14C-32P Quench Indicator tSIE External Std Terminator (sec) 05 2s Pre-Count Delay (min) 000
Quench Set na Count Time (min) 100 Count Mode Normal Assay Count Cycles 1 Repeat Sample Count 1 VialsSample 1 Calculate Reference Off
Background Subtract Off Low CPM Threshold Off 2 Sigma Terminator Off
Regions LL UL A 00 120 B 120 1560 C 1560 17000
Count Corrections-
Static Controller On Luminescence Correction Off Colored Samples na Heterogeneity Monitor na Coincidence Time (nsec) 18 Delay Before Burst (nsec) 75
Half Life-
Half Life Correction Off Regions Half Life Units Reference Date Reference Time A B C
Cycle 1 Results S Count Time CPMA MESSAGES CPMB CPMC
1 1 00 20 18 5 2 1 00 8 4 5 3 1 00 15 16 12
1
2 3
4
5
6
7
8
9
10 11
12 13
14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
34 35 36 37 38 39 40 41 42 43
SUMMARY OF SITE PLAN AND SWIPE TEST RESULTS
dpm H3 dpm C14 dpm P32 on the plan swipe sample cpmH3 cpm C14 cpm P32
31 15 7 316 18 7 4 background 20 14 7
28 7 4
318S 20 14 2 31 15 2 321SA 18 12 7 28 13 7
321BRA 14 17 8 22 18 8
321BRB 11 15 6 17 16 6
321Centrifuge 17 23 11 27 24 11 321Thermo 18 10 3 28 10 3
3215VWR 23 13 4 36 14 4
3215BlB 13 20 5 20 21 5
3215BLA 12 8 8 19 8 8
321SB 15 11 6 23 11 6
319Scint 17 17 6 27 18 6
319Hood 14 17 7 22 18 7
319B2A 16 11 9 25 11 9
319B2B 12 11 7 19 11 7
319B2S 19 15 5 30 16 5
319B3A 20 11 12 31 11 12 319B3B 19 12 10 30 13 10 319B4A 12 14 10 19 15 10
319B4B 16 15 5 25 16 5
319B5A 12 8 12 19 8 12 319B5B 19 18 12 30 19 12 319B6A 5 17 5 8 18 5
319B6B 19 12 5 30 13 5 319Ce ntrifuge 20 13 6 31 14 6 319Shaker 17 14 9 27 15 9
319B7A 16 17 6 25 18 6
319B7B 19 9 3 30 9 3 319B8A 25 13 6 39 14 6
319B8B 14 13 5 22 14 5 319B9E 14 7 5 22 7 5 319B9A 9 20 6 14 21 6 319B9B 13 9 10 20 9 10 319BlOA 20 28 8 31 29 8 319Microwave 31 24 10 48 25 10 319B10B 19 20 5 30 21 5
319B10S 19 11 9 30 11 9 319W 568 17 8 888 18 8 319B12A 16 10 7 25 10 7 319B12B 15 8 9 23 8 9 309B12E 30 13 6 47 14 6 309B12A 18 12 8 28 13 8
309B12B 44 11 13 11 17 14 11
309B11A 45 19 12 12 30 13 12
309B11B 46 11 13 7 17 14 7
309BlOE 47 13 16 10 20 17 10
309BlOA 48 23 14 7 36 15 7
309Bl0B 49 12 11 3 19 11 3
309B9A 50 14 13 6 22 14 6
309B9B 51 15 21 4 23 22 4
309B85 52 15 18 8 23 19 8
309B8A 53 18 12 3 28 13 3 309B8RS 54 16 11 9 25 11 9 309B7A 55 23 9 9 36 9 9 309B7B 56 17 11 6 27 11 6 309B6E 57 21 23 4 33 24 4 309B6A 58 15 13 10 23 14 10 309B6B 59 15 11 6 23 11 6 309B5A 60 11 20 10 17 21 10 309B5B 61 23 7 8 36 7 8 309B5C 62 19 12 5 30 13 5 309B4E 63 25 12 4 39 13 4 309B4A 64 20 9 3 31 9 3 309B4B 65 11 13 4 17 14 4 309B3A 66 25 7 7 39 7 7 309B3B 67 13 17 5 20 18 5 309B25 68 18 12 14 28 13 14 309B2 69 13 7 9 20 7 9 309B1A 70 27 12 9 42 13 9 309B1C 71 22 17 7 34 18 7 QAQC 72 17 19 5 27 20 5 QAQC 73 20 12 4 31 13 4 QAQC 74 19 19 4 30 20 4
Sample key 309 Room number e for 3H=064 dpm=cpme
Sample surface BshyB bench S-sink e for 14C=096 6 Bench number e for 32P=10
Description or E sequence
REPEAT OF THE RESULTS IN QUESTION
plan sample cpmH3 cpm C14 cpm P32 dpmH3 dpm C14 dpm P32 background 1 20 18 5 31 19 5 319Wa 2 8 4 5 13 4 5
319W b 3 15 16 12 23 17 12
Connecticut Department of Energy amp Environmental Protection Bureau of Air Management Radiation Division
Radioactive Material and Industrial X-Ray Device Registration
Please complete this form in accordance with the instructions (DEP-RAD-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation along with this form Please retain a copy of this completed form at your facility
Part I Registration Type
CPPU USE ONLY
App____________
Doc ______________
Check ____________
Program Radiation
Requested Year of Registration Period materials license termination
Registrations are based on the calendar year January 1st through December 31 stbull
Provide Permit Number (aka Facility ID see DEEP correspondence to
Check the appropriate box(es) identifying the registration type
D new registration (ie never registered with the DEEP) [221] registrant)
D new ownership [221] 01576
D renewal of an existing registration [221] If renewing or amending an existing
181 amendment to an existing registration [1467] registration please indicate any changes to tile existing registration information by using reel ink
Note If you are terminating your registration or removing a device(s) from registration refer to the registration instructions (DEP-RAD-INST-100) for required documentation necessary to comply with DEEP requirements
own I(here site is located New Haven
Part II Fee Information
An annual registration fee of $20000 is to be submitted by December 31 S with each registration and applies for the period covering the requested calendar year The fee is not pro-rated New registrants are required to pay the fee regardless of when they register with the DEEP There is no fee for amendments The registration will not be processed without the fee The fee shall be non-refundable and shall be paid by check or money order to the Department of Energy and Environmental Protection
Part III Registrant Information
bull If a registrant is a corporation limited liability company limited partnership limited liability partnership or a statutory trost it must be registered with the Secretary of State If applicable registrants name shall be stated exactly as it is registered with the Secretary of State Please note for those entities registered with the Secretary of State the registered name will be the name used by DEEP This information can be accessed at the Secretary of States database (CONCORD) (wwwconcord-sotsctgovICONCORDlindexjsp)
bull If a registrant is an individual provide the legal name (include suffix) in the following format First Name Middle Initial Last Name Suffix (Jr Sr II III etc)
DEP-RAD-REG-100 1 of 9 Rev 103112
Part III Registrant Information (continued)
1 Registrant Name BioRelix Inc
Mailing Address 5 Science Park (401 Winchester Avenue)
CitylTown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
Contact Person Izabela Puskarz Phone (203) 785-9282 ext 305
E-mail ipuskarzbiorelixcom
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from nctgov addresses Also please notify the department if your e-mail address changes
a) Registrant Type (check one) 0 individual [8J business entity o federal agency
o state agency o municipality tribal
If a business entity (If a business entity complete i through iii)
i) check type [8J corporation 0 limited liability company o limited partnership o Other ________o limited liability partnership 0 statutory trust
ii) provide Secretary of the State business ID ~08~67~696~___This information can be accessed at CONCORD
iii) 0 Check here if you are NOT registered with the SOTS
b) Registrants interest in property at which the proposed activity is to be located
o site owner 0 option holder [8J lessee 0 easement holder operator
o other (specify)
o Check here if any co-registrants If so attach additional sheet(s) with the required information as requested above
2 List billing contact if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
3 List primary contact for departmental cprrespondence and inquiries if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from ctgov addresses Also please notify the department if your e-mail address changes
DEP-RAD-REG-100 2of9 Rev 103112
---
Part III Registrant Information (continued)
4 List the Radiation Safety Officer (RSO) There must be one RSO listed per registration
Name Izabela J Puskarz
Direct Phone (203) 785-9282 ext 305 Fax (203) 785-8058
E-Mail Addressipuskarzbiorelixcom
24-Hour Emergency Phone ~---
List other contact people in the radiation safety section
Name Kenneth F Blount
Title Director of Biology
Direct Phone (203) 785-9282 ext 302 Fax (203) 785-8058
E-Mail Addresskblountbiorelixcom
24-Hour Emergency Pho
Name Brian R Dixon
Title President and CEO
Direct Phone (203) 785-9282 ext 303 Fax (203) 785-8058
E-Mail Addressbdizonbiorelixcom
24-Hour Emergency Phone
Part IV Site Information
1 Company Name BioRelix Inc
Site Name (if different)
Address 5 Science Park (401 Winchester Avenue)
Cityrrown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
2 Location of Material (if different than above)
Cityrrown State Zip Code
Part V NRC Licenses
For new licenses attach a copy of each license for renewals or modifications attach any amended pages of each license
06-31263-01 3 August 312017
DEP-RAD-REG-100 30f9 Rev 103112
Part VI Personnel Dosimetry
1 Indicate whether personnel dosimetry is performed at your facility Yes t8J No
2 If yes indicate the name of vendor that provides this service
Part VII Compliance
If you answer yes to any of the questions below you must complete Part VIII Table of Enforcement Actions as directed in the instructions for your registration
A During the five years immediately preceding submission of this registration has the registrant been convicted in any jurisdiction of a criminal violation of any environmental law
DYes t8J No
B During the five years immediately preceding submission of this registration has a civil penalty been imposed upon the registrant in any state including Connecticut or federal judicial proceeding for any other violation of an environmental law
DYes t8J No
C During the five years immediately preceding submission of this registration has a civil penalty exceeding five thousand dollars been imposed on the registrant in any state including Connecticut or federal administrative proceeding for any violation of an environmental law
DYes t8J No
D During the five years immediately preceding submission of this registration has any state including Connecticut or federal court issued any order or entered any judgment to the registrant concerning a violation of any environmental law
DYes t8J No
E During the five years immediately preceding submission of this registration has any state including Connecticut or federal administrative agency issued any order to the registrant concerning a violation of any environmental law
DYes t8J No
DEP-RAD-REG-100 4of9 Rev 103112
Part VIII Table of Enforcement Actions
Type of Action Type of Action Type of Action
Date Commenced Date Commenced Date Commenced
Date Terminated Date Terminated Date Terminated
Jurisdiction Jurisdiction Jurisdiction
CaselDocketlOrder Number CaselDocketlOrder Number CaseDocketlOrder Number
Description of Violation Description of Violation Description of Violation
D Check the box if additional sheets are attached Copies of this form may be duplicated for additional space
DEP-RAD-REG-100 50f9 Rev 1013112
For Parts IX through XVI you may hit the tab button at the end of each table in the last cell and create additional rows
Part IX Industrial X-Ray Equipment
Part X Analytic Equipment for Examination of Material
aXlimum mA
~~t JiUIp
(Including but not limited to X-ray diffraction units electron microscopes gauging devices spectroscopic equipment gas chromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or therapy)
MQttatltl I t
Serial Manufacturer r~ M~_ilil I Maximum mA
Part XI Industrial Radiographic Equipment
(For examination of structure with a sealed source)
I I TYRe Model ibmll Serial I Manufactu~middot l i i
Part XII Particle Accelerators
(Including but not limited to Van de Graffs Linacs Cyclotrons Electronic Beam Welders)
lI~f ler1 bull Ma~ufacturer p~Itf ii
DEP-RAD-REG-100 6 af9 Rev 103112
Part XIII Special Nuclear Material (Special nuclear material [SNM] refers to plutonium 233U uranium enriched in the isotope 233 or in the isotope 235 greater than its natural abundance and any other material which the US NRC pursuant to the provisions of Section 510f the Atomic Energy Act of 1954 determines to be special nuclear material SNM does not include source material)
Part XIV Source Material
(Source material [SM] refers to uranium or thorium or any combination thereof in any physical or chemical form or ores which contain at least 005 by weight uranium thorium or any combination thereof except when the material is designated as special nuclear material)
Part XV Sealed Sources
No1~er ofSikrcesltc
Part XVI Other Radioactive Materials (including medical isotopes)
3 Hydrogen 25mCi
33 Phosphorous 25mCi
DEP-RAD-REG-100 7of9 Rev 103112
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
Bio bullbullbull Reli~i
5 Science Park at Yale bull New Haven CT 06511 Tel (203) 785-9282 bull Fax (203) 785-8058
January 22 2012
US NRC Region I Attn Elizabeth Ullrich 2100 Renaissance Boulevard Renaissance Park King of Prussia P A 19406 610-337-5000
Re BioRelix 5 Science Park NRC License No 06-31263-01 CT DEEP Permit No 01576 New Haven CT 06511
Introduction The purpose of this document is to provide details and supporting information for the terminating the radiation use license for BioRelix Inc located at 5 Science Park New Haven Connecticut The information is presented to satisfy the US Nuclear Regulatory Commission in the license termination
On October 112012 a final shipment of three drums containing all remaining radioactive materials was shipped under uniform low-level radioactive waste manifest A copy of the manifest is enclosed
On October 15 2012 a survey was conducted in the laboratories of BioRelix for the purpose of termination of the companys radioactive use license The permit for radiation use at BioRelix had been issued for the use of P32 P33 H3 S35 and 1125 Survey was performed by
Safdoc Systems LLC Kenneth S Weinberg PhD 20 Thompson Court Stoughton MA 02072 SafdocSysaolcom PhoneFax 7813413893
A survey of all the equipment hoods benches and sinks in the following rooms 309 316 318 319 321 was conducted A sketch showing the radioactive use locations and sample locations is enclosed The survey included Room 309 that had previously been used to store radioactive waste for disposal
An initial survey was conducted using a handheld Geiger-Muller with a pancake probe (Ludlum Measurements Inc Model 3 SN 244273 and pancake probe Model 44-9 SN PR257735 both calibrated on May 21 2012) The areas were slowly scanned so that
each location had a two second observation interval No radioactivity was detected to have been present To further characterize any potential residual radioactivity wipe samples were collected A total of74 wipe samples as well as field blanks and quality assurance and quality control (QAlQC) samples were counted in a scintillation counter (PerkinElmer TriCarb 2900TR SN 432701 calibrated October 2012) Each wipe sample covered an area of 100 cm2 were counted for one minute Since the presence of residual H3 cannot be determined using the GM tube the use of wipe samples will confirm the absence of this isotope as well as the absence of any beta particles from the other isotopes used in the laboratory The scintillation counter results are enclosed
Observations Samples 72 through 74 represent the control and QAIQC samples The results of all wipe samples except for sample No 39 were consistent as the background samples Sample No39 was collected from inside of a piece of equipment in Room 319 on Bench 12 This sample was several orders of magnitude higher than all of the other samples collected On October 182012 the equipment was sampled a second time The second sample event included a control sample and two samples from within the equipment The results of the second samples found count levels consistent with background A copy of the results is enclosed
Results A total of72 wipe samples each covering 100 cm2 three field blanks and QAlQC samples were analyzed in a PerkinElmer TriCarb 2900TR scintillation counter (SN 432701 calibrated October 2012) All results on a first run of samples fell within the range of background as shown by the controls and QAlQC samples One sample No39 was found to be above background The sample location No 39 was sampled again splitting the area in half and the results demonstrated that the equipment met the criteria ofcleanliness as demonstrated by a reading consistent with background similar to the previous 69 samples collected in the BioRelix laboratories To reiterate NUREG 1570 NUREG 1757 Consolidated NMSS Decommissioning Guidance Vol 2 and Subpart E of 10 CFR Part 20 was consulted in evaluating this data and it was established that the wipe samples values were below screening values for building surface contamination for betagamma emitters However because ofthe nature of the isotopes used and the failure to detect any removable H3 there was no rational for the use ofadditional techniques for characterization such as a proportional counter to further evaluate the area The results of the surveys for removable contamination fixed surface contamination and radiation dose rates qualify the facilities for release for unrestricted use per 10 CFR 20 subpart E Radiological Criteria for License Termination and the Nuclear Regulatory Commission (NRC) document entitled Guidelines for Decontamination of Facilities and Equipment Prior to Release for Unrestricted Use Table 1 A copy of the signed CT DEEP Radioactive Materials and Industrial X-Ray Device Registration (termination) form is enclosed
Respectfully Submitted
---r- 1rY~ (hlt- f- -c v
Izabela J Puskarz Radiation Safety Officer BioRelix Inc
Enclosures cc CT DEEP - Central Pennit Processing Unit Attn Andrew Zwick 79 Elm Street Hartford CT 06106 860-424-3035
gt
tlRCFCfIIlUgt40 15 ftPP=R-HNoEAM) FACILITY EHPIgtat II) lit IMC t5QJUrKlS4M PAGef_l~ 8~tI~
ae~QoupInI NtA MMfOIIWM~ OF _1~ (IJoo _ _ DIfI
UNIFORM LOW-LEVl5L 1WlI0ACnVE 1145cWaaenscn Court XI~ - --1-JIG~ WASTEMANlFSST L4IiIlyeniIeKY 40299 -shy ~(amp) ro-201~middot28S
SliIlPlMG PNa it---~ ~ -_ ~_WtJlY_ ~ t_~_E~_~
T-KY(l(G112 rroxCO Inc RiCkLcw 8OC-424-Q300 COCTACT 1aIAItflltt 109 F1intRoad IT~ Nlimber(1Dcbde _ COde)
~ Janet eater BliS25G4593 Oak RidQe IN3183O 886-4S2-S532 CHEMTREC IB~ NAUENJOAI)f)RESS reAI[)~
-~--DaSeo
Ilf~WC~ III01IIUIIIIlERCII iSJ Transpollaltln Co tnc NJD0716299i5
xJ YES _1OIlH1IID 3 PO Boic i 69shy lIH_ampWE 10Qetilication NO TIIS_ Woortsawn NJ 0SEl9S 1011112012 ~~___Dl___W-C~
lIIIPIonCI [ lYES m_JiIWIIIR CCNTAC1 lEllPHOIElII ~~_~~~Ml - [X J NO Kevln Elder 866-169-2741 __~~__~-n___
---shy ~~t~ OiltTE -l)~~~~ TITIE tIPJE CU-flttshy bull Ggt~ r~I~ (C-lt-t2
1fl1amp DEPMJIEN QIl_A11ltlfI~ i2 110 I~ 5 II 11 -shy 1IIlD ~_~___UIID_
DotWlil -shy ~- - TOTAlPAC~ IJiWSCO _ _Of -It__ - ~1aIM _1laIleS IICTIIffi IN UBq CtiOCSS m3 -UN2910 Ratlloadive material ~ package- IJIA NIA SoJidIOxfde H--3 P-32 P-33 536E+02 NlA D212 To-CT-E-1~-eD4
limited quantity ofmalEftal T
On~ drum with DAW far dlsllO$al UN2910 RadioacWe materia~ exceptied package- NtA NlA SOlidOxide H--3 P-32 P-33 S~E+02 NfA 1)212 TO-CT-amp12-005 limiied qlisnlity of mafamprilaJ 7
One dlllOl wlth CAW dlarps foe disposalINon oar Regltlated Material NlA NlA liquidlOraquoie P-32 7nE+OO NlA 0114 lO--L$-E-12e06
One drum wittt ampQUeolS$ lIalAd l1on-haz ISV fer dIsc )Sal ~ -
GElMratar CeTtificatioo Satement tnre cansituenl$ of1t1e Waste mafifested herein are 1rnown to tile getlererlor Theft are no EPA ReM patboael1icor o1iIer hazards pmenhlUlElrthan those specilleally listed on the Foms541
1p~q ez S~ ~ PrlJ1tnams ---shy ___~natutle __ ___ _ _ _
OOIgtlSIGNEE QRI(JI1tW MUST ACCOMPAlNWASTE IN rWINlm
~_1lOtoIIoI_
INU_
srewNUClEAAIlATlORlAl(a _ - -shyUNIFORM LOWEVEL RADIOACTIVE -shy _Ill
_ lJ2S3shy t U-235 Pu TOTAl TQ2012286
WASTe MANIFEST 3 0538 no ta-COtnA1tIERANOWA$IEDESCRrFTlON PAGE 1 OF I PAGiSrm
ACiTMlY SOORCpound SHfPfER WM AU1-UOIlIleS T lRInJIpound T Co14 I Tc4 I-m Im Chase E~v GrDUJ)
1085+03 MflQ TS61E+02f NP I NIP NIP NIP fsitFPElR 10 KJbllBER 290E+01 mCl 1976amp001 1 NJA
DlSPOSAL()OHAIIampOEBCRIPTlON ~I5SCaJPTlO~ 1OR5Itf WASTETlPE 1N00NTJiIIMSR shySccmAIIIER ~ 1 II
s_ shy ~IIS9CIIIPT1OH ~~- 161Ia~_
~ -shy -shy -shy - n_ ~ shy - ~---- shy- _M - lIId - shy - - - p-----shy -shy-shy 1t (m3) - 11shy -shy - _-r - --shy _ ~~ tkrl~ shy - - IIoo_ Em --shy 11 01 Nuclrae MBa mCI
_0 TO-Cfe12-604 0212 lt5(10 lt361amp6 lt367E-5 39 l212 jeD OxidaINP NP K-S 242aQ2 Gs~E+OD NfA
1159 Pa2 18QE+02 486E+OD
4G F-33 1tgtlE+a2 3tItaOl
P~t1claJ 53SE+02 1A5E+01TQCT-E-12-605 4 0212 lt500 lt3S1E-S lt367amp0 39 0212 100 NP fiS 24~ eB3E+OO NfA1159
Jt f32 1a1E+02 4IIBEoo p~ 114EltfOli 301E+C0
~1ltane1Cllil1 s3tJE+02 ~ TQlSE-12-606 A of14 0$00 lt367E-6 lt3amp75-$ 2559 0114 100 0lddeNP If P-S2 771E+OO 210amp011159 3 ~I Water IIOn-haz lJN Pa~tofal 777E+W 2fQen1
yen p 10P
~1__~_lltIt_
~---tWA__ ____shy -__shyI-o__n____
JItshy ~- _shy r--~1-s----_~11~1 ~1t---_lII__ p_ ~~ --shy shy ~ shy~ --shy ~ -_ 0shy pshy trt c~ t-Dd -shy - _shy shy DO_10- _-shy _shy -shy ~-
- - lItIIIR1rDr
01 __ -~-- shy ta-shy _JrIIII --_ ia2-1IojI -shy _1 -shy shyDIItiur shy 1--shy --- ~ ~ -shy IIshy shy~~clhll - 10- __ --shy ~- ~HIDOI _ T~U -shy-- _shy shy ~~- ~0IIMtt ~1It11or bull ~_T 1t~3130 ~IItIIIIdttIQ
Ir __ _ - -shy ~~
1J __
_shy
I i I
~ t3
0 d gt
I m ~
I i ~ g
2 I ~ g I s
q
~ 8 0 d
S 12
I II ~ ~ sect
I d
II ~ I t
Ii If
id i ampII 0
-I I ~
I ti IIi
lot I ~~ Ii II~I II I i
I~ ti 1l
101 i g If
T ~ fO
I i I ~ I~b
I I 11lt[ i
8~
~ I~i 0
~ ~ I 101 i I
IIi I pIi ~ I II II
Si I I i ci ~ = ~ - i
sect iI I ~ -IL fa
II IB i
It II
I
Key 309 B
~ ~ (fJ Olraquo
0 ampJS3 rTl1j
l -Z n rTl
r~ flkr (fJraquorTl 5 n
9 m
T ~1middot~~~~~~Imiddot~112Bmiddotmiddot3119~~ili1()middotBmiddot3119~i9iBI3i119Il8filiBmiddot31111i9~BI7B1i3iic1li9I~Iii-nuiigiiii1Iii19IIl5IBmiddot3~191~B4IBmiddot3i1ii19~B~3iBi3middot19IBili2BIllli311l9il1H~IOoi~i51i111middotIIBi)iIiI2RmiddotlI3231nmfuge iyen8 319W 319Microwave r- I I I
I 319BIOA I ~ 3215BLA 321BRA ~
1319B12A I 319B9A 3191l8A 319~7A 319116A 319B5A 319B4A 319B3A 319B2A319Sdnti amp I ~ 319B105 1319B9EI 319S~aker I U 319825J L321S~bull
I 321SA
1 bull ( l
~ ~ ~31amps(f) - ~~-JCit)
csect) e e reg etr)-~I J
(sectV ~
Hlt shy ~r Mtl~1 It~ -
JnA T1+ +rV+ oAr j Ii 8 el L (amp aor ~J U I 309BSC
Figure 1 Site Plan BioRelix
5 Science Park 3rd Floor New Haven CT
TRIUMVIRATE TRIUMVIRATE ENVIRONMENTAL INC
ENViRONMENTAL 200 Inner Belt Road Somerville MA 02143
(800) 966-9282 Fax (617) 628-8099
gt
1 UZlpound bull Ji
e LJ
rreg ~9 middotu
J J e
6
~ l nr Z 3 r l
~
( ~ e
e E
~ ~ ~i
0 1 rTl
l r rTl shy
Assay Definition-
Assay Description Wipe Test
Assay Type CPM Report Name Report1 Output Data Path CPackardTricarbResultswipe testwipe test20121015 1702 Raw Results Path CPackardTricarbResu1tswipe testwipe test20l21015 170220121015 1702results Comma-Delimited File Name CPackardTricarbResultswipe testwipe test201210 02Report1csv Assay File Name CPackardTriCarbAssayswipe testlsa
Count Conditions-
Nuclide 3H-14C-32P Quench Indicator tSIE External Std Terminator (sec) 05 2s Pre-Count Delay (min) 000
Quench Set na Count Time (min) 100 Count Mode Normal Assay Count Cycles 1 Sample Count 1 VialsSamp1e 1 Calculate Reference Off
Background Subtract Off Low CPM Threshold Off 2 Sigma Terminator Off
Regions LL UL A 00 120 B 120 1560 C 1560 17000
Count Corrections-
Static Controller On Luminescence Correction Off Colored na Heterogeneity Monitor na Coincidence Time (nsec) 18 Delay Before Burst (nsec) 75
Half Life-
Half Life Correction Off Regions Half Life Units Reference Date Reference Time A B
C
Cycle 1 Results S Count Time CPMA MESSAGES CPMB CPMC
1 1 00 20 14 7 2 1 00 18 7 4 3 1 00 20 14 2 4 1 00 18 12 7
5
10
15
20
25
30
35
40
45
50
55
60
1 00 14 l7 8 6 1 00 11 15 6 7 1 00 17 23 11 8 1 00 18 10 3 9 100 23 13 4
1 00 l3 20 5 11 1 00 12 8 8 12 1 00 15 11 6 l3 1 00 17 l7 6 14 1 00 14 l7 7
1 00 16 11 9 16 1 00 12 11 7 l7 100 19 15 5 18 1 00 20 11 12 19 1 00 19 12 10
1 00 12 14 10 21 1 00 16 15 5 22 1 00 12 8 12 23 1 00 19 18 12 24 1 00 5 l7 5
1 00 19 12 5 26 1 00 20 13 6 27 1 00 l7 14 9 28 100 16 17 6 29 1 00 19 9 3
1 00 25 13 6 31 1 00 14 13 5 32 1 00 14 7 5 33 1 00 9 20 6 34 1 00 13 9 10
1 00 20 28 8 36 100 31 24 10 37 1 00 19 20 5 38 1 00 19 11 9 39 1 00 568 l7 8
1 00 16 10 7 41 1 00 15 8 9 42 1 00 30 13 6 43 1 00 18 12 8 44 1 00 11 13 11
1 00 19 12 12 46 100 11 13 7 47 1 00 13 16 10 48 1 00 23 14 7 49 1 00 12 11 3
1 00 14 13 6 51 1 00 15 21 4 52 1 00 15 18 8 53 1 00 18 12 3 54 1 00 16 11 9
1 00 23 9 9 56 1 00 l7 11 6 57 1 00 21 23 4 58 1 00 15 13 10 59 100 15 11 6
1 00 11 20 10 61 1 00 23 7 8
62 1 00 63 1 00 64 1 00 65 1 00 66 1 00 67 1 00 68 1 00 69 1 00 70 1 00 71 1 00 72 1 00 73 1 00 74 1 00
19 25 20 11 25 13 18 13 27 22 17 20 19
12 5 12 4
9 3 13 4
7 7 17 5 12 14
7 9 12 9 17 7 19 5 12 4 19 4
Assay Definition-
Assay Description Wipe Test
Assay Type CPM Report Name Reportl Output Data Path CPackardTricarbResultswipe testwipe test20121018 1436 Raw Results Path CPackardTricarbResultswipe testwipe test20121018 143620121018 1436results Comma-Delimited File Name CPackardTricarbResultswipe testwipe test20121018 436Reportlcsv Assay File Name CPackardTriCarbAssayswipe testlsa
Count Conditions-
Nuclide 3H-14C-32P Quench Indicator tSIE External Std Terminator (sec) 05 2s Pre-Count Delay (min) 000
Quench Set na Count Time (min) 100 Count Mode Normal Assay Count Cycles 1 Repeat Sample Count 1 VialsSample 1 Calculate Reference Off
Background Subtract Off Low CPM Threshold Off 2 Sigma Terminator Off
Regions LL UL A 00 120 B 120 1560 C 1560 17000
Count Corrections-
Static Controller On Luminescence Correction Off Colored Samples na Heterogeneity Monitor na Coincidence Time (nsec) 18 Delay Before Burst (nsec) 75
Half Life-
Half Life Correction Off Regions Half Life Units Reference Date Reference Time A B C
Cycle 1 Results S Count Time CPMA MESSAGES CPMB CPMC
1 1 00 20 18 5 2 1 00 8 4 5 3 1 00 15 16 12
1
2 3
4
5
6
7
8
9
10 11
12 13
14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
34 35 36 37 38 39 40 41 42 43
SUMMARY OF SITE PLAN AND SWIPE TEST RESULTS
dpm H3 dpm C14 dpm P32 on the plan swipe sample cpmH3 cpm C14 cpm P32
31 15 7 316 18 7 4 background 20 14 7
28 7 4
318S 20 14 2 31 15 2 321SA 18 12 7 28 13 7
321BRA 14 17 8 22 18 8
321BRB 11 15 6 17 16 6
321Centrifuge 17 23 11 27 24 11 321Thermo 18 10 3 28 10 3
3215VWR 23 13 4 36 14 4
3215BlB 13 20 5 20 21 5
3215BLA 12 8 8 19 8 8
321SB 15 11 6 23 11 6
319Scint 17 17 6 27 18 6
319Hood 14 17 7 22 18 7
319B2A 16 11 9 25 11 9
319B2B 12 11 7 19 11 7
319B2S 19 15 5 30 16 5
319B3A 20 11 12 31 11 12 319B3B 19 12 10 30 13 10 319B4A 12 14 10 19 15 10
319B4B 16 15 5 25 16 5
319B5A 12 8 12 19 8 12 319B5B 19 18 12 30 19 12 319B6A 5 17 5 8 18 5
319B6B 19 12 5 30 13 5 319Ce ntrifuge 20 13 6 31 14 6 319Shaker 17 14 9 27 15 9
319B7A 16 17 6 25 18 6
319B7B 19 9 3 30 9 3 319B8A 25 13 6 39 14 6
319B8B 14 13 5 22 14 5 319B9E 14 7 5 22 7 5 319B9A 9 20 6 14 21 6 319B9B 13 9 10 20 9 10 319BlOA 20 28 8 31 29 8 319Microwave 31 24 10 48 25 10 319B10B 19 20 5 30 21 5
319B10S 19 11 9 30 11 9 319W 568 17 8 888 18 8 319B12A 16 10 7 25 10 7 319B12B 15 8 9 23 8 9 309B12E 30 13 6 47 14 6 309B12A 18 12 8 28 13 8
309B12B 44 11 13 11 17 14 11
309B11A 45 19 12 12 30 13 12
309B11B 46 11 13 7 17 14 7
309BlOE 47 13 16 10 20 17 10
309BlOA 48 23 14 7 36 15 7
309Bl0B 49 12 11 3 19 11 3
309B9A 50 14 13 6 22 14 6
309B9B 51 15 21 4 23 22 4
309B85 52 15 18 8 23 19 8
309B8A 53 18 12 3 28 13 3 309B8RS 54 16 11 9 25 11 9 309B7A 55 23 9 9 36 9 9 309B7B 56 17 11 6 27 11 6 309B6E 57 21 23 4 33 24 4 309B6A 58 15 13 10 23 14 10 309B6B 59 15 11 6 23 11 6 309B5A 60 11 20 10 17 21 10 309B5B 61 23 7 8 36 7 8 309B5C 62 19 12 5 30 13 5 309B4E 63 25 12 4 39 13 4 309B4A 64 20 9 3 31 9 3 309B4B 65 11 13 4 17 14 4 309B3A 66 25 7 7 39 7 7 309B3B 67 13 17 5 20 18 5 309B25 68 18 12 14 28 13 14 309B2 69 13 7 9 20 7 9 309B1A 70 27 12 9 42 13 9 309B1C 71 22 17 7 34 18 7 QAQC 72 17 19 5 27 20 5 QAQC 73 20 12 4 31 13 4 QAQC 74 19 19 4 30 20 4
Sample key 309 Room number e for 3H=064 dpm=cpme
Sample surface BshyB bench S-sink e for 14C=096 6 Bench number e for 32P=10
Description or E sequence
REPEAT OF THE RESULTS IN QUESTION
plan sample cpmH3 cpm C14 cpm P32 dpmH3 dpm C14 dpm P32 background 1 20 18 5 31 19 5 319Wa 2 8 4 5 13 4 5
319W b 3 15 16 12 23 17 12
Connecticut Department of Energy amp Environmental Protection Bureau of Air Management Radiation Division
Radioactive Material and Industrial X-Ray Device Registration
Please complete this form in accordance with the instructions (DEP-RAD-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation along with this form Please retain a copy of this completed form at your facility
Part I Registration Type
CPPU USE ONLY
App____________
Doc ______________
Check ____________
Program Radiation
Requested Year of Registration Period materials license termination
Registrations are based on the calendar year January 1st through December 31 stbull
Provide Permit Number (aka Facility ID see DEEP correspondence to
Check the appropriate box(es) identifying the registration type
D new registration (ie never registered with the DEEP) [221] registrant)
D new ownership [221] 01576
D renewal of an existing registration [221] If renewing or amending an existing
181 amendment to an existing registration [1467] registration please indicate any changes to tile existing registration information by using reel ink
Note If you are terminating your registration or removing a device(s) from registration refer to the registration instructions (DEP-RAD-INST-100) for required documentation necessary to comply with DEEP requirements
own I(here site is located New Haven
Part II Fee Information
An annual registration fee of $20000 is to be submitted by December 31 S with each registration and applies for the period covering the requested calendar year The fee is not pro-rated New registrants are required to pay the fee regardless of when they register with the DEEP There is no fee for amendments The registration will not be processed without the fee The fee shall be non-refundable and shall be paid by check or money order to the Department of Energy and Environmental Protection
Part III Registrant Information
bull If a registrant is a corporation limited liability company limited partnership limited liability partnership or a statutory trost it must be registered with the Secretary of State If applicable registrants name shall be stated exactly as it is registered with the Secretary of State Please note for those entities registered with the Secretary of State the registered name will be the name used by DEEP This information can be accessed at the Secretary of States database (CONCORD) (wwwconcord-sotsctgovICONCORDlindexjsp)
bull If a registrant is an individual provide the legal name (include suffix) in the following format First Name Middle Initial Last Name Suffix (Jr Sr II III etc)
DEP-RAD-REG-100 1 of 9 Rev 103112
Part III Registrant Information (continued)
1 Registrant Name BioRelix Inc
Mailing Address 5 Science Park (401 Winchester Avenue)
CitylTown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
Contact Person Izabela Puskarz Phone (203) 785-9282 ext 305
E-mail ipuskarzbiorelixcom
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from nctgov addresses Also please notify the department if your e-mail address changes
a) Registrant Type (check one) 0 individual [8J business entity o federal agency
o state agency o municipality tribal
If a business entity (If a business entity complete i through iii)
i) check type [8J corporation 0 limited liability company o limited partnership o Other ________o limited liability partnership 0 statutory trust
ii) provide Secretary of the State business ID ~08~67~696~___This information can be accessed at CONCORD
iii) 0 Check here if you are NOT registered with the SOTS
b) Registrants interest in property at which the proposed activity is to be located
o site owner 0 option holder [8J lessee 0 easement holder operator
o other (specify)
o Check here if any co-registrants If so attach additional sheet(s) with the required information as requested above
2 List billing contact if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
3 List primary contact for departmental cprrespondence and inquiries if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from ctgov addresses Also please notify the department if your e-mail address changes
DEP-RAD-REG-100 2of9 Rev 103112
---
Part III Registrant Information (continued)
4 List the Radiation Safety Officer (RSO) There must be one RSO listed per registration
Name Izabela J Puskarz
Direct Phone (203) 785-9282 ext 305 Fax (203) 785-8058
E-Mail Addressipuskarzbiorelixcom
24-Hour Emergency Phone ~---
List other contact people in the radiation safety section
Name Kenneth F Blount
Title Director of Biology
Direct Phone (203) 785-9282 ext 302 Fax (203) 785-8058
E-Mail Addresskblountbiorelixcom
24-Hour Emergency Pho
Name Brian R Dixon
Title President and CEO
Direct Phone (203) 785-9282 ext 303 Fax (203) 785-8058
E-Mail Addressbdizonbiorelixcom
24-Hour Emergency Phone
Part IV Site Information
1 Company Name BioRelix Inc
Site Name (if different)
Address 5 Science Park (401 Winchester Avenue)
Cityrrown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
2 Location of Material (if different than above)
Cityrrown State Zip Code
Part V NRC Licenses
For new licenses attach a copy of each license for renewals or modifications attach any amended pages of each license
06-31263-01 3 August 312017
DEP-RAD-REG-100 30f9 Rev 103112
Part VI Personnel Dosimetry
1 Indicate whether personnel dosimetry is performed at your facility Yes t8J No
2 If yes indicate the name of vendor that provides this service
Part VII Compliance
If you answer yes to any of the questions below you must complete Part VIII Table of Enforcement Actions as directed in the instructions for your registration
A During the five years immediately preceding submission of this registration has the registrant been convicted in any jurisdiction of a criminal violation of any environmental law
DYes t8J No
B During the five years immediately preceding submission of this registration has a civil penalty been imposed upon the registrant in any state including Connecticut or federal judicial proceeding for any other violation of an environmental law
DYes t8J No
C During the five years immediately preceding submission of this registration has a civil penalty exceeding five thousand dollars been imposed on the registrant in any state including Connecticut or federal administrative proceeding for any violation of an environmental law
DYes t8J No
D During the five years immediately preceding submission of this registration has any state including Connecticut or federal court issued any order or entered any judgment to the registrant concerning a violation of any environmental law
DYes t8J No
E During the five years immediately preceding submission of this registration has any state including Connecticut or federal administrative agency issued any order to the registrant concerning a violation of any environmental law
DYes t8J No
DEP-RAD-REG-100 4of9 Rev 103112
Part VIII Table of Enforcement Actions
Type of Action Type of Action Type of Action
Date Commenced Date Commenced Date Commenced
Date Terminated Date Terminated Date Terminated
Jurisdiction Jurisdiction Jurisdiction
CaselDocketlOrder Number CaselDocketlOrder Number CaseDocketlOrder Number
Description of Violation Description of Violation Description of Violation
D Check the box if additional sheets are attached Copies of this form may be duplicated for additional space
DEP-RAD-REG-100 50f9 Rev 1013112
For Parts IX through XVI you may hit the tab button at the end of each table in the last cell and create additional rows
Part IX Industrial X-Ray Equipment
Part X Analytic Equipment for Examination of Material
aXlimum mA
~~t JiUIp
(Including but not limited to X-ray diffraction units electron microscopes gauging devices spectroscopic equipment gas chromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or therapy)
MQttatltl I t
Serial Manufacturer r~ M~_ilil I Maximum mA
Part XI Industrial Radiographic Equipment
(For examination of structure with a sealed source)
I I TYRe Model ibmll Serial I Manufactu~middot l i i
Part XII Particle Accelerators
(Including but not limited to Van de Graffs Linacs Cyclotrons Electronic Beam Welders)
lI~f ler1 bull Ma~ufacturer p~Itf ii
DEP-RAD-REG-100 6 af9 Rev 103112
Part XIII Special Nuclear Material (Special nuclear material [SNM] refers to plutonium 233U uranium enriched in the isotope 233 or in the isotope 235 greater than its natural abundance and any other material which the US NRC pursuant to the provisions of Section 510f the Atomic Energy Act of 1954 determines to be special nuclear material SNM does not include source material)
Part XIV Source Material
(Source material [SM] refers to uranium or thorium or any combination thereof in any physical or chemical form or ores which contain at least 005 by weight uranium thorium or any combination thereof except when the material is designated as special nuclear material)
Part XV Sealed Sources
No1~er ofSikrcesltc
Part XVI Other Radioactive Materials (including medical isotopes)
3 Hydrogen 25mCi
33 Phosphorous 25mCi
DEP-RAD-REG-100 7of9 Rev 103112
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
each location had a two second observation interval No radioactivity was detected to have been present To further characterize any potential residual radioactivity wipe samples were collected A total of74 wipe samples as well as field blanks and quality assurance and quality control (QAlQC) samples were counted in a scintillation counter (PerkinElmer TriCarb 2900TR SN 432701 calibrated October 2012) Each wipe sample covered an area of 100 cm2 were counted for one minute Since the presence of residual H3 cannot be determined using the GM tube the use of wipe samples will confirm the absence of this isotope as well as the absence of any beta particles from the other isotopes used in the laboratory The scintillation counter results are enclosed
Observations Samples 72 through 74 represent the control and QAIQC samples The results of all wipe samples except for sample No 39 were consistent as the background samples Sample No39 was collected from inside of a piece of equipment in Room 319 on Bench 12 This sample was several orders of magnitude higher than all of the other samples collected On October 182012 the equipment was sampled a second time The second sample event included a control sample and two samples from within the equipment The results of the second samples found count levels consistent with background A copy of the results is enclosed
Results A total of72 wipe samples each covering 100 cm2 three field blanks and QAlQC samples were analyzed in a PerkinElmer TriCarb 2900TR scintillation counter (SN 432701 calibrated October 2012) All results on a first run of samples fell within the range of background as shown by the controls and QAlQC samples One sample No39 was found to be above background The sample location No 39 was sampled again splitting the area in half and the results demonstrated that the equipment met the criteria ofcleanliness as demonstrated by a reading consistent with background similar to the previous 69 samples collected in the BioRelix laboratories To reiterate NUREG 1570 NUREG 1757 Consolidated NMSS Decommissioning Guidance Vol 2 and Subpart E of 10 CFR Part 20 was consulted in evaluating this data and it was established that the wipe samples values were below screening values for building surface contamination for betagamma emitters However because ofthe nature of the isotopes used and the failure to detect any removable H3 there was no rational for the use ofadditional techniques for characterization such as a proportional counter to further evaluate the area The results of the surveys for removable contamination fixed surface contamination and radiation dose rates qualify the facilities for release for unrestricted use per 10 CFR 20 subpart E Radiological Criteria for License Termination and the Nuclear Regulatory Commission (NRC) document entitled Guidelines for Decontamination of Facilities and Equipment Prior to Release for Unrestricted Use Table 1 A copy of the signed CT DEEP Radioactive Materials and Industrial X-Ray Device Registration (termination) form is enclosed
Respectfully Submitted
---r- 1rY~ (hlt- f- -c v
Izabela J Puskarz Radiation Safety Officer BioRelix Inc
Enclosures cc CT DEEP - Central Pennit Processing Unit Attn Andrew Zwick 79 Elm Street Hartford CT 06106 860-424-3035
gt
tlRCFCfIIlUgt40 15 ftPP=R-HNoEAM) FACILITY EHPIgtat II) lit IMC t5QJUrKlS4M PAGef_l~ 8~tI~
ae~QoupInI NtA MMfOIIWM~ OF _1~ (IJoo _ _ DIfI
UNIFORM LOW-LEVl5L 1WlI0ACnVE 1145cWaaenscn Court XI~ - --1-JIG~ WASTEMANlFSST L4IiIlyeniIeKY 40299 -shy ~(amp) ro-201~middot28S
SliIlPlMG PNa it---~ ~ -_ ~_WtJlY_ ~ t_~_E~_~
T-KY(l(G112 rroxCO Inc RiCkLcw 8OC-424-Q300 COCTACT 1aIAItflltt 109 F1intRoad IT~ Nlimber(1Dcbde _ COde)
~ Janet eater BliS25G4593 Oak RidQe IN3183O 886-4S2-S532 CHEMTREC IB~ NAUENJOAI)f)RESS reAI[)~
-~--DaSeo
Ilf~WC~ III01IIUIIIIlERCII iSJ Transpollaltln Co tnc NJD0716299i5
xJ YES _1OIlH1IID 3 PO Boic i 69shy lIH_ampWE 10Qetilication NO TIIS_ Woortsawn NJ 0SEl9S 1011112012 ~~___Dl___W-C~
lIIIPIonCI [ lYES m_JiIWIIIR CCNTAC1 lEllPHOIElII ~~_~~~Ml - [X J NO Kevln Elder 866-169-2741 __~~__~-n___
---shy ~~t~ OiltTE -l)~~~~ TITIE tIPJE CU-flttshy bull Ggt~ r~I~ (C-lt-t2
1fl1amp DEPMJIEN QIl_A11ltlfI~ i2 110 I~ 5 II 11 -shy 1IIlD ~_~___UIID_
DotWlil -shy ~- - TOTAlPAC~ IJiWSCO _ _Of -It__ - ~1aIM _1laIleS IICTIIffi IN UBq CtiOCSS m3 -UN2910 Ratlloadive material ~ package- IJIA NIA SoJidIOxfde H--3 P-32 P-33 536E+02 NlA D212 To-CT-E-1~-eD4
limited quantity ofmalEftal T
On~ drum with DAW far dlsllO$al UN2910 RadioacWe materia~ exceptied package- NtA NlA SOlidOxide H--3 P-32 P-33 S~E+02 NfA 1)212 TO-CT-amp12-005 limiied qlisnlity of mafamprilaJ 7
One dlllOl wlth CAW dlarps foe disposalINon oar Regltlated Material NlA NlA liquidlOraquoie P-32 7nE+OO NlA 0114 lO--L$-E-12e06
One drum wittt ampQUeolS$ lIalAd l1on-haz ISV fer dIsc )Sal ~ -
GElMratar CeTtificatioo Satement tnre cansituenl$ of1t1e Waste mafifested herein are 1rnown to tile getlererlor Theft are no EPA ReM patboael1icor o1iIer hazards pmenhlUlElrthan those specilleally listed on the Foms541
1p~q ez S~ ~ PrlJ1tnams ---shy ___~natutle __ ___ _ _ _
OOIgtlSIGNEE QRI(JI1tW MUST ACCOMPAlNWASTE IN rWINlm
~_1lOtoIIoI_
INU_
srewNUClEAAIlATlORlAl(a _ - -shyUNIFORM LOWEVEL RADIOACTIVE -shy _Ill
_ lJ2S3shy t U-235 Pu TOTAl TQ2012286
WASTe MANIFEST 3 0538 no ta-COtnA1tIERANOWA$IEDESCRrFTlON PAGE 1 OF I PAGiSrm
ACiTMlY SOORCpound SHfPfER WM AU1-UOIlIleS T lRInJIpound T Co14 I Tc4 I-m Im Chase E~v GrDUJ)
1085+03 MflQ TS61E+02f NP I NIP NIP NIP fsitFPElR 10 KJbllBER 290E+01 mCl 1976amp001 1 NJA
DlSPOSAL()OHAIIampOEBCRIPTlON ~I5SCaJPTlO~ 1OR5Itf WASTETlPE 1N00NTJiIIMSR shySccmAIIIER ~ 1 II
s_ shy ~IIS9CIIIPT1OH ~~- 161Ia~_
~ -shy -shy -shy - n_ ~ shy - ~---- shy- _M - lIId - shy - - - p-----shy -shy-shy 1t (m3) - 11shy -shy - _-r - --shy _ ~~ tkrl~ shy - - IIoo_ Em --shy 11 01 Nuclrae MBa mCI
_0 TO-Cfe12-604 0212 lt5(10 lt361amp6 lt367E-5 39 l212 jeD OxidaINP NP K-S 242aQ2 Gs~E+OD NfA
1159 Pa2 18QE+02 486E+OD
4G F-33 1tgtlE+a2 3tItaOl
P~t1claJ 53SE+02 1A5E+01TQCT-E-12-605 4 0212 lt500 lt3S1E-S lt367amp0 39 0212 100 NP fiS 24~ eB3E+OO NfA1159
Jt f32 1a1E+02 4IIBEoo p~ 114EltfOli 301E+C0
~1ltane1Cllil1 s3tJE+02 ~ TQlSE-12-606 A of14 0$00 lt367E-6 lt3amp75-$ 2559 0114 100 0lddeNP If P-S2 771E+OO 210amp011159 3 ~I Water IIOn-haz lJN Pa~tofal 777E+W 2fQen1
yen p 10P
~1__~_lltIt_
~---tWA__ ____shy -__shyI-o__n____
JItshy ~- _shy r--~1-s----_~11~1 ~1t---_lII__ p_ ~~ --shy shy ~ shy~ --shy ~ -_ 0shy pshy trt c~ t-Dd -shy - _shy shy DO_10- _-shy _shy -shy ~-
- - lItIIIR1rDr
01 __ -~-- shy ta-shy _JrIIII --_ ia2-1IojI -shy _1 -shy shyDIItiur shy 1--shy --- ~ ~ -shy IIshy shy~~clhll - 10- __ --shy ~- ~HIDOI _ T~U -shy-- _shy shy ~~- ~0IIMtt ~1It11or bull ~_T 1t~3130 ~IItIIIIdttIQ
Ir __ _ - -shy ~~
1J __
_shy
I i I
~ t3
0 d gt
I m ~
I i ~ g
2 I ~ g I s
q
~ 8 0 d
S 12
I II ~ ~ sect
I d
II ~ I t
Ii If
id i ampII 0
-I I ~
I ti IIi
lot I ~~ Ii II~I II I i
I~ ti 1l
101 i g If
T ~ fO
I i I ~ I~b
I I 11lt[ i
8~
~ I~i 0
~ ~ I 101 i I
IIi I pIi ~ I II II
Si I I i ci ~ = ~ - i
sect iI I ~ -IL fa
II IB i
It II
I
Key 309 B
~ ~ (fJ Olraquo
0 ampJS3 rTl1j
l -Z n rTl
r~ flkr (fJraquorTl 5 n
9 m
T ~1middot~~~~~~Imiddot~112Bmiddotmiddot3119~~ili1()middotBmiddot3119~i9iBI3i119Il8filiBmiddot31111i9~BI7B1i3iic1li9I~Iii-nuiigiiii1Iii19IIl5IBmiddot3~191~B4IBmiddot3i1ii19~B~3iBi3middot19IBili2BIllli311l9il1H~IOoi~i51i111middotIIBi)iIiI2RmiddotlI3231nmfuge iyen8 319W 319Microwave r- I I I
I 319BIOA I ~ 3215BLA 321BRA ~
1319B12A I 319B9A 3191l8A 319~7A 319116A 319B5A 319B4A 319B3A 319B2A319Sdnti amp I ~ 319B105 1319B9EI 319S~aker I U 319825J L321S~bull
I 321SA
1 bull ( l
~ ~ ~31amps(f) - ~~-JCit)
csect) e e reg etr)-~I J
(sectV ~
Hlt shy ~r Mtl~1 It~ -
JnA T1+ +rV+ oAr j Ii 8 el L (amp aor ~J U I 309BSC
Figure 1 Site Plan BioRelix
5 Science Park 3rd Floor New Haven CT
TRIUMVIRATE TRIUMVIRATE ENVIRONMENTAL INC
ENViRONMENTAL 200 Inner Belt Road Somerville MA 02143
(800) 966-9282 Fax (617) 628-8099
gt
1 UZlpound bull Ji
e LJ
rreg ~9 middotu
J J e
6
~ l nr Z 3 r l
~
( ~ e
e E
~ ~ ~i
0 1 rTl
l r rTl shy
Assay Definition-
Assay Description Wipe Test
Assay Type CPM Report Name Report1 Output Data Path CPackardTricarbResultswipe testwipe test20121015 1702 Raw Results Path CPackardTricarbResu1tswipe testwipe test20l21015 170220121015 1702results Comma-Delimited File Name CPackardTricarbResultswipe testwipe test201210 02Report1csv Assay File Name CPackardTriCarbAssayswipe testlsa
Count Conditions-
Nuclide 3H-14C-32P Quench Indicator tSIE External Std Terminator (sec) 05 2s Pre-Count Delay (min) 000
Quench Set na Count Time (min) 100 Count Mode Normal Assay Count Cycles 1 Sample Count 1 VialsSamp1e 1 Calculate Reference Off
Background Subtract Off Low CPM Threshold Off 2 Sigma Terminator Off
Regions LL UL A 00 120 B 120 1560 C 1560 17000
Count Corrections-
Static Controller On Luminescence Correction Off Colored na Heterogeneity Monitor na Coincidence Time (nsec) 18 Delay Before Burst (nsec) 75
Half Life-
Half Life Correction Off Regions Half Life Units Reference Date Reference Time A B
C
Cycle 1 Results S Count Time CPMA MESSAGES CPMB CPMC
1 1 00 20 14 7 2 1 00 18 7 4 3 1 00 20 14 2 4 1 00 18 12 7
5
10
15
20
25
30
35
40
45
50
55
60
1 00 14 l7 8 6 1 00 11 15 6 7 1 00 17 23 11 8 1 00 18 10 3 9 100 23 13 4
1 00 l3 20 5 11 1 00 12 8 8 12 1 00 15 11 6 l3 1 00 17 l7 6 14 1 00 14 l7 7
1 00 16 11 9 16 1 00 12 11 7 l7 100 19 15 5 18 1 00 20 11 12 19 1 00 19 12 10
1 00 12 14 10 21 1 00 16 15 5 22 1 00 12 8 12 23 1 00 19 18 12 24 1 00 5 l7 5
1 00 19 12 5 26 1 00 20 13 6 27 1 00 l7 14 9 28 100 16 17 6 29 1 00 19 9 3
1 00 25 13 6 31 1 00 14 13 5 32 1 00 14 7 5 33 1 00 9 20 6 34 1 00 13 9 10
1 00 20 28 8 36 100 31 24 10 37 1 00 19 20 5 38 1 00 19 11 9 39 1 00 568 l7 8
1 00 16 10 7 41 1 00 15 8 9 42 1 00 30 13 6 43 1 00 18 12 8 44 1 00 11 13 11
1 00 19 12 12 46 100 11 13 7 47 1 00 13 16 10 48 1 00 23 14 7 49 1 00 12 11 3
1 00 14 13 6 51 1 00 15 21 4 52 1 00 15 18 8 53 1 00 18 12 3 54 1 00 16 11 9
1 00 23 9 9 56 1 00 l7 11 6 57 1 00 21 23 4 58 1 00 15 13 10 59 100 15 11 6
1 00 11 20 10 61 1 00 23 7 8
62 1 00 63 1 00 64 1 00 65 1 00 66 1 00 67 1 00 68 1 00 69 1 00 70 1 00 71 1 00 72 1 00 73 1 00 74 1 00
19 25 20 11 25 13 18 13 27 22 17 20 19
12 5 12 4
9 3 13 4
7 7 17 5 12 14
7 9 12 9 17 7 19 5 12 4 19 4
Assay Definition-
Assay Description Wipe Test
Assay Type CPM Report Name Reportl Output Data Path CPackardTricarbResultswipe testwipe test20121018 1436 Raw Results Path CPackardTricarbResultswipe testwipe test20121018 143620121018 1436results Comma-Delimited File Name CPackardTricarbResultswipe testwipe test20121018 436Reportlcsv Assay File Name CPackardTriCarbAssayswipe testlsa
Count Conditions-
Nuclide 3H-14C-32P Quench Indicator tSIE External Std Terminator (sec) 05 2s Pre-Count Delay (min) 000
Quench Set na Count Time (min) 100 Count Mode Normal Assay Count Cycles 1 Repeat Sample Count 1 VialsSample 1 Calculate Reference Off
Background Subtract Off Low CPM Threshold Off 2 Sigma Terminator Off
Regions LL UL A 00 120 B 120 1560 C 1560 17000
Count Corrections-
Static Controller On Luminescence Correction Off Colored Samples na Heterogeneity Monitor na Coincidence Time (nsec) 18 Delay Before Burst (nsec) 75
Half Life-
Half Life Correction Off Regions Half Life Units Reference Date Reference Time A B C
Cycle 1 Results S Count Time CPMA MESSAGES CPMB CPMC
1 1 00 20 18 5 2 1 00 8 4 5 3 1 00 15 16 12
1
2 3
4
5
6
7
8
9
10 11
12 13
14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
34 35 36 37 38 39 40 41 42 43
SUMMARY OF SITE PLAN AND SWIPE TEST RESULTS
dpm H3 dpm C14 dpm P32 on the plan swipe sample cpmH3 cpm C14 cpm P32
31 15 7 316 18 7 4 background 20 14 7
28 7 4
318S 20 14 2 31 15 2 321SA 18 12 7 28 13 7
321BRA 14 17 8 22 18 8
321BRB 11 15 6 17 16 6
321Centrifuge 17 23 11 27 24 11 321Thermo 18 10 3 28 10 3
3215VWR 23 13 4 36 14 4
3215BlB 13 20 5 20 21 5
3215BLA 12 8 8 19 8 8
321SB 15 11 6 23 11 6
319Scint 17 17 6 27 18 6
319Hood 14 17 7 22 18 7
319B2A 16 11 9 25 11 9
319B2B 12 11 7 19 11 7
319B2S 19 15 5 30 16 5
319B3A 20 11 12 31 11 12 319B3B 19 12 10 30 13 10 319B4A 12 14 10 19 15 10
319B4B 16 15 5 25 16 5
319B5A 12 8 12 19 8 12 319B5B 19 18 12 30 19 12 319B6A 5 17 5 8 18 5
319B6B 19 12 5 30 13 5 319Ce ntrifuge 20 13 6 31 14 6 319Shaker 17 14 9 27 15 9
319B7A 16 17 6 25 18 6
319B7B 19 9 3 30 9 3 319B8A 25 13 6 39 14 6
319B8B 14 13 5 22 14 5 319B9E 14 7 5 22 7 5 319B9A 9 20 6 14 21 6 319B9B 13 9 10 20 9 10 319BlOA 20 28 8 31 29 8 319Microwave 31 24 10 48 25 10 319B10B 19 20 5 30 21 5
319B10S 19 11 9 30 11 9 319W 568 17 8 888 18 8 319B12A 16 10 7 25 10 7 319B12B 15 8 9 23 8 9 309B12E 30 13 6 47 14 6 309B12A 18 12 8 28 13 8
309B12B 44 11 13 11 17 14 11
309B11A 45 19 12 12 30 13 12
309B11B 46 11 13 7 17 14 7
309BlOE 47 13 16 10 20 17 10
309BlOA 48 23 14 7 36 15 7
309Bl0B 49 12 11 3 19 11 3
309B9A 50 14 13 6 22 14 6
309B9B 51 15 21 4 23 22 4
309B85 52 15 18 8 23 19 8
309B8A 53 18 12 3 28 13 3 309B8RS 54 16 11 9 25 11 9 309B7A 55 23 9 9 36 9 9 309B7B 56 17 11 6 27 11 6 309B6E 57 21 23 4 33 24 4 309B6A 58 15 13 10 23 14 10 309B6B 59 15 11 6 23 11 6 309B5A 60 11 20 10 17 21 10 309B5B 61 23 7 8 36 7 8 309B5C 62 19 12 5 30 13 5 309B4E 63 25 12 4 39 13 4 309B4A 64 20 9 3 31 9 3 309B4B 65 11 13 4 17 14 4 309B3A 66 25 7 7 39 7 7 309B3B 67 13 17 5 20 18 5 309B25 68 18 12 14 28 13 14 309B2 69 13 7 9 20 7 9 309B1A 70 27 12 9 42 13 9 309B1C 71 22 17 7 34 18 7 QAQC 72 17 19 5 27 20 5 QAQC 73 20 12 4 31 13 4 QAQC 74 19 19 4 30 20 4
Sample key 309 Room number e for 3H=064 dpm=cpme
Sample surface BshyB bench S-sink e for 14C=096 6 Bench number e for 32P=10
Description or E sequence
REPEAT OF THE RESULTS IN QUESTION
plan sample cpmH3 cpm C14 cpm P32 dpmH3 dpm C14 dpm P32 background 1 20 18 5 31 19 5 319Wa 2 8 4 5 13 4 5
319W b 3 15 16 12 23 17 12
Connecticut Department of Energy amp Environmental Protection Bureau of Air Management Radiation Division
Radioactive Material and Industrial X-Ray Device Registration
Please complete this form in accordance with the instructions (DEP-RAD-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation along with this form Please retain a copy of this completed form at your facility
Part I Registration Type
CPPU USE ONLY
App____________
Doc ______________
Check ____________
Program Radiation
Requested Year of Registration Period materials license termination
Registrations are based on the calendar year January 1st through December 31 stbull
Provide Permit Number (aka Facility ID see DEEP correspondence to
Check the appropriate box(es) identifying the registration type
D new registration (ie never registered with the DEEP) [221] registrant)
D new ownership [221] 01576
D renewal of an existing registration [221] If renewing or amending an existing
181 amendment to an existing registration [1467] registration please indicate any changes to tile existing registration information by using reel ink
Note If you are terminating your registration or removing a device(s) from registration refer to the registration instructions (DEP-RAD-INST-100) for required documentation necessary to comply with DEEP requirements
own I(here site is located New Haven
Part II Fee Information
An annual registration fee of $20000 is to be submitted by December 31 S with each registration and applies for the period covering the requested calendar year The fee is not pro-rated New registrants are required to pay the fee regardless of when they register with the DEEP There is no fee for amendments The registration will not be processed without the fee The fee shall be non-refundable and shall be paid by check or money order to the Department of Energy and Environmental Protection
Part III Registrant Information
bull If a registrant is a corporation limited liability company limited partnership limited liability partnership or a statutory trost it must be registered with the Secretary of State If applicable registrants name shall be stated exactly as it is registered with the Secretary of State Please note for those entities registered with the Secretary of State the registered name will be the name used by DEEP This information can be accessed at the Secretary of States database (CONCORD) (wwwconcord-sotsctgovICONCORDlindexjsp)
bull If a registrant is an individual provide the legal name (include suffix) in the following format First Name Middle Initial Last Name Suffix (Jr Sr II III etc)
DEP-RAD-REG-100 1 of 9 Rev 103112
Part III Registrant Information (continued)
1 Registrant Name BioRelix Inc
Mailing Address 5 Science Park (401 Winchester Avenue)
CitylTown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
Contact Person Izabela Puskarz Phone (203) 785-9282 ext 305
E-mail ipuskarzbiorelixcom
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from nctgov addresses Also please notify the department if your e-mail address changes
a) Registrant Type (check one) 0 individual [8J business entity o federal agency
o state agency o municipality tribal
If a business entity (If a business entity complete i through iii)
i) check type [8J corporation 0 limited liability company o limited partnership o Other ________o limited liability partnership 0 statutory trust
ii) provide Secretary of the State business ID ~08~67~696~___This information can be accessed at CONCORD
iii) 0 Check here if you are NOT registered with the SOTS
b) Registrants interest in property at which the proposed activity is to be located
o site owner 0 option holder [8J lessee 0 easement holder operator
o other (specify)
o Check here if any co-registrants If so attach additional sheet(s) with the required information as requested above
2 List billing contact if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
3 List primary contact for departmental cprrespondence and inquiries if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from ctgov addresses Also please notify the department if your e-mail address changes
DEP-RAD-REG-100 2of9 Rev 103112
---
Part III Registrant Information (continued)
4 List the Radiation Safety Officer (RSO) There must be one RSO listed per registration
Name Izabela J Puskarz
Direct Phone (203) 785-9282 ext 305 Fax (203) 785-8058
E-Mail Addressipuskarzbiorelixcom
24-Hour Emergency Phone ~---
List other contact people in the radiation safety section
Name Kenneth F Blount
Title Director of Biology
Direct Phone (203) 785-9282 ext 302 Fax (203) 785-8058
E-Mail Addresskblountbiorelixcom
24-Hour Emergency Pho
Name Brian R Dixon
Title President and CEO
Direct Phone (203) 785-9282 ext 303 Fax (203) 785-8058
E-Mail Addressbdizonbiorelixcom
24-Hour Emergency Phone
Part IV Site Information
1 Company Name BioRelix Inc
Site Name (if different)
Address 5 Science Park (401 Winchester Avenue)
Cityrrown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
2 Location of Material (if different than above)
Cityrrown State Zip Code
Part V NRC Licenses
For new licenses attach a copy of each license for renewals or modifications attach any amended pages of each license
06-31263-01 3 August 312017
DEP-RAD-REG-100 30f9 Rev 103112
Part VI Personnel Dosimetry
1 Indicate whether personnel dosimetry is performed at your facility Yes t8J No
2 If yes indicate the name of vendor that provides this service
Part VII Compliance
If you answer yes to any of the questions below you must complete Part VIII Table of Enforcement Actions as directed in the instructions for your registration
A During the five years immediately preceding submission of this registration has the registrant been convicted in any jurisdiction of a criminal violation of any environmental law
DYes t8J No
B During the five years immediately preceding submission of this registration has a civil penalty been imposed upon the registrant in any state including Connecticut or federal judicial proceeding for any other violation of an environmental law
DYes t8J No
C During the five years immediately preceding submission of this registration has a civil penalty exceeding five thousand dollars been imposed on the registrant in any state including Connecticut or federal administrative proceeding for any violation of an environmental law
DYes t8J No
D During the five years immediately preceding submission of this registration has any state including Connecticut or federal court issued any order or entered any judgment to the registrant concerning a violation of any environmental law
DYes t8J No
E During the five years immediately preceding submission of this registration has any state including Connecticut or federal administrative agency issued any order to the registrant concerning a violation of any environmental law
DYes t8J No
DEP-RAD-REG-100 4of9 Rev 103112
Part VIII Table of Enforcement Actions
Type of Action Type of Action Type of Action
Date Commenced Date Commenced Date Commenced
Date Terminated Date Terminated Date Terminated
Jurisdiction Jurisdiction Jurisdiction
CaselDocketlOrder Number CaselDocketlOrder Number CaseDocketlOrder Number
Description of Violation Description of Violation Description of Violation
D Check the box if additional sheets are attached Copies of this form may be duplicated for additional space
DEP-RAD-REG-100 50f9 Rev 1013112
For Parts IX through XVI you may hit the tab button at the end of each table in the last cell and create additional rows
Part IX Industrial X-Ray Equipment
Part X Analytic Equipment for Examination of Material
aXlimum mA
~~t JiUIp
(Including but not limited to X-ray diffraction units electron microscopes gauging devices spectroscopic equipment gas chromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or therapy)
MQttatltl I t
Serial Manufacturer r~ M~_ilil I Maximum mA
Part XI Industrial Radiographic Equipment
(For examination of structure with a sealed source)
I I TYRe Model ibmll Serial I Manufactu~middot l i i
Part XII Particle Accelerators
(Including but not limited to Van de Graffs Linacs Cyclotrons Electronic Beam Welders)
lI~f ler1 bull Ma~ufacturer p~Itf ii
DEP-RAD-REG-100 6 af9 Rev 103112
Part XIII Special Nuclear Material (Special nuclear material [SNM] refers to plutonium 233U uranium enriched in the isotope 233 or in the isotope 235 greater than its natural abundance and any other material which the US NRC pursuant to the provisions of Section 510f the Atomic Energy Act of 1954 determines to be special nuclear material SNM does not include source material)
Part XIV Source Material
(Source material [SM] refers to uranium or thorium or any combination thereof in any physical or chemical form or ores which contain at least 005 by weight uranium thorium or any combination thereof except when the material is designated as special nuclear material)
Part XV Sealed Sources
No1~er ofSikrcesltc
Part XVI Other Radioactive Materials (including medical isotopes)
3 Hydrogen 25mCi
33 Phosphorous 25mCi
DEP-RAD-REG-100 7of9 Rev 103112
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
Enclosures cc CT DEEP - Central Pennit Processing Unit Attn Andrew Zwick 79 Elm Street Hartford CT 06106 860-424-3035
gt
tlRCFCfIIlUgt40 15 ftPP=R-HNoEAM) FACILITY EHPIgtat II) lit IMC t5QJUrKlS4M PAGef_l~ 8~tI~
ae~QoupInI NtA MMfOIIWM~ OF _1~ (IJoo _ _ DIfI
UNIFORM LOW-LEVl5L 1WlI0ACnVE 1145cWaaenscn Court XI~ - --1-JIG~ WASTEMANlFSST L4IiIlyeniIeKY 40299 -shy ~(amp) ro-201~middot28S
SliIlPlMG PNa it---~ ~ -_ ~_WtJlY_ ~ t_~_E~_~
T-KY(l(G112 rroxCO Inc RiCkLcw 8OC-424-Q300 COCTACT 1aIAItflltt 109 F1intRoad IT~ Nlimber(1Dcbde _ COde)
~ Janet eater BliS25G4593 Oak RidQe IN3183O 886-4S2-S532 CHEMTREC IB~ NAUENJOAI)f)RESS reAI[)~
-~--DaSeo
Ilf~WC~ III01IIUIIIIlERCII iSJ Transpollaltln Co tnc NJD0716299i5
xJ YES _1OIlH1IID 3 PO Boic i 69shy lIH_ampWE 10Qetilication NO TIIS_ Woortsawn NJ 0SEl9S 1011112012 ~~___Dl___W-C~
lIIIPIonCI [ lYES m_JiIWIIIR CCNTAC1 lEllPHOIElII ~~_~~~Ml - [X J NO Kevln Elder 866-169-2741 __~~__~-n___
---shy ~~t~ OiltTE -l)~~~~ TITIE tIPJE CU-flttshy bull Ggt~ r~I~ (C-lt-t2
1fl1amp DEPMJIEN QIl_A11ltlfI~ i2 110 I~ 5 II 11 -shy 1IIlD ~_~___UIID_
DotWlil -shy ~- - TOTAlPAC~ IJiWSCO _ _Of -It__ - ~1aIM _1laIleS IICTIIffi IN UBq CtiOCSS m3 -UN2910 Ratlloadive material ~ package- IJIA NIA SoJidIOxfde H--3 P-32 P-33 536E+02 NlA D212 To-CT-E-1~-eD4
limited quantity ofmalEftal T
On~ drum with DAW far dlsllO$al UN2910 RadioacWe materia~ exceptied package- NtA NlA SOlidOxide H--3 P-32 P-33 S~E+02 NfA 1)212 TO-CT-amp12-005 limiied qlisnlity of mafamprilaJ 7
One dlllOl wlth CAW dlarps foe disposalINon oar Regltlated Material NlA NlA liquidlOraquoie P-32 7nE+OO NlA 0114 lO--L$-E-12e06
One drum wittt ampQUeolS$ lIalAd l1on-haz ISV fer dIsc )Sal ~ -
GElMratar CeTtificatioo Satement tnre cansituenl$ of1t1e Waste mafifested herein are 1rnown to tile getlererlor Theft are no EPA ReM patboael1icor o1iIer hazards pmenhlUlElrthan those specilleally listed on the Foms541
1p~q ez S~ ~ PrlJ1tnams ---shy ___~natutle __ ___ _ _ _
OOIgtlSIGNEE QRI(JI1tW MUST ACCOMPAlNWASTE IN rWINlm
~_1lOtoIIoI_
INU_
srewNUClEAAIlATlORlAl(a _ - -shyUNIFORM LOWEVEL RADIOACTIVE -shy _Ill
_ lJ2S3shy t U-235 Pu TOTAl TQ2012286
WASTe MANIFEST 3 0538 no ta-COtnA1tIERANOWA$IEDESCRrFTlON PAGE 1 OF I PAGiSrm
ACiTMlY SOORCpound SHfPfER WM AU1-UOIlIleS T lRInJIpound T Co14 I Tc4 I-m Im Chase E~v GrDUJ)
1085+03 MflQ TS61E+02f NP I NIP NIP NIP fsitFPElR 10 KJbllBER 290E+01 mCl 1976amp001 1 NJA
DlSPOSAL()OHAIIampOEBCRIPTlON ~I5SCaJPTlO~ 1OR5Itf WASTETlPE 1N00NTJiIIMSR shySccmAIIIER ~ 1 II
s_ shy ~IIS9CIIIPT1OH ~~- 161Ia~_
~ -shy -shy -shy - n_ ~ shy - ~---- shy- _M - lIId - shy - - - p-----shy -shy-shy 1t (m3) - 11shy -shy - _-r - --shy _ ~~ tkrl~ shy - - IIoo_ Em --shy 11 01 Nuclrae MBa mCI
_0 TO-Cfe12-604 0212 lt5(10 lt361amp6 lt367E-5 39 l212 jeD OxidaINP NP K-S 242aQ2 Gs~E+OD NfA
1159 Pa2 18QE+02 486E+OD
4G F-33 1tgtlE+a2 3tItaOl
P~t1claJ 53SE+02 1A5E+01TQCT-E-12-605 4 0212 lt500 lt3S1E-S lt367amp0 39 0212 100 NP fiS 24~ eB3E+OO NfA1159
Jt f32 1a1E+02 4IIBEoo p~ 114EltfOli 301E+C0
~1ltane1Cllil1 s3tJE+02 ~ TQlSE-12-606 A of14 0$00 lt367E-6 lt3amp75-$ 2559 0114 100 0lddeNP If P-S2 771E+OO 210amp011159 3 ~I Water IIOn-haz lJN Pa~tofal 777E+W 2fQen1
yen p 10P
~1__~_lltIt_
~---tWA__ ____shy -__shyI-o__n____
JItshy ~- _shy r--~1-s----_~11~1 ~1t---_lII__ p_ ~~ --shy shy ~ shy~ --shy ~ -_ 0shy pshy trt c~ t-Dd -shy - _shy shy DO_10- _-shy _shy -shy ~-
- - lItIIIR1rDr
01 __ -~-- shy ta-shy _JrIIII --_ ia2-1IojI -shy _1 -shy shyDIItiur shy 1--shy --- ~ ~ -shy IIshy shy~~clhll - 10- __ --shy ~- ~HIDOI _ T~U -shy-- _shy shy ~~- ~0IIMtt ~1It11or bull ~_T 1t~3130 ~IItIIIIdttIQ
Ir __ _ - -shy ~~
1J __
_shy
I i I
~ t3
0 d gt
I m ~
I i ~ g
2 I ~ g I s
q
~ 8 0 d
S 12
I II ~ ~ sect
I d
II ~ I t
Ii If
id i ampII 0
-I I ~
I ti IIi
lot I ~~ Ii II~I II I i
I~ ti 1l
101 i g If
T ~ fO
I i I ~ I~b
I I 11lt[ i
8~
~ I~i 0
~ ~ I 101 i I
IIi I pIi ~ I II II
Si I I i ci ~ = ~ - i
sect iI I ~ -IL fa
II IB i
It II
I
Key 309 B
~ ~ (fJ Olraquo
0 ampJS3 rTl1j
l -Z n rTl
r~ flkr (fJraquorTl 5 n
9 m
T ~1middot~~~~~~Imiddot~112Bmiddotmiddot3119~~ili1()middotBmiddot3119~i9iBI3i119Il8filiBmiddot31111i9~BI7B1i3iic1li9I~Iii-nuiigiiii1Iii19IIl5IBmiddot3~191~B4IBmiddot3i1ii19~B~3iBi3middot19IBili2BIllli311l9il1H~IOoi~i51i111middotIIBi)iIiI2RmiddotlI3231nmfuge iyen8 319W 319Microwave r- I I I
I 319BIOA I ~ 3215BLA 321BRA ~
1319B12A I 319B9A 3191l8A 319~7A 319116A 319B5A 319B4A 319B3A 319B2A319Sdnti amp I ~ 319B105 1319B9EI 319S~aker I U 319825J L321S~bull
I 321SA
1 bull ( l
~ ~ ~31amps(f) - ~~-JCit)
csect) e e reg etr)-~I J
(sectV ~
Hlt shy ~r Mtl~1 It~ -
JnA T1+ +rV+ oAr j Ii 8 el L (amp aor ~J U I 309BSC
Figure 1 Site Plan BioRelix
5 Science Park 3rd Floor New Haven CT
TRIUMVIRATE TRIUMVIRATE ENVIRONMENTAL INC
ENViRONMENTAL 200 Inner Belt Road Somerville MA 02143
(800) 966-9282 Fax (617) 628-8099
gt
1 UZlpound bull Ji
e LJ
rreg ~9 middotu
J J e
6
~ l nr Z 3 r l
~
( ~ e
e E
~ ~ ~i
0 1 rTl
l r rTl shy
Assay Definition-
Assay Description Wipe Test
Assay Type CPM Report Name Report1 Output Data Path CPackardTricarbResultswipe testwipe test20121015 1702 Raw Results Path CPackardTricarbResu1tswipe testwipe test20l21015 170220121015 1702results Comma-Delimited File Name CPackardTricarbResultswipe testwipe test201210 02Report1csv Assay File Name CPackardTriCarbAssayswipe testlsa
Count Conditions-
Nuclide 3H-14C-32P Quench Indicator tSIE External Std Terminator (sec) 05 2s Pre-Count Delay (min) 000
Quench Set na Count Time (min) 100 Count Mode Normal Assay Count Cycles 1 Sample Count 1 VialsSamp1e 1 Calculate Reference Off
Background Subtract Off Low CPM Threshold Off 2 Sigma Terminator Off
Regions LL UL A 00 120 B 120 1560 C 1560 17000
Count Corrections-
Static Controller On Luminescence Correction Off Colored na Heterogeneity Monitor na Coincidence Time (nsec) 18 Delay Before Burst (nsec) 75
Half Life-
Half Life Correction Off Regions Half Life Units Reference Date Reference Time A B
C
Cycle 1 Results S Count Time CPMA MESSAGES CPMB CPMC
1 1 00 20 14 7 2 1 00 18 7 4 3 1 00 20 14 2 4 1 00 18 12 7
5
10
15
20
25
30
35
40
45
50
55
60
1 00 14 l7 8 6 1 00 11 15 6 7 1 00 17 23 11 8 1 00 18 10 3 9 100 23 13 4
1 00 l3 20 5 11 1 00 12 8 8 12 1 00 15 11 6 l3 1 00 17 l7 6 14 1 00 14 l7 7
1 00 16 11 9 16 1 00 12 11 7 l7 100 19 15 5 18 1 00 20 11 12 19 1 00 19 12 10
1 00 12 14 10 21 1 00 16 15 5 22 1 00 12 8 12 23 1 00 19 18 12 24 1 00 5 l7 5
1 00 19 12 5 26 1 00 20 13 6 27 1 00 l7 14 9 28 100 16 17 6 29 1 00 19 9 3
1 00 25 13 6 31 1 00 14 13 5 32 1 00 14 7 5 33 1 00 9 20 6 34 1 00 13 9 10
1 00 20 28 8 36 100 31 24 10 37 1 00 19 20 5 38 1 00 19 11 9 39 1 00 568 l7 8
1 00 16 10 7 41 1 00 15 8 9 42 1 00 30 13 6 43 1 00 18 12 8 44 1 00 11 13 11
1 00 19 12 12 46 100 11 13 7 47 1 00 13 16 10 48 1 00 23 14 7 49 1 00 12 11 3
1 00 14 13 6 51 1 00 15 21 4 52 1 00 15 18 8 53 1 00 18 12 3 54 1 00 16 11 9
1 00 23 9 9 56 1 00 l7 11 6 57 1 00 21 23 4 58 1 00 15 13 10 59 100 15 11 6
1 00 11 20 10 61 1 00 23 7 8
62 1 00 63 1 00 64 1 00 65 1 00 66 1 00 67 1 00 68 1 00 69 1 00 70 1 00 71 1 00 72 1 00 73 1 00 74 1 00
19 25 20 11 25 13 18 13 27 22 17 20 19
12 5 12 4
9 3 13 4
7 7 17 5 12 14
7 9 12 9 17 7 19 5 12 4 19 4
Assay Definition-
Assay Description Wipe Test
Assay Type CPM Report Name Reportl Output Data Path CPackardTricarbResultswipe testwipe test20121018 1436 Raw Results Path CPackardTricarbResultswipe testwipe test20121018 143620121018 1436results Comma-Delimited File Name CPackardTricarbResultswipe testwipe test20121018 436Reportlcsv Assay File Name CPackardTriCarbAssayswipe testlsa
Count Conditions-
Nuclide 3H-14C-32P Quench Indicator tSIE External Std Terminator (sec) 05 2s Pre-Count Delay (min) 000
Quench Set na Count Time (min) 100 Count Mode Normal Assay Count Cycles 1 Repeat Sample Count 1 VialsSample 1 Calculate Reference Off
Background Subtract Off Low CPM Threshold Off 2 Sigma Terminator Off
Regions LL UL A 00 120 B 120 1560 C 1560 17000
Count Corrections-
Static Controller On Luminescence Correction Off Colored Samples na Heterogeneity Monitor na Coincidence Time (nsec) 18 Delay Before Burst (nsec) 75
Half Life-
Half Life Correction Off Regions Half Life Units Reference Date Reference Time A B C
Cycle 1 Results S Count Time CPMA MESSAGES CPMB CPMC
1 1 00 20 18 5 2 1 00 8 4 5 3 1 00 15 16 12
1
2 3
4
5
6
7
8
9
10 11
12 13
14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
34 35 36 37 38 39 40 41 42 43
SUMMARY OF SITE PLAN AND SWIPE TEST RESULTS
dpm H3 dpm C14 dpm P32 on the plan swipe sample cpmH3 cpm C14 cpm P32
31 15 7 316 18 7 4 background 20 14 7
28 7 4
318S 20 14 2 31 15 2 321SA 18 12 7 28 13 7
321BRA 14 17 8 22 18 8
321BRB 11 15 6 17 16 6
321Centrifuge 17 23 11 27 24 11 321Thermo 18 10 3 28 10 3
3215VWR 23 13 4 36 14 4
3215BlB 13 20 5 20 21 5
3215BLA 12 8 8 19 8 8
321SB 15 11 6 23 11 6
319Scint 17 17 6 27 18 6
319Hood 14 17 7 22 18 7
319B2A 16 11 9 25 11 9
319B2B 12 11 7 19 11 7
319B2S 19 15 5 30 16 5
319B3A 20 11 12 31 11 12 319B3B 19 12 10 30 13 10 319B4A 12 14 10 19 15 10
319B4B 16 15 5 25 16 5
319B5A 12 8 12 19 8 12 319B5B 19 18 12 30 19 12 319B6A 5 17 5 8 18 5
319B6B 19 12 5 30 13 5 319Ce ntrifuge 20 13 6 31 14 6 319Shaker 17 14 9 27 15 9
319B7A 16 17 6 25 18 6
319B7B 19 9 3 30 9 3 319B8A 25 13 6 39 14 6
319B8B 14 13 5 22 14 5 319B9E 14 7 5 22 7 5 319B9A 9 20 6 14 21 6 319B9B 13 9 10 20 9 10 319BlOA 20 28 8 31 29 8 319Microwave 31 24 10 48 25 10 319B10B 19 20 5 30 21 5
319B10S 19 11 9 30 11 9 319W 568 17 8 888 18 8 319B12A 16 10 7 25 10 7 319B12B 15 8 9 23 8 9 309B12E 30 13 6 47 14 6 309B12A 18 12 8 28 13 8
309B12B 44 11 13 11 17 14 11
309B11A 45 19 12 12 30 13 12
309B11B 46 11 13 7 17 14 7
309BlOE 47 13 16 10 20 17 10
309BlOA 48 23 14 7 36 15 7
309Bl0B 49 12 11 3 19 11 3
309B9A 50 14 13 6 22 14 6
309B9B 51 15 21 4 23 22 4
309B85 52 15 18 8 23 19 8
309B8A 53 18 12 3 28 13 3 309B8RS 54 16 11 9 25 11 9 309B7A 55 23 9 9 36 9 9 309B7B 56 17 11 6 27 11 6 309B6E 57 21 23 4 33 24 4 309B6A 58 15 13 10 23 14 10 309B6B 59 15 11 6 23 11 6 309B5A 60 11 20 10 17 21 10 309B5B 61 23 7 8 36 7 8 309B5C 62 19 12 5 30 13 5 309B4E 63 25 12 4 39 13 4 309B4A 64 20 9 3 31 9 3 309B4B 65 11 13 4 17 14 4 309B3A 66 25 7 7 39 7 7 309B3B 67 13 17 5 20 18 5 309B25 68 18 12 14 28 13 14 309B2 69 13 7 9 20 7 9 309B1A 70 27 12 9 42 13 9 309B1C 71 22 17 7 34 18 7 QAQC 72 17 19 5 27 20 5 QAQC 73 20 12 4 31 13 4 QAQC 74 19 19 4 30 20 4
Sample key 309 Room number e for 3H=064 dpm=cpme
Sample surface BshyB bench S-sink e for 14C=096 6 Bench number e for 32P=10
Description or E sequence
REPEAT OF THE RESULTS IN QUESTION
plan sample cpmH3 cpm C14 cpm P32 dpmH3 dpm C14 dpm P32 background 1 20 18 5 31 19 5 319Wa 2 8 4 5 13 4 5
319W b 3 15 16 12 23 17 12
Connecticut Department of Energy amp Environmental Protection Bureau of Air Management Radiation Division
Radioactive Material and Industrial X-Ray Device Registration
Please complete this form in accordance with the instructions (DEP-RAD-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation along with this form Please retain a copy of this completed form at your facility
Part I Registration Type
CPPU USE ONLY
App____________
Doc ______________
Check ____________
Program Radiation
Requested Year of Registration Period materials license termination
Registrations are based on the calendar year January 1st through December 31 stbull
Provide Permit Number (aka Facility ID see DEEP correspondence to
Check the appropriate box(es) identifying the registration type
D new registration (ie never registered with the DEEP) [221] registrant)
D new ownership [221] 01576
D renewal of an existing registration [221] If renewing or amending an existing
181 amendment to an existing registration [1467] registration please indicate any changes to tile existing registration information by using reel ink
Note If you are terminating your registration or removing a device(s) from registration refer to the registration instructions (DEP-RAD-INST-100) for required documentation necessary to comply with DEEP requirements
own I(here site is located New Haven
Part II Fee Information
An annual registration fee of $20000 is to be submitted by December 31 S with each registration and applies for the period covering the requested calendar year The fee is not pro-rated New registrants are required to pay the fee regardless of when they register with the DEEP There is no fee for amendments The registration will not be processed without the fee The fee shall be non-refundable and shall be paid by check or money order to the Department of Energy and Environmental Protection
Part III Registrant Information
bull If a registrant is a corporation limited liability company limited partnership limited liability partnership or a statutory trost it must be registered with the Secretary of State If applicable registrants name shall be stated exactly as it is registered with the Secretary of State Please note for those entities registered with the Secretary of State the registered name will be the name used by DEEP This information can be accessed at the Secretary of States database (CONCORD) (wwwconcord-sotsctgovICONCORDlindexjsp)
bull If a registrant is an individual provide the legal name (include suffix) in the following format First Name Middle Initial Last Name Suffix (Jr Sr II III etc)
DEP-RAD-REG-100 1 of 9 Rev 103112
Part III Registrant Information (continued)
1 Registrant Name BioRelix Inc
Mailing Address 5 Science Park (401 Winchester Avenue)
CitylTown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
Contact Person Izabela Puskarz Phone (203) 785-9282 ext 305
E-mail ipuskarzbiorelixcom
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from nctgov addresses Also please notify the department if your e-mail address changes
a) Registrant Type (check one) 0 individual [8J business entity o federal agency
o state agency o municipality tribal
If a business entity (If a business entity complete i through iii)
i) check type [8J corporation 0 limited liability company o limited partnership o Other ________o limited liability partnership 0 statutory trust
ii) provide Secretary of the State business ID ~08~67~696~___This information can be accessed at CONCORD
iii) 0 Check here if you are NOT registered with the SOTS
b) Registrants interest in property at which the proposed activity is to be located
o site owner 0 option holder [8J lessee 0 easement holder operator
o other (specify)
o Check here if any co-registrants If so attach additional sheet(s) with the required information as requested above
2 List billing contact if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
3 List primary contact for departmental cprrespondence and inquiries if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from ctgov addresses Also please notify the department if your e-mail address changes
DEP-RAD-REG-100 2of9 Rev 103112
---
Part III Registrant Information (continued)
4 List the Radiation Safety Officer (RSO) There must be one RSO listed per registration
Name Izabela J Puskarz
Direct Phone (203) 785-9282 ext 305 Fax (203) 785-8058
E-Mail Addressipuskarzbiorelixcom
24-Hour Emergency Phone ~---
List other contact people in the radiation safety section
Name Kenneth F Blount
Title Director of Biology
Direct Phone (203) 785-9282 ext 302 Fax (203) 785-8058
E-Mail Addresskblountbiorelixcom
24-Hour Emergency Pho
Name Brian R Dixon
Title President and CEO
Direct Phone (203) 785-9282 ext 303 Fax (203) 785-8058
E-Mail Addressbdizonbiorelixcom
24-Hour Emergency Phone
Part IV Site Information
1 Company Name BioRelix Inc
Site Name (if different)
Address 5 Science Park (401 Winchester Avenue)
Cityrrown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
2 Location of Material (if different than above)
Cityrrown State Zip Code
Part V NRC Licenses
For new licenses attach a copy of each license for renewals or modifications attach any amended pages of each license
06-31263-01 3 August 312017
DEP-RAD-REG-100 30f9 Rev 103112
Part VI Personnel Dosimetry
1 Indicate whether personnel dosimetry is performed at your facility Yes t8J No
2 If yes indicate the name of vendor that provides this service
Part VII Compliance
If you answer yes to any of the questions below you must complete Part VIII Table of Enforcement Actions as directed in the instructions for your registration
A During the five years immediately preceding submission of this registration has the registrant been convicted in any jurisdiction of a criminal violation of any environmental law
DYes t8J No
B During the five years immediately preceding submission of this registration has a civil penalty been imposed upon the registrant in any state including Connecticut or federal judicial proceeding for any other violation of an environmental law
DYes t8J No
C During the five years immediately preceding submission of this registration has a civil penalty exceeding five thousand dollars been imposed on the registrant in any state including Connecticut or federal administrative proceeding for any violation of an environmental law
DYes t8J No
D During the five years immediately preceding submission of this registration has any state including Connecticut or federal court issued any order or entered any judgment to the registrant concerning a violation of any environmental law
DYes t8J No
E During the five years immediately preceding submission of this registration has any state including Connecticut or federal administrative agency issued any order to the registrant concerning a violation of any environmental law
DYes t8J No
DEP-RAD-REG-100 4of9 Rev 103112
Part VIII Table of Enforcement Actions
Type of Action Type of Action Type of Action
Date Commenced Date Commenced Date Commenced
Date Terminated Date Terminated Date Terminated
Jurisdiction Jurisdiction Jurisdiction
CaselDocketlOrder Number CaselDocketlOrder Number CaseDocketlOrder Number
Description of Violation Description of Violation Description of Violation
D Check the box if additional sheets are attached Copies of this form may be duplicated for additional space
DEP-RAD-REG-100 50f9 Rev 1013112
For Parts IX through XVI you may hit the tab button at the end of each table in the last cell and create additional rows
Part IX Industrial X-Ray Equipment
Part X Analytic Equipment for Examination of Material
aXlimum mA
~~t JiUIp
(Including but not limited to X-ray diffraction units electron microscopes gauging devices spectroscopic equipment gas chromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or therapy)
MQttatltl I t
Serial Manufacturer r~ M~_ilil I Maximum mA
Part XI Industrial Radiographic Equipment
(For examination of structure with a sealed source)
I I TYRe Model ibmll Serial I Manufactu~middot l i i
Part XII Particle Accelerators
(Including but not limited to Van de Graffs Linacs Cyclotrons Electronic Beam Welders)
lI~f ler1 bull Ma~ufacturer p~Itf ii
DEP-RAD-REG-100 6 af9 Rev 103112
Part XIII Special Nuclear Material (Special nuclear material [SNM] refers to plutonium 233U uranium enriched in the isotope 233 or in the isotope 235 greater than its natural abundance and any other material which the US NRC pursuant to the provisions of Section 510f the Atomic Energy Act of 1954 determines to be special nuclear material SNM does not include source material)
Part XIV Source Material
(Source material [SM] refers to uranium or thorium or any combination thereof in any physical or chemical form or ores which contain at least 005 by weight uranium thorium or any combination thereof except when the material is designated as special nuclear material)
Part XV Sealed Sources
No1~er ofSikrcesltc
Part XVI Other Radioactive Materials (including medical isotopes)
3 Hydrogen 25mCi
33 Phosphorous 25mCi
DEP-RAD-REG-100 7of9 Rev 103112
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
gt
tlRCFCfIIlUgt40 15 ftPP=R-HNoEAM) FACILITY EHPIgtat II) lit IMC t5QJUrKlS4M PAGef_l~ 8~tI~
ae~QoupInI NtA MMfOIIWM~ OF _1~ (IJoo _ _ DIfI
UNIFORM LOW-LEVl5L 1WlI0ACnVE 1145cWaaenscn Court XI~ - --1-JIG~ WASTEMANlFSST L4IiIlyeniIeKY 40299 -shy ~(amp) ro-201~middot28S
SliIlPlMG PNa it---~ ~ -_ ~_WtJlY_ ~ t_~_E~_~
T-KY(l(G112 rroxCO Inc RiCkLcw 8OC-424-Q300 COCTACT 1aIAItflltt 109 F1intRoad IT~ Nlimber(1Dcbde _ COde)
~ Janet eater BliS25G4593 Oak RidQe IN3183O 886-4S2-S532 CHEMTREC IB~ NAUENJOAI)f)RESS reAI[)~
-~--DaSeo
Ilf~WC~ III01IIUIIIIlERCII iSJ Transpollaltln Co tnc NJD0716299i5
xJ YES _1OIlH1IID 3 PO Boic i 69shy lIH_ampWE 10Qetilication NO TIIS_ Woortsawn NJ 0SEl9S 1011112012 ~~___Dl___W-C~
lIIIPIonCI [ lYES m_JiIWIIIR CCNTAC1 lEllPHOIElII ~~_~~~Ml - [X J NO Kevln Elder 866-169-2741 __~~__~-n___
---shy ~~t~ OiltTE -l)~~~~ TITIE tIPJE CU-flttshy bull Ggt~ r~I~ (C-lt-t2
1fl1amp DEPMJIEN QIl_A11ltlfI~ i2 110 I~ 5 II 11 -shy 1IIlD ~_~___UIID_
DotWlil -shy ~- - TOTAlPAC~ IJiWSCO _ _Of -It__ - ~1aIM _1laIleS IICTIIffi IN UBq CtiOCSS m3 -UN2910 Ratlloadive material ~ package- IJIA NIA SoJidIOxfde H--3 P-32 P-33 536E+02 NlA D212 To-CT-E-1~-eD4
limited quantity ofmalEftal T
On~ drum with DAW far dlsllO$al UN2910 RadioacWe materia~ exceptied package- NtA NlA SOlidOxide H--3 P-32 P-33 S~E+02 NfA 1)212 TO-CT-amp12-005 limiied qlisnlity of mafamprilaJ 7
One dlllOl wlth CAW dlarps foe disposalINon oar Regltlated Material NlA NlA liquidlOraquoie P-32 7nE+OO NlA 0114 lO--L$-E-12e06
One drum wittt ampQUeolS$ lIalAd l1on-haz ISV fer dIsc )Sal ~ -
GElMratar CeTtificatioo Satement tnre cansituenl$ of1t1e Waste mafifested herein are 1rnown to tile getlererlor Theft are no EPA ReM patboael1icor o1iIer hazards pmenhlUlElrthan those specilleally listed on the Foms541
1p~q ez S~ ~ PrlJ1tnams ---shy ___~natutle __ ___ _ _ _
OOIgtlSIGNEE QRI(JI1tW MUST ACCOMPAlNWASTE IN rWINlm
~_1lOtoIIoI_
INU_
srewNUClEAAIlATlORlAl(a _ - -shyUNIFORM LOWEVEL RADIOACTIVE -shy _Ill
_ lJ2S3shy t U-235 Pu TOTAl TQ2012286
WASTe MANIFEST 3 0538 no ta-COtnA1tIERANOWA$IEDESCRrFTlON PAGE 1 OF I PAGiSrm
ACiTMlY SOORCpound SHfPfER WM AU1-UOIlIleS T lRInJIpound T Co14 I Tc4 I-m Im Chase E~v GrDUJ)
1085+03 MflQ TS61E+02f NP I NIP NIP NIP fsitFPElR 10 KJbllBER 290E+01 mCl 1976amp001 1 NJA
DlSPOSAL()OHAIIampOEBCRIPTlON ~I5SCaJPTlO~ 1OR5Itf WASTETlPE 1N00NTJiIIMSR shySccmAIIIER ~ 1 II
s_ shy ~IIS9CIIIPT1OH ~~- 161Ia~_
~ -shy -shy -shy - n_ ~ shy - ~---- shy- _M - lIId - shy - - - p-----shy -shy-shy 1t (m3) - 11shy -shy - _-r - --shy _ ~~ tkrl~ shy - - IIoo_ Em --shy 11 01 Nuclrae MBa mCI
_0 TO-Cfe12-604 0212 lt5(10 lt361amp6 lt367E-5 39 l212 jeD OxidaINP NP K-S 242aQ2 Gs~E+OD NfA
1159 Pa2 18QE+02 486E+OD
4G F-33 1tgtlE+a2 3tItaOl
P~t1claJ 53SE+02 1A5E+01TQCT-E-12-605 4 0212 lt500 lt3S1E-S lt367amp0 39 0212 100 NP fiS 24~ eB3E+OO NfA1159
Jt f32 1a1E+02 4IIBEoo p~ 114EltfOli 301E+C0
~1ltane1Cllil1 s3tJE+02 ~ TQlSE-12-606 A of14 0$00 lt367E-6 lt3amp75-$ 2559 0114 100 0lddeNP If P-S2 771E+OO 210amp011159 3 ~I Water IIOn-haz lJN Pa~tofal 777E+W 2fQen1
yen p 10P
~1__~_lltIt_
~---tWA__ ____shy -__shyI-o__n____
JItshy ~- _shy r--~1-s----_~11~1 ~1t---_lII__ p_ ~~ --shy shy ~ shy~ --shy ~ -_ 0shy pshy trt c~ t-Dd -shy - _shy shy DO_10- _-shy _shy -shy ~-
- - lItIIIR1rDr
01 __ -~-- shy ta-shy _JrIIII --_ ia2-1IojI -shy _1 -shy shyDIItiur shy 1--shy --- ~ ~ -shy IIshy shy~~clhll - 10- __ --shy ~- ~HIDOI _ T~U -shy-- _shy shy ~~- ~0IIMtt ~1It11or bull ~_T 1t~3130 ~IItIIIIdttIQ
Ir __ _ - -shy ~~
1J __
_shy
I i I
~ t3
0 d gt
I m ~
I i ~ g
2 I ~ g I s
q
~ 8 0 d
S 12
I II ~ ~ sect
I d
II ~ I t
Ii If
id i ampII 0
-I I ~
I ti IIi
lot I ~~ Ii II~I II I i
I~ ti 1l
101 i g If
T ~ fO
I i I ~ I~b
I I 11lt[ i
8~
~ I~i 0
~ ~ I 101 i I
IIi I pIi ~ I II II
Si I I i ci ~ = ~ - i
sect iI I ~ -IL fa
II IB i
It II
I
Key 309 B
~ ~ (fJ Olraquo
0 ampJS3 rTl1j
l -Z n rTl
r~ flkr (fJraquorTl 5 n
9 m
T ~1middot~~~~~~Imiddot~112Bmiddotmiddot3119~~ili1()middotBmiddot3119~i9iBI3i119Il8filiBmiddot31111i9~BI7B1i3iic1li9I~Iii-nuiigiiii1Iii19IIl5IBmiddot3~191~B4IBmiddot3i1ii19~B~3iBi3middot19IBili2BIllli311l9il1H~IOoi~i51i111middotIIBi)iIiI2RmiddotlI3231nmfuge iyen8 319W 319Microwave r- I I I
I 319BIOA I ~ 3215BLA 321BRA ~
1319B12A I 319B9A 3191l8A 319~7A 319116A 319B5A 319B4A 319B3A 319B2A319Sdnti amp I ~ 319B105 1319B9EI 319S~aker I U 319825J L321S~bull
I 321SA
1 bull ( l
~ ~ ~31amps(f) - ~~-JCit)
csect) e e reg etr)-~I J
(sectV ~
Hlt shy ~r Mtl~1 It~ -
JnA T1+ +rV+ oAr j Ii 8 el L (amp aor ~J U I 309BSC
Figure 1 Site Plan BioRelix
5 Science Park 3rd Floor New Haven CT
TRIUMVIRATE TRIUMVIRATE ENVIRONMENTAL INC
ENViRONMENTAL 200 Inner Belt Road Somerville MA 02143
(800) 966-9282 Fax (617) 628-8099
gt
1 UZlpound bull Ji
e LJ
rreg ~9 middotu
J J e
6
~ l nr Z 3 r l
~
( ~ e
e E
~ ~ ~i
0 1 rTl
l r rTl shy
Assay Definition-
Assay Description Wipe Test
Assay Type CPM Report Name Report1 Output Data Path CPackardTricarbResultswipe testwipe test20121015 1702 Raw Results Path CPackardTricarbResu1tswipe testwipe test20l21015 170220121015 1702results Comma-Delimited File Name CPackardTricarbResultswipe testwipe test201210 02Report1csv Assay File Name CPackardTriCarbAssayswipe testlsa
Count Conditions-
Nuclide 3H-14C-32P Quench Indicator tSIE External Std Terminator (sec) 05 2s Pre-Count Delay (min) 000
Quench Set na Count Time (min) 100 Count Mode Normal Assay Count Cycles 1 Sample Count 1 VialsSamp1e 1 Calculate Reference Off
Background Subtract Off Low CPM Threshold Off 2 Sigma Terminator Off
Regions LL UL A 00 120 B 120 1560 C 1560 17000
Count Corrections-
Static Controller On Luminescence Correction Off Colored na Heterogeneity Monitor na Coincidence Time (nsec) 18 Delay Before Burst (nsec) 75
Half Life-
Half Life Correction Off Regions Half Life Units Reference Date Reference Time A B
C
Cycle 1 Results S Count Time CPMA MESSAGES CPMB CPMC
1 1 00 20 14 7 2 1 00 18 7 4 3 1 00 20 14 2 4 1 00 18 12 7
5
10
15
20
25
30
35
40
45
50
55
60
1 00 14 l7 8 6 1 00 11 15 6 7 1 00 17 23 11 8 1 00 18 10 3 9 100 23 13 4
1 00 l3 20 5 11 1 00 12 8 8 12 1 00 15 11 6 l3 1 00 17 l7 6 14 1 00 14 l7 7
1 00 16 11 9 16 1 00 12 11 7 l7 100 19 15 5 18 1 00 20 11 12 19 1 00 19 12 10
1 00 12 14 10 21 1 00 16 15 5 22 1 00 12 8 12 23 1 00 19 18 12 24 1 00 5 l7 5
1 00 19 12 5 26 1 00 20 13 6 27 1 00 l7 14 9 28 100 16 17 6 29 1 00 19 9 3
1 00 25 13 6 31 1 00 14 13 5 32 1 00 14 7 5 33 1 00 9 20 6 34 1 00 13 9 10
1 00 20 28 8 36 100 31 24 10 37 1 00 19 20 5 38 1 00 19 11 9 39 1 00 568 l7 8
1 00 16 10 7 41 1 00 15 8 9 42 1 00 30 13 6 43 1 00 18 12 8 44 1 00 11 13 11
1 00 19 12 12 46 100 11 13 7 47 1 00 13 16 10 48 1 00 23 14 7 49 1 00 12 11 3
1 00 14 13 6 51 1 00 15 21 4 52 1 00 15 18 8 53 1 00 18 12 3 54 1 00 16 11 9
1 00 23 9 9 56 1 00 l7 11 6 57 1 00 21 23 4 58 1 00 15 13 10 59 100 15 11 6
1 00 11 20 10 61 1 00 23 7 8
62 1 00 63 1 00 64 1 00 65 1 00 66 1 00 67 1 00 68 1 00 69 1 00 70 1 00 71 1 00 72 1 00 73 1 00 74 1 00
19 25 20 11 25 13 18 13 27 22 17 20 19
12 5 12 4
9 3 13 4
7 7 17 5 12 14
7 9 12 9 17 7 19 5 12 4 19 4
Assay Definition-
Assay Description Wipe Test
Assay Type CPM Report Name Reportl Output Data Path CPackardTricarbResultswipe testwipe test20121018 1436 Raw Results Path CPackardTricarbResultswipe testwipe test20121018 143620121018 1436results Comma-Delimited File Name CPackardTricarbResultswipe testwipe test20121018 436Reportlcsv Assay File Name CPackardTriCarbAssayswipe testlsa
Count Conditions-
Nuclide 3H-14C-32P Quench Indicator tSIE External Std Terminator (sec) 05 2s Pre-Count Delay (min) 000
Quench Set na Count Time (min) 100 Count Mode Normal Assay Count Cycles 1 Repeat Sample Count 1 VialsSample 1 Calculate Reference Off
Background Subtract Off Low CPM Threshold Off 2 Sigma Terminator Off
Regions LL UL A 00 120 B 120 1560 C 1560 17000
Count Corrections-
Static Controller On Luminescence Correction Off Colored Samples na Heterogeneity Monitor na Coincidence Time (nsec) 18 Delay Before Burst (nsec) 75
Half Life-
Half Life Correction Off Regions Half Life Units Reference Date Reference Time A B C
Cycle 1 Results S Count Time CPMA MESSAGES CPMB CPMC
1 1 00 20 18 5 2 1 00 8 4 5 3 1 00 15 16 12
1
2 3
4
5
6
7
8
9
10 11
12 13
14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
34 35 36 37 38 39 40 41 42 43
SUMMARY OF SITE PLAN AND SWIPE TEST RESULTS
dpm H3 dpm C14 dpm P32 on the plan swipe sample cpmH3 cpm C14 cpm P32
31 15 7 316 18 7 4 background 20 14 7
28 7 4
318S 20 14 2 31 15 2 321SA 18 12 7 28 13 7
321BRA 14 17 8 22 18 8
321BRB 11 15 6 17 16 6
321Centrifuge 17 23 11 27 24 11 321Thermo 18 10 3 28 10 3
3215VWR 23 13 4 36 14 4
3215BlB 13 20 5 20 21 5
3215BLA 12 8 8 19 8 8
321SB 15 11 6 23 11 6
319Scint 17 17 6 27 18 6
319Hood 14 17 7 22 18 7
319B2A 16 11 9 25 11 9
319B2B 12 11 7 19 11 7
319B2S 19 15 5 30 16 5
319B3A 20 11 12 31 11 12 319B3B 19 12 10 30 13 10 319B4A 12 14 10 19 15 10
319B4B 16 15 5 25 16 5
319B5A 12 8 12 19 8 12 319B5B 19 18 12 30 19 12 319B6A 5 17 5 8 18 5
319B6B 19 12 5 30 13 5 319Ce ntrifuge 20 13 6 31 14 6 319Shaker 17 14 9 27 15 9
319B7A 16 17 6 25 18 6
319B7B 19 9 3 30 9 3 319B8A 25 13 6 39 14 6
319B8B 14 13 5 22 14 5 319B9E 14 7 5 22 7 5 319B9A 9 20 6 14 21 6 319B9B 13 9 10 20 9 10 319BlOA 20 28 8 31 29 8 319Microwave 31 24 10 48 25 10 319B10B 19 20 5 30 21 5
319B10S 19 11 9 30 11 9 319W 568 17 8 888 18 8 319B12A 16 10 7 25 10 7 319B12B 15 8 9 23 8 9 309B12E 30 13 6 47 14 6 309B12A 18 12 8 28 13 8
309B12B 44 11 13 11 17 14 11
309B11A 45 19 12 12 30 13 12
309B11B 46 11 13 7 17 14 7
309BlOE 47 13 16 10 20 17 10
309BlOA 48 23 14 7 36 15 7
309Bl0B 49 12 11 3 19 11 3
309B9A 50 14 13 6 22 14 6
309B9B 51 15 21 4 23 22 4
309B85 52 15 18 8 23 19 8
309B8A 53 18 12 3 28 13 3 309B8RS 54 16 11 9 25 11 9 309B7A 55 23 9 9 36 9 9 309B7B 56 17 11 6 27 11 6 309B6E 57 21 23 4 33 24 4 309B6A 58 15 13 10 23 14 10 309B6B 59 15 11 6 23 11 6 309B5A 60 11 20 10 17 21 10 309B5B 61 23 7 8 36 7 8 309B5C 62 19 12 5 30 13 5 309B4E 63 25 12 4 39 13 4 309B4A 64 20 9 3 31 9 3 309B4B 65 11 13 4 17 14 4 309B3A 66 25 7 7 39 7 7 309B3B 67 13 17 5 20 18 5 309B25 68 18 12 14 28 13 14 309B2 69 13 7 9 20 7 9 309B1A 70 27 12 9 42 13 9 309B1C 71 22 17 7 34 18 7 QAQC 72 17 19 5 27 20 5 QAQC 73 20 12 4 31 13 4 QAQC 74 19 19 4 30 20 4
Sample key 309 Room number e for 3H=064 dpm=cpme
Sample surface BshyB bench S-sink e for 14C=096 6 Bench number e for 32P=10
Description or E sequence
REPEAT OF THE RESULTS IN QUESTION
plan sample cpmH3 cpm C14 cpm P32 dpmH3 dpm C14 dpm P32 background 1 20 18 5 31 19 5 319Wa 2 8 4 5 13 4 5
319W b 3 15 16 12 23 17 12
Connecticut Department of Energy amp Environmental Protection Bureau of Air Management Radiation Division
Radioactive Material and Industrial X-Ray Device Registration
Please complete this form in accordance with the instructions (DEP-RAD-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation along with this form Please retain a copy of this completed form at your facility
Part I Registration Type
CPPU USE ONLY
App____________
Doc ______________
Check ____________
Program Radiation
Requested Year of Registration Period materials license termination
Registrations are based on the calendar year January 1st through December 31 stbull
Provide Permit Number (aka Facility ID see DEEP correspondence to
Check the appropriate box(es) identifying the registration type
D new registration (ie never registered with the DEEP) [221] registrant)
D new ownership [221] 01576
D renewal of an existing registration [221] If renewing or amending an existing
181 amendment to an existing registration [1467] registration please indicate any changes to tile existing registration information by using reel ink
Note If you are terminating your registration or removing a device(s) from registration refer to the registration instructions (DEP-RAD-INST-100) for required documentation necessary to comply with DEEP requirements
own I(here site is located New Haven
Part II Fee Information
An annual registration fee of $20000 is to be submitted by December 31 S with each registration and applies for the period covering the requested calendar year The fee is not pro-rated New registrants are required to pay the fee regardless of when they register with the DEEP There is no fee for amendments The registration will not be processed without the fee The fee shall be non-refundable and shall be paid by check or money order to the Department of Energy and Environmental Protection
Part III Registrant Information
bull If a registrant is a corporation limited liability company limited partnership limited liability partnership or a statutory trost it must be registered with the Secretary of State If applicable registrants name shall be stated exactly as it is registered with the Secretary of State Please note for those entities registered with the Secretary of State the registered name will be the name used by DEEP This information can be accessed at the Secretary of States database (CONCORD) (wwwconcord-sotsctgovICONCORDlindexjsp)
bull If a registrant is an individual provide the legal name (include suffix) in the following format First Name Middle Initial Last Name Suffix (Jr Sr II III etc)
DEP-RAD-REG-100 1 of 9 Rev 103112
Part III Registrant Information (continued)
1 Registrant Name BioRelix Inc
Mailing Address 5 Science Park (401 Winchester Avenue)
CitylTown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
Contact Person Izabela Puskarz Phone (203) 785-9282 ext 305
E-mail ipuskarzbiorelixcom
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from nctgov addresses Also please notify the department if your e-mail address changes
a) Registrant Type (check one) 0 individual [8J business entity o federal agency
o state agency o municipality tribal
If a business entity (If a business entity complete i through iii)
i) check type [8J corporation 0 limited liability company o limited partnership o Other ________o limited liability partnership 0 statutory trust
ii) provide Secretary of the State business ID ~08~67~696~___This information can be accessed at CONCORD
iii) 0 Check here if you are NOT registered with the SOTS
b) Registrants interest in property at which the proposed activity is to be located
o site owner 0 option holder [8J lessee 0 easement holder operator
o other (specify)
o Check here if any co-registrants If so attach additional sheet(s) with the required information as requested above
2 List billing contact if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
3 List primary contact for departmental cprrespondence and inquiries if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from ctgov addresses Also please notify the department if your e-mail address changes
DEP-RAD-REG-100 2of9 Rev 103112
---
Part III Registrant Information (continued)
4 List the Radiation Safety Officer (RSO) There must be one RSO listed per registration
Name Izabela J Puskarz
Direct Phone (203) 785-9282 ext 305 Fax (203) 785-8058
E-Mail Addressipuskarzbiorelixcom
24-Hour Emergency Phone ~---
List other contact people in the radiation safety section
Name Kenneth F Blount
Title Director of Biology
Direct Phone (203) 785-9282 ext 302 Fax (203) 785-8058
E-Mail Addresskblountbiorelixcom
24-Hour Emergency Pho
Name Brian R Dixon
Title President and CEO
Direct Phone (203) 785-9282 ext 303 Fax (203) 785-8058
E-Mail Addressbdizonbiorelixcom
24-Hour Emergency Phone
Part IV Site Information
1 Company Name BioRelix Inc
Site Name (if different)
Address 5 Science Park (401 Winchester Avenue)
Cityrrown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
2 Location of Material (if different than above)
Cityrrown State Zip Code
Part V NRC Licenses
For new licenses attach a copy of each license for renewals or modifications attach any amended pages of each license
06-31263-01 3 August 312017
DEP-RAD-REG-100 30f9 Rev 103112
Part VI Personnel Dosimetry
1 Indicate whether personnel dosimetry is performed at your facility Yes t8J No
2 If yes indicate the name of vendor that provides this service
Part VII Compliance
If you answer yes to any of the questions below you must complete Part VIII Table of Enforcement Actions as directed in the instructions for your registration
A During the five years immediately preceding submission of this registration has the registrant been convicted in any jurisdiction of a criminal violation of any environmental law
DYes t8J No
B During the five years immediately preceding submission of this registration has a civil penalty been imposed upon the registrant in any state including Connecticut or federal judicial proceeding for any other violation of an environmental law
DYes t8J No
C During the five years immediately preceding submission of this registration has a civil penalty exceeding five thousand dollars been imposed on the registrant in any state including Connecticut or federal administrative proceeding for any violation of an environmental law
DYes t8J No
D During the five years immediately preceding submission of this registration has any state including Connecticut or federal court issued any order or entered any judgment to the registrant concerning a violation of any environmental law
DYes t8J No
E During the five years immediately preceding submission of this registration has any state including Connecticut or federal administrative agency issued any order to the registrant concerning a violation of any environmental law
DYes t8J No
DEP-RAD-REG-100 4of9 Rev 103112
Part VIII Table of Enforcement Actions
Type of Action Type of Action Type of Action
Date Commenced Date Commenced Date Commenced
Date Terminated Date Terminated Date Terminated
Jurisdiction Jurisdiction Jurisdiction
CaselDocketlOrder Number CaselDocketlOrder Number CaseDocketlOrder Number
Description of Violation Description of Violation Description of Violation
D Check the box if additional sheets are attached Copies of this form may be duplicated for additional space
DEP-RAD-REG-100 50f9 Rev 1013112
For Parts IX through XVI you may hit the tab button at the end of each table in the last cell and create additional rows
Part IX Industrial X-Ray Equipment
Part X Analytic Equipment for Examination of Material
aXlimum mA
~~t JiUIp
(Including but not limited to X-ray diffraction units electron microscopes gauging devices spectroscopic equipment gas chromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or therapy)
MQttatltl I t
Serial Manufacturer r~ M~_ilil I Maximum mA
Part XI Industrial Radiographic Equipment
(For examination of structure with a sealed source)
I I TYRe Model ibmll Serial I Manufactu~middot l i i
Part XII Particle Accelerators
(Including but not limited to Van de Graffs Linacs Cyclotrons Electronic Beam Welders)
lI~f ler1 bull Ma~ufacturer p~Itf ii
DEP-RAD-REG-100 6 af9 Rev 103112
Part XIII Special Nuclear Material (Special nuclear material [SNM] refers to plutonium 233U uranium enriched in the isotope 233 or in the isotope 235 greater than its natural abundance and any other material which the US NRC pursuant to the provisions of Section 510f the Atomic Energy Act of 1954 determines to be special nuclear material SNM does not include source material)
Part XIV Source Material
(Source material [SM] refers to uranium or thorium or any combination thereof in any physical or chemical form or ores which contain at least 005 by weight uranium thorium or any combination thereof except when the material is designated as special nuclear material)
Part XV Sealed Sources
No1~er ofSikrcesltc
Part XVI Other Radioactive Materials (including medical isotopes)
3 Hydrogen 25mCi
33 Phosphorous 25mCi
DEP-RAD-REG-100 7of9 Rev 103112
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
~_1lOtoIIoI_
INU_
srewNUClEAAIlATlORlAl(a _ - -shyUNIFORM LOWEVEL RADIOACTIVE -shy _Ill
_ lJ2S3shy t U-235 Pu TOTAl TQ2012286
WASTe MANIFEST 3 0538 no ta-COtnA1tIERANOWA$IEDESCRrFTlON PAGE 1 OF I PAGiSrm
ACiTMlY SOORCpound SHfPfER WM AU1-UOIlIleS T lRInJIpound T Co14 I Tc4 I-m Im Chase E~v GrDUJ)
1085+03 MflQ TS61E+02f NP I NIP NIP NIP fsitFPElR 10 KJbllBER 290E+01 mCl 1976amp001 1 NJA
DlSPOSAL()OHAIIampOEBCRIPTlON ~I5SCaJPTlO~ 1OR5Itf WASTETlPE 1N00NTJiIIMSR shySccmAIIIER ~ 1 II
s_ shy ~IIS9CIIIPT1OH ~~- 161Ia~_
~ -shy -shy -shy - n_ ~ shy - ~---- shy- _M - lIId - shy - - - p-----shy -shy-shy 1t (m3) - 11shy -shy - _-r - --shy _ ~~ tkrl~ shy - - IIoo_ Em --shy 11 01 Nuclrae MBa mCI
_0 TO-Cfe12-604 0212 lt5(10 lt361amp6 lt367E-5 39 l212 jeD OxidaINP NP K-S 242aQ2 Gs~E+OD NfA
1159 Pa2 18QE+02 486E+OD
4G F-33 1tgtlE+a2 3tItaOl
P~t1claJ 53SE+02 1A5E+01TQCT-E-12-605 4 0212 lt500 lt3S1E-S lt367amp0 39 0212 100 NP fiS 24~ eB3E+OO NfA1159
Jt f32 1a1E+02 4IIBEoo p~ 114EltfOli 301E+C0
~1ltane1Cllil1 s3tJE+02 ~ TQlSE-12-606 A of14 0$00 lt367E-6 lt3amp75-$ 2559 0114 100 0lddeNP If P-S2 771E+OO 210amp011159 3 ~I Water IIOn-haz lJN Pa~tofal 777E+W 2fQen1
yen p 10P
~1__~_lltIt_
~---tWA__ ____shy -__shyI-o__n____
JItshy ~- _shy r--~1-s----_~11~1 ~1t---_lII__ p_ ~~ --shy shy ~ shy~ --shy ~ -_ 0shy pshy trt c~ t-Dd -shy - _shy shy DO_10- _-shy _shy -shy ~-
- - lItIIIR1rDr
01 __ -~-- shy ta-shy _JrIIII --_ ia2-1IojI -shy _1 -shy shyDIItiur shy 1--shy --- ~ ~ -shy IIshy shy~~clhll - 10- __ --shy ~- ~HIDOI _ T~U -shy-- _shy shy ~~- ~0IIMtt ~1It11or bull ~_T 1t~3130 ~IItIIIIdttIQ
Ir __ _ - -shy ~~
1J __
_shy
I i I
~ t3
0 d gt
I m ~
I i ~ g
2 I ~ g I s
q
~ 8 0 d
S 12
I II ~ ~ sect
I d
II ~ I t
Ii If
id i ampII 0
-I I ~
I ti IIi
lot I ~~ Ii II~I II I i
I~ ti 1l
101 i g If
T ~ fO
I i I ~ I~b
I I 11lt[ i
8~
~ I~i 0
~ ~ I 101 i I
IIi I pIi ~ I II II
Si I I i ci ~ = ~ - i
sect iI I ~ -IL fa
II IB i
It II
I
Key 309 B
~ ~ (fJ Olraquo
0 ampJS3 rTl1j
l -Z n rTl
r~ flkr (fJraquorTl 5 n
9 m
T ~1middot~~~~~~Imiddot~112Bmiddotmiddot3119~~ili1()middotBmiddot3119~i9iBI3i119Il8filiBmiddot31111i9~BI7B1i3iic1li9I~Iii-nuiigiiii1Iii19IIl5IBmiddot3~191~B4IBmiddot3i1ii19~B~3iBi3middot19IBili2BIllli311l9il1H~IOoi~i51i111middotIIBi)iIiI2RmiddotlI3231nmfuge iyen8 319W 319Microwave r- I I I
I 319BIOA I ~ 3215BLA 321BRA ~
1319B12A I 319B9A 3191l8A 319~7A 319116A 319B5A 319B4A 319B3A 319B2A319Sdnti amp I ~ 319B105 1319B9EI 319S~aker I U 319825J L321S~bull
I 321SA
1 bull ( l
~ ~ ~31amps(f) - ~~-JCit)
csect) e e reg etr)-~I J
(sectV ~
Hlt shy ~r Mtl~1 It~ -
JnA T1+ +rV+ oAr j Ii 8 el L (amp aor ~J U I 309BSC
Figure 1 Site Plan BioRelix
5 Science Park 3rd Floor New Haven CT
TRIUMVIRATE TRIUMVIRATE ENVIRONMENTAL INC
ENViRONMENTAL 200 Inner Belt Road Somerville MA 02143
(800) 966-9282 Fax (617) 628-8099
gt
1 UZlpound bull Ji
e LJ
rreg ~9 middotu
J J e
6
~ l nr Z 3 r l
~
( ~ e
e E
~ ~ ~i
0 1 rTl
l r rTl shy
Assay Definition-
Assay Description Wipe Test
Assay Type CPM Report Name Report1 Output Data Path CPackardTricarbResultswipe testwipe test20121015 1702 Raw Results Path CPackardTricarbResu1tswipe testwipe test20l21015 170220121015 1702results Comma-Delimited File Name CPackardTricarbResultswipe testwipe test201210 02Report1csv Assay File Name CPackardTriCarbAssayswipe testlsa
Count Conditions-
Nuclide 3H-14C-32P Quench Indicator tSIE External Std Terminator (sec) 05 2s Pre-Count Delay (min) 000
Quench Set na Count Time (min) 100 Count Mode Normal Assay Count Cycles 1 Sample Count 1 VialsSamp1e 1 Calculate Reference Off
Background Subtract Off Low CPM Threshold Off 2 Sigma Terminator Off
Regions LL UL A 00 120 B 120 1560 C 1560 17000
Count Corrections-
Static Controller On Luminescence Correction Off Colored na Heterogeneity Monitor na Coincidence Time (nsec) 18 Delay Before Burst (nsec) 75
Half Life-
Half Life Correction Off Regions Half Life Units Reference Date Reference Time A B
C
Cycle 1 Results S Count Time CPMA MESSAGES CPMB CPMC
1 1 00 20 14 7 2 1 00 18 7 4 3 1 00 20 14 2 4 1 00 18 12 7
5
10
15
20
25
30
35
40
45
50
55
60
1 00 14 l7 8 6 1 00 11 15 6 7 1 00 17 23 11 8 1 00 18 10 3 9 100 23 13 4
1 00 l3 20 5 11 1 00 12 8 8 12 1 00 15 11 6 l3 1 00 17 l7 6 14 1 00 14 l7 7
1 00 16 11 9 16 1 00 12 11 7 l7 100 19 15 5 18 1 00 20 11 12 19 1 00 19 12 10
1 00 12 14 10 21 1 00 16 15 5 22 1 00 12 8 12 23 1 00 19 18 12 24 1 00 5 l7 5
1 00 19 12 5 26 1 00 20 13 6 27 1 00 l7 14 9 28 100 16 17 6 29 1 00 19 9 3
1 00 25 13 6 31 1 00 14 13 5 32 1 00 14 7 5 33 1 00 9 20 6 34 1 00 13 9 10
1 00 20 28 8 36 100 31 24 10 37 1 00 19 20 5 38 1 00 19 11 9 39 1 00 568 l7 8
1 00 16 10 7 41 1 00 15 8 9 42 1 00 30 13 6 43 1 00 18 12 8 44 1 00 11 13 11
1 00 19 12 12 46 100 11 13 7 47 1 00 13 16 10 48 1 00 23 14 7 49 1 00 12 11 3
1 00 14 13 6 51 1 00 15 21 4 52 1 00 15 18 8 53 1 00 18 12 3 54 1 00 16 11 9
1 00 23 9 9 56 1 00 l7 11 6 57 1 00 21 23 4 58 1 00 15 13 10 59 100 15 11 6
1 00 11 20 10 61 1 00 23 7 8
62 1 00 63 1 00 64 1 00 65 1 00 66 1 00 67 1 00 68 1 00 69 1 00 70 1 00 71 1 00 72 1 00 73 1 00 74 1 00
19 25 20 11 25 13 18 13 27 22 17 20 19
12 5 12 4
9 3 13 4
7 7 17 5 12 14
7 9 12 9 17 7 19 5 12 4 19 4
Assay Definition-
Assay Description Wipe Test
Assay Type CPM Report Name Reportl Output Data Path CPackardTricarbResultswipe testwipe test20121018 1436 Raw Results Path CPackardTricarbResultswipe testwipe test20121018 143620121018 1436results Comma-Delimited File Name CPackardTricarbResultswipe testwipe test20121018 436Reportlcsv Assay File Name CPackardTriCarbAssayswipe testlsa
Count Conditions-
Nuclide 3H-14C-32P Quench Indicator tSIE External Std Terminator (sec) 05 2s Pre-Count Delay (min) 000
Quench Set na Count Time (min) 100 Count Mode Normal Assay Count Cycles 1 Repeat Sample Count 1 VialsSample 1 Calculate Reference Off
Background Subtract Off Low CPM Threshold Off 2 Sigma Terminator Off
Regions LL UL A 00 120 B 120 1560 C 1560 17000
Count Corrections-
Static Controller On Luminescence Correction Off Colored Samples na Heterogeneity Monitor na Coincidence Time (nsec) 18 Delay Before Burst (nsec) 75
Half Life-
Half Life Correction Off Regions Half Life Units Reference Date Reference Time A B C
Cycle 1 Results S Count Time CPMA MESSAGES CPMB CPMC
1 1 00 20 18 5 2 1 00 8 4 5 3 1 00 15 16 12
1
2 3
4
5
6
7
8
9
10 11
12 13
14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
34 35 36 37 38 39 40 41 42 43
SUMMARY OF SITE PLAN AND SWIPE TEST RESULTS
dpm H3 dpm C14 dpm P32 on the plan swipe sample cpmH3 cpm C14 cpm P32
31 15 7 316 18 7 4 background 20 14 7
28 7 4
318S 20 14 2 31 15 2 321SA 18 12 7 28 13 7
321BRA 14 17 8 22 18 8
321BRB 11 15 6 17 16 6
321Centrifuge 17 23 11 27 24 11 321Thermo 18 10 3 28 10 3
3215VWR 23 13 4 36 14 4
3215BlB 13 20 5 20 21 5
3215BLA 12 8 8 19 8 8
321SB 15 11 6 23 11 6
319Scint 17 17 6 27 18 6
319Hood 14 17 7 22 18 7
319B2A 16 11 9 25 11 9
319B2B 12 11 7 19 11 7
319B2S 19 15 5 30 16 5
319B3A 20 11 12 31 11 12 319B3B 19 12 10 30 13 10 319B4A 12 14 10 19 15 10
319B4B 16 15 5 25 16 5
319B5A 12 8 12 19 8 12 319B5B 19 18 12 30 19 12 319B6A 5 17 5 8 18 5
319B6B 19 12 5 30 13 5 319Ce ntrifuge 20 13 6 31 14 6 319Shaker 17 14 9 27 15 9
319B7A 16 17 6 25 18 6
319B7B 19 9 3 30 9 3 319B8A 25 13 6 39 14 6
319B8B 14 13 5 22 14 5 319B9E 14 7 5 22 7 5 319B9A 9 20 6 14 21 6 319B9B 13 9 10 20 9 10 319BlOA 20 28 8 31 29 8 319Microwave 31 24 10 48 25 10 319B10B 19 20 5 30 21 5
319B10S 19 11 9 30 11 9 319W 568 17 8 888 18 8 319B12A 16 10 7 25 10 7 319B12B 15 8 9 23 8 9 309B12E 30 13 6 47 14 6 309B12A 18 12 8 28 13 8
309B12B 44 11 13 11 17 14 11
309B11A 45 19 12 12 30 13 12
309B11B 46 11 13 7 17 14 7
309BlOE 47 13 16 10 20 17 10
309BlOA 48 23 14 7 36 15 7
309Bl0B 49 12 11 3 19 11 3
309B9A 50 14 13 6 22 14 6
309B9B 51 15 21 4 23 22 4
309B85 52 15 18 8 23 19 8
309B8A 53 18 12 3 28 13 3 309B8RS 54 16 11 9 25 11 9 309B7A 55 23 9 9 36 9 9 309B7B 56 17 11 6 27 11 6 309B6E 57 21 23 4 33 24 4 309B6A 58 15 13 10 23 14 10 309B6B 59 15 11 6 23 11 6 309B5A 60 11 20 10 17 21 10 309B5B 61 23 7 8 36 7 8 309B5C 62 19 12 5 30 13 5 309B4E 63 25 12 4 39 13 4 309B4A 64 20 9 3 31 9 3 309B4B 65 11 13 4 17 14 4 309B3A 66 25 7 7 39 7 7 309B3B 67 13 17 5 20 18 5 309B25 68 18 12 14 28 13 14 309B2 69 13 7 9 20 7 9 309B1A 70 27 12 9 42 13 9 309B1C 71 22 17 7 34 18 7 QAQC 72 17 19 5 27 20 5 QAQC 73 20 12 4 31 13 4 QAQC 74 19 19 4 30 20 4
Sample key 309 Room number e for 3H=064 dpm=cpme
Sample surface BshyB bench S-sink e for 14C=096 6 Bench number e for 32P=10
Description or E sequence
REPEAT OF THE RESULTS IN QUESTION
plan sample cpmH3 cpm C14 cpm P32 dpmH3 dpm C14 dpm P32 background 1 20 18 5 31 19 5 319Wa 2 8 4 5 13 4 5
319W b 3 15 16 12 23 17 12
Connecticut Department of Energy amp Environmental Protection Bureau of Air Management Radiation Division
Radioactive Material and Industrial X-Ray Device Registration
Please complete this form in accordance with the instructions (DEP-RAD-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation along with this form Please retain a copy of this completed form at your facility
Part I Registration Type
CPPU USE ONLY
App____________
Doc ______________
Check ____________
Program Radiation
Requested Year of Registration Period materials license termination
Registrations are based on the calendar year January 1st through December 31 stbull
Provide Permit Number (aka Facility ID see DEEP correspondence to
Check the appropriate box(es) identifying the registration type
D new registration (ie never registered with the DEEP) [221] registrant)
D new ownership [221] 01576
D renewal of an existing registration [221] If renewing or amending an existing
181 amendment to an existing registration [1467] registration please indicate any changes to tile existing registration information by using reel ink
Note If you are terminating your registration or removing a device(s) from registration refer to the registration instructions (DEP-RAD-INST-100) for required documentation necessary to comply with DEEP requirements
own I(here site is located New Haven
Part II Fee Information
An annual registration fee of $20000 is to be submitted by December 31 S with each registration and applies for the period covering the requested calendar year The fee is not pro-rated New registrants are required to pay the fee regardless of when they register with the DEEP There is no fee for amendments The registration will not be processed without the fee The fee shall be non-refundable and shall be paid by check or money order to the Department of Energy and Environmental Protection
Part III Registrant Information
bull If a registrant is a corporation limited liability company limited partnership limited liability partnership or a statutory trost it must be registered with the Secretary of State If applicable registrants name shall be stated exactly as it is registered with the Secretary of State Please note for those entities registered with the Secretary of State the registered name will be the name used by DEEP This information can be accessed at the Secretary of States database (CONCORD) (wwwconcord-sotsctgovICONCORDlindexjsp)
bull If a registrant is an individual provide the legal name (include suffix) in the following format First Name Middle Initial Last Name Suffix (Jr Sr II III etc)
DEP-RAD-REG-100 1 of 9 Rev 103112
Part III Registrant Information (continued)
1 Registrant Name BioRelix Inc
Mailing Address 5 Science Park (401 Winchester Avenue)
CitylTown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
Contact Person Izabela Puskarz Phone (203) 785-9282 ext 305
E-mail ipuskarzbiorelixcom
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from nctgov addresses Also please notify the department if your e-mail address changes
a) Registrant Type (check one) 0 individual [8J business entity o federal agency
o state agency o municipality tribal
If a business entity (If a business entity complete i through iii)
i) check type [8J corporation 0 limited liability company o limited partnership o Other ________o limited liability partnership 0 statutory trust
ii) provide Secretary of the State business ID ~08~67~696~___This information can be accessed at CONCORD
iii) 0 Check here if you are NOT registered with the SOTS
b) Registrants interest in property at which the proposed activity is to be located
o site owner 0 option holder [8J lessee 0 easement holder operator
o other (specify)
o Check here if any co-registrants If so attach additional sheet(s) with the required information as requested above
2 List billing contact if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
3 List primary contact for departmental cprrespondence and inquiries if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from ctgov addresses Also please notify the department if your e-mail address changes
DEP-RAD-REG-100 2of9 Rev 103112
---
Part III Registrant Information (continued)
4 List the Radiation Safety Officer (RSO) There must be one RSO listed per registration
Name Izabela J Puskarz
Direct Phone (203) 785-9282 ext 305 Fax (203) 785-8058
E-Mail Addressipuskarzbiorelixcom
24-Hour Emergency Phone ~---
List other contact people in the radiation safety section
Name Kenneth F Blount
Title Director of Biology
Direct Phone (203) 785-9282 ext 302 Fax (203) 785-8058
E-Mail Addresskblountbiorelixcom
24-Hour Emergency Pho
Name Brian R Dixon
Title President and CEO
Direct Phone (203) 785-9282 ext 303 Fax (203) 785-8058
E-Mail Addressbdizonbiorelixcom
24-Hour Emergency Phone
Part IV Site Information
1 Company Name BioRelix Inc
Site Name (if different)
Address 5 Science Park (401 Winchester Avenue)
Cityrrown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
2 Location of Material (if different than above)
Cityrrown State Zip Code
Part V NRC Licenses
For new licenses attach a copy of each license for renewals or modifications attach any amended pages of each license
06-31263-01 3 August 312017
DEP-RAD-REG-100 30f9 Rev 103112
Part VI Personnel Dosimetry
1 Indicate whether personnel dosimetry is performed at your facility Yes t8J No
2 If yes indicate the name of vendor that provides this service
Part VII Compliance
If you answer yes to any of the questions below you must complete Part VIII Table of Enforcement Actions as directed in the instructions for your registration
A During the five years immediately preceding submission of this registration has the registrant been convicted in any jurisdiction of a criminal violation of any environmental law
DYes t8J No
B During the five years immediately preceding submission of this registration has a civil penalty been imposed upon the registrant in any state including Connecticut or federal judicial proceeding for any other violation of an environmental law
DYes t8J No
C During the five years immediately preceding submission of this registration has a civil penalty exceeding five thousand dollars been imposed on the registrant in any state including Connecticut or federal administrative proceeding for any violation of an environmental law
DYes t8J No
D During the five years immediately preceding submission of this registration has any state including Connecticut or federal court issued any order or entered any judgment to the registrant concerning a violation of any environmental law
DYes t8J No
E During the five years immediately preceding submission of this registration has any state including Connecticut or federal administrative agency issued any order to the registrant concerning a violation of any environmental law
DYes t8J No
DEP-RAD-REG-100 4of9 Rev 103112
Part VIII Table of Enforcement Actions
Type of Action Type of Action Type of Action
Date Commenced Date Commenced Date Commenced
Date Terminated Date Terminated Date Terminated
Jurisdiction Jurisdiction Jurisdiction
CaselDocketlOrder Number CaselDocketlOrder Number CaseDocketlOrder Number
Description of Violation Description of Violation Description of Violation
D Check the box if additional sheets are attached Copies of this form may be duplicated for additional space
DEP-RAD-REG-100 50f9 Rev 1013112
For Parts IX through XVI you may hit the tab button at the end of each table in the last cell and create additional rows
Part IX Industrial X-Ray Equipment
Part X Analytic Equipment for Examination of Material
aXlimum mA
~~t JiUIp
(Including but not limited to X-ray diffraction units electron microscopes gauging devices spectroscopic equipment gas chromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or therapy)
MQttatltl I t
Serial Manufacturer r~ M~_ilil I Maximum mA
Part XI Industrial Radiographic Equipment
(For examination of structure with a sealed source)
I I TYRe Model ibmll Serial I Manufactu~middot l i i
Part XII Particle Accelerators
(Including but not limited to Van de Graffs Linacs Cyclotrons Electronic Beam Welders)
lI~f ler1 bull Ma~ufacturer p~Itf ii
DEP-RAD-REG-100 6 af9 Rev 103112
Part XIII Special Nuclear Material (Special nuclear material [SNM] refers to plutonium 233U uranium enriched in the isotope 233 or in the isotope 235 greater than its natural abundance and any other material which the US NRC pursuant to the provisions of Section 510f the Atomic Energy Act of 1954 determines to be special nuclear material SNM does not include source material)
Part XIV Source Material
(Source material [SM] refers to uranium or thorium or any combination thereof in any physical or chemical form or ores which contain at least 005 by weight uranium thorium or any combination thereof except when the material is designated as special nuclear material)
Part XV Sealed Sources
No1~er ofSikrcesltc
Part XVI Other Radioactive Materials (including medical isotopes)
3 Hydrogen 25mCi
33 Phosphorous 25mCi
DEP-RAD-REG-100 7of9 Rev 103112
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
I i I
~ t3
0 d gt
I m ~
I i ~ g
2 I ~ g I s
q
~ 8 0 d
S 12
I II ~ ~ sect
I d
II ~ I t
Ii If
id i ampII 0
-I I ~
I ti IIi
lot I ~~ Ii II~I II I i
I~ ti 1l
101 i g If
T ~ fO
I i I ~ I~b
I I 11lt[ i
8~
~ I~i 0
~ ~ I 101 i I
IIi I pIi ~ I II II
Si I I i ci ~ = ~ - i
sect iI I ~ -IL fa
II IB i
It II
I
Key 309 B
~ ~ (fJ Olraquo
0 ampJS3 rTl1j
l -Z n rTl
r~ flkr (fJraquorTl 5 n
9 m
T ~1middot~~~~~~Imiddot~112Bmiddotmiddot3119~~ili1()middotBmiddot3119~i9iBI3i119Il8filiBmiddot31111i9~BI7B1i3iic1li9I~Iii-nuiigiiii1Iii19IIl5IBmiddot3~191~B4IBmiddot3i1ii19~B~3iBi3middot19IBili2BIllli311l9il1H~IOoi~i51i111middotIIBi)iIiI2RmiddotlI3231nmfuge iyen8 319W 319Microwave r- I I I
I 319BIOA I ~ 3215BLA 321BRA ~
1319B12A I 319B9A 3191l8A 319~7A 319116A 319B5A 319B4A 319B3A 319B2A319Sdnti amp I ~ 319B105 1319B9EI 319S~aker I U 319825J L321S~bull
I 321SA
1 bull ( l
~ ~ ~31amps(f) - ~~-JCit)
csect) e e reg etr)-~I J
(sectV ~
Hlt shy ~r Mtl~1 It~ -
JnA T1+ +rV+ oAr j Ii 8 el L (amp aor ~J U I 309BSC
Figure 1 Site Plan BioRelix
5 Science Park 3rd Floor New Haven CT
TRIUMVIRATE TRIUMVIRATE ENVIRONMENTAL INC
ENViRONMENTAL 200 Inner Belt Road Somerville MA 02143
(800) 966-9282 Fax (617) 628-8099
gt
1 UZlpound bull Ji
e LJ
rreg ~9 middotu
J J e
6
~ l nr Z 3 r l
~
( ~ e
e E
~ ~ ~i
0 1 rTl
l r rTl shy
Assay Definition-
Assay Description Wipe Test
Assay Type CPM Report Name Report1 Output Data Path CPackardTricarbResultswipe testwipe test20121015 1702 Raw Results Path CPackardTricarbResu1tswipe testwipe test20l21015 170220121015 1702results Comma-Delimited File Name CPackardTricarbResultswipe testwipe test201210 02Report1csv Assay File Name CPackardTriCarbAssayswipe testlsa
Count Conditions-
Nuclide 3H-14C-32P Quench Indicator tSIE External Std Terminator (sec) 05 2s Pre-Count Delay (min) 000
Quench Set na Count Time (min) 100 Count Mode Normal Assay Count Cycles 1 Sample Count 1 VialsSamp1e 1 Calculate Reference Off
Background Subtract Off Low CPM Threshold Off 2 Sigma Terminator Off
Regions LL UL A 00 120 B 120 1560 C 1560 17000
Count Corrections-
Static Controller On Luminescence Correction Off Colored na Heterogeneity Monitor na Coincidence Time (nsec) 18 Delay Before Burst (nsec) 75
Half Life-
Half Life Correction Off Regions Half Life Units Reference Date Reference Time A B
C
Cycle 1 Results S Count Time CPMA MESSAGES CPMB CPMC
1 1 00 20 14 7 2 1 00 18 7 4 3 1 00 20 14 2 4 1 00 18 12 7
5
10
15
20
25
30
35
40
45
50
55
60
1 00 14 l7 8 6 1 00 11 15 6 7 1 00 17 23 11 8 1 00 18 10 3 9 100 23 13 4
1 00 l3 20 5 11 1 00 12 8 8 12 1 00 15 11 6 l3 1 00 17 l7 6 14 1 00 14 l7 7
1 00 16 11 9 16 1 00 12 11 7 l7 100 19 15 5 18 1 00 20 11 12 19 1 00 19 12 10
1 00 12 14 10 21 1 00 16 15 5 22 1 00 12 8 12 23 1 00 19 18 12 24 1 00 5 l7 5
1 00 19 12 5 26 1 00 20 13 6 27 1 00 l7 14 9 28 100 16 17 6 29 1 00 19 9 3
1 00 25 13 6 31 1 00 14 13 5 32 1 00 14 7 5 33 1 00 9 20 6 34 1 00 13 9 10
1 00 20 28 8 36 100 31 24 10 37 1 00 19 20 5 38 1 00 19 11 9 39 1 00 568 l7 8
1 00 16 10 7 41 1 00 15 8 9 42 1 00 30 13 6 43 1 00 18 12 8 44 1 00 11 13 11
1 00 19 12 12 46 100 11 13 7 47 1 00 13 16 10 48 1 00 23 14 7 49 1 00 12 11 3
1 00 14 13 6 51 1 00 15 21 4 52 1 00 15 18 8 53 1 00 18 12 3 54 1 00 16 11 9
1 00 23 9 9 56 1 00 l7 11 6 57 1 00 21 23 4 58 1 00 15 13 10 59 100 15 11 6
1 00 11 20 10 61 1 00 23 7 8
62 1 00 63 1 00 64 1 00 65 1 00 66 1 00 67 1 00 68 1 00 69 1 00 70 1 00 71 1 00 72 1 00 73 1 00 74 1 00
19 25 20 11 25 13 18 13 27 22 17 20 19
12 5 12 4
9 3 13 4
7 7 17 5 12 14
7 9 12 9 17 7 19 5 12 4 19 4
Assay Definition-
Assay Description Wipe Test
Assay Type CPM Report Name Reportl Output Data Path CPackardTricarbResultswipe testwipe test20121018 1436 Raw Results Path CPackardTricarbResultswipe testwipe test20121018 143620121018 1436results Comma-Delimited File Name CPackardTricarbResultswipe testwipe test20121018 436Reportlcsv Assay File Name CPackardTriCarbAssayswipe testlsa
Count Conditions-
Nuclide 3H-14C-32P Quench Indicator tSIE External Std Terminator (sec) 05 2s Pre-Count Delay (min) 000
Quench Set na Count Time (min) 100 Count Mode Normal Assay Count Cycles 1 Repeat Sample Count 1 VialsSample 1 Calculate Reference Off
Background Subtract Off Low CPM Threshold Off 2 Sigma Terminator Off
Regions LL UL A 00 120 B 120 1560 C 1560 17000
Count Corrections-
Static Controller On Luminescence Correction Off Colored Samples na Heterogeneity Monitor na Coincidence Time (nsec) 18 Delay Before Burst (nsec) 75
Half Life-
Half Life Correction Off Regions Half Life Units Reference Date Reference Time A B C
Cycle 1 Results S Count Time CPMA MESSAGES CPMB CPMC
1 1 00 20 18 5 2 1 00 8 4 5 3 1 00 15 16 12
1
2 3
4
5
6
7
8
9
10 11
12 13
14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
34 35 36 37 38 39 40 41 42 43
SUMMARY OF SITE PLAN AND SWIPE TEST RESULTS
dpm H3 dpm C14 dpm P32 on the plan swipe sample cpmH3 cpm C14 cpm P32
31 15 7 316 18 7 4 background 20 14 7
28 7 4
318S 20 14 2 31 15 2 321SA 18 12 7 28 13 7
321BRA 14 17 8 22 18 8
321BRB 11 15 6 17 16 6
321Centrifuge 17 23 11 27 24 11 321Thermo 18 10 3 28 10 3
3215VWR 23 13 4 36 14 4
3215BlB 13 20 5 20 21 5
3215BLA 12 8 8 19 8 8
321SB 15 11 6 23 11 6
319Scint 17 17 6 27 18 6
319Hood 14 17 7 22 18 7
319B2A 16 11 9 25 11 9
319B2B 12 11 7 19 11 7
319B2S 19 15 5 30 16 5
319B3A 20 11 12 31 11 12 319B3B 19 12 10 30 13 10 319B4A 12 14 10 19 15 10
319B4B 16 15 5 25 16 5
319B5A 12 8 12 19 8 12 319B5B 19 18 12 30 19 12 319B6A 5 17 5 8 18 5
319B6B 19 12 5 30 13 5 319Ce ntrifuge 20 13 6 31 14 6 319Shaker 17 14 9 27 15 9
319B7A 16 17 6 25 18 6
319B7B 19 9 3 30 9 3 319B8A 25 13 6 39 14 6
319B8B 14 13 5 22 14 5 319B9E 14 7 5 22 7 5 319B9A 9 20 6 14 21 6 319B9B 13 9 10 20 9 10 319BlOA 20 28 8 31 29 8 319Microwave 31 24 10 48 25 10 319B10B 19 20 5 30 21 5
319B10S 19 11 9 30 11 9 319W 568 17 8 888 18 8 319B12A 16 10 7 25 10 7 319B12B 15 8 9 23 8 9 309B12E 30 13 6 47 14 6 309B12A 18 12 8 28 13 8
309B12B 44 11 13 11 17 14 11
309B11A 45 19 12 12 30 13 12
309B11B 46 11 13 7 17 14 7
309BlOE 47 13 16 10 20 17 10
309BlOA 48 23 14 7 36 15 7
309Bl0B 49 12 11 3 19 11 3
309B9A 50 14 13 6 22 14 6
309B9B 51 15 21 4 23 22 4
309B85 52 15 18 8 23 19 8
309B8A 53 18 12 3 28 13 3 309B8RS 54 16 11 9 25 11 9 309B7A 55 23 9 9 36 9 9 309B7B 56 17 11 6 27 11 6 309B6E 57 21 23 4 33 24 4 309B6A 58 15 13 10 23 14 10 309B6B 59 15 11 6 23 11 6 309B5A 60 11 20 10 17 21 10 309B5B 61 23 7 8 36 7 8 309B5C 62 19 12 5 30 13 5 309B4E 63 25 12 4 39 13 4 309B4A 64 20 9 3 31 9 3 309B4B 65 11 13 4 17 14 4 309B3A 66 25 7 7 39 7 7 309B3B 67 13 17 5 20 18 5 309B25 68 18 12 14 28 13 14 309B2 69 13 7 9 20 7 9 309B1A 70 27 12 9 42 13 9 309B1C 71 22 17 7 34 18 7 QAQC 72 17 19 5 27 20 5 QAQC 73 20 12 4 31 13 4 QAQC 74 19 19 4 30 20 4
Sample key 309 Room number e for 3H=064 dpm=cpme
Sample surface BshyB bench S-sink e for 14C=096 6 Bench number e for 32P=10
Description or E sequence
REPEAT OF THE RESULTS IN QUESTION
plan sample cpmH3 cpm C14 cpm P32 dpmH3 dpm C14 dpm P32 background 1 20 18 5 31 19 5 319Wa 2 8 4 5 13 4 5
319W b 3 15 16 12 23 17 12
Connecticut Department of Energy amp Environmental Protection Bureau of Air Management Radiation Division
Radioactive Material and Industrial X-Ray Device Registration
Please complete this form in accordance with the instructions (DEP-RAD-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation along with this form Please retain a copy of this completed form at your facility
Part I Registration Type
CPPU USE ONLY
App____________
Doc ______________
Check ____________
Program Radiation
Requested Year of Registration Period materials license termination
Registrations are based on the calendar year January 1st through December 31 stbull
Provide Permit Number (aka Facility ID see DEEP correspondence to
Check the appropriate box(es) identifying the registration type
D new registration (ie never registered with the DEEP) [221] registrant)
D new ownership [221] 01576
D renewal of an existing registration [221] If renewing or amending an existing
181 amendment to an existing registration [1467] registration please indicate any changes to tile existing registration information by using reel ink
Note If you are terminating your registration or removing a device(s) from registration refer to the registration instructions (DEP-RAD-INST-100) for required documentation necessary to comply with DEEP requirements
own I(here site is located New Haven
Part II Fee Information
An annual registration fee of $20000 is to be submitted by December 31 S with each registration and applies for the period covering the requested calendar year The fee is not pro-rated New registrants are required to pay the fee regardless of when they register with the DEEP There is no fee for amendments The registration will not be processed without the fee The fee shall be non-refundable and shall be paid by check or money order to the Department of Energy and Environmental Protection
Part III Registrant Information
bull If a registrant is a corporation limited liability company limited partnership limited liability partnership or a statutory trost it must be registered with the Secretary of State If applicable registrants name shall be stated exactly as it is registered with the Secretary of State Please note for those entities registered with the Secretary of State the registered name will be the name used by DEEP This information can be accessed at the Secretary of States database (CONCORD) (wwwconcord-sotsctgovICONCORDlindexjsp)
bull If a registrant is an individual provide the legal name (include suffix) in the following format First Name Middle Initial Last Name Suffix (Jr Sr II III etc)
DEP-RAD-REG-100 1 of 9 Rev 103112
Part III Registrant Information (continued)
1 Registrant Name BioRelix Inc
Mailing Address 5 Science Park (401 Winchester Avenue)
CitylTown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
Contact Person Izabela Puskarz Phone (203) 785-9282 ext 305
E-mail ipuskarzbiorelixcom
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from nctgov addresses Also please notify the department if your e-mail address changes
a) Registrant Type (check one) 0 individual [8J business entity o federal agency
o state agency o municipality tribal
If a business entity (If a business entity complete i through iii)
i) check type [8J corporation 0 limited liability company o limited partnership o Other ________o limited liability partnership 0 statutory trust
ii) provide Secretary of the State business ID ~08~67~696~___This information can be accessed at CONCORD
iii) 0 Check here if you are NOT registered with the SOTS
b) Registrants interest in property at which the proposed activity is to be located
o site owner 0 option holder [8J lessee 0 easement holder operator
o other (specify)
o Check here if any co-registrants If so attach additional sheet(s) with the required information as requested above
2 List billing contact if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
3 List primary contact for departmental cprrespondence and inquiries if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from ctgov addresses Also please notify the department if your e-mail address changes
DEP-RAD-REG-100 2of9 Rev 103112
---
Part III Registrant Information (continued)
4 List the Radiation Safety Officer (RSO) There must be one RSO listed per registration
Name Izabela J Puskarz
Direct Phone (203) 785-9282 ext 305 Fax (203) 785-8058
E-Mail Addressipuskarzbiorelixcom
24-Hour Emergency Phone ~---
List other contact people in the radiation safety section
Name Kenneth F Blount
Title Director of Biology
Direct Phone (203) 785-9282 ext 302 Fax (203) 785-8058
E-Mail Addresskblountbiorelixcom
24-Hour Emergency Pho
Name Brian R Dixon
Title President and CEO
Direct Phone (203) 785-9282 ext 303 Fax (203) 785-8058
E-Mail Addressbdizonbiorelixcom
24-Hour Emergency Phone
Part IV Site Information
1 Company Name BioRelix Inc
Site Name (if different)
Address 5 Science Park (401 Winchester Avenue)
Cityrrown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
2 Location of Material (if different than above)
Cityrrown State Zip Code
Part V NRC Licenses
For new licenses attach a copy of each license for renewals or modifications attach any amended pages of each license
06-31263-01 3 August 312017
DEP-RAD-REG-100 30f9 Rev 103112
Part VI Personnel Dosimetry
1 Indicate whether personnel dosimetry is performed at your facility Yes t8J No
2 If yes indicate the name of vendor that provides this service
Part VII Compliance
If you answer yes to any of the questions below you must complete Part VIII Table of Enforcement Actions as directed in the instructions for your registration
A During the five years immediately preceding submission of this registration has the registrant been convicted in any jurisdiction of a criminal violation of any environmental law
DYes t8J No
B During the five years immediately preceding submission of this registration has a civil penalty been imposed upon the registrant in any state including Connecticut or federal judicial proceeding for any other violation of an environmental law
DYes t8J No
C During the five years immediately preceding submission of this registration has a civil penalty exceeding five thousand dollars been imposed on the registrant in any state including Connecticut or federal administrative proceeding for any violation of an environmental law
DYes t8J No
D During the five years immediately preceding submission of this registration has any state including Connecticut or federal court issued any order or entered any judgment to the registrant concerning a violation of any environmental law
DYes t8J No
E During the five years immediately preceding submission of this registration has any state including Connecticut or federal administrative agency issued any order to the registrant concerning a violation of any environmental law
DYes t8J No
DEP-RAD-REG-100 4of9 Rev 103112
Part VIII Table of Enforcement Actions
Type of Action Type of Action Type of Action
Date Commenced Date Commenced Date Commenced
Date Terminated Date Terminated Date Terminated
Jurisdiction Jurisdiction Jurisdiction
CaselDocketlOrder Number CaselDocketlOrder Number CaseDocketlOrder Number
Description of Violation Description of Violation Description of Violation
D Check the box if additional sheets are attached Copies of this form may be duplicated for additional space
DEP-RAD-REG-100 50f9 Rev 1013112
For Parts IX through XVI you may hit the tab button at the end of each table in the last cell and create additional rows
Part IX Industrial X-Ray Equipment
Part X Analytic Equipment for Examination of Material
aXlimum mA
~~t JiUIp
(Including but not limited to X-ray diffraction units electron microscopes gauging devices spectroscopic equipment gas chromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or therapy)
MQttatltl I t
Serial Manufacturer r~ M~_ilil I Maximum mA
Part XI Industrial Radiographic Equipment
(For examination of structure with a sealed source)
I I TYRe Model ibmll Serial I Manufactu~middot l i i
Part XII Particle Accelerators
(Including but not limited to Van de Graffs Linacs Cyclotrons Electronic Beam Welders)
lI~f ler1 bull Ma~ufacturer p~Itf ii
DEP-RAD-REG-100 6 af9 Rev 103112
Part XIII Special Nuclear Material (Special nuclear material [SNM] refers to plutonium 233U uranium enriched in the isotope 233 or in the isotope 235 greater than its natural abundance and any other material which the US NRC pursuant to the provisions of Section 510f the Atomic Energy Act of 1954 determines to be special nuclear material SNM does not include source material)
Part XIV Source Material
(Source material [SM] refers to uranium or thorium or any combination thereof in any physical or chemical form or ores which contain at least 005 by weight uranium thorium or any combination thereof except when the material is designated as special nuclear material)
Part XV Sealed Sources
No1~er ofSikrcesltc
Part XVI Other Radioactive Materials (including medical isotopes)
3 Hydrogen 25mCi
33 Phosphorous 25mCi
DEP-RAD-REG-100 7of9 Rev 103112
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
Key 309 B
~ ~ (fJ Olraquo
0 ampJS3 rTl1j
l -Z n rTl
r~ flkr (fJraquorTl 5 n
9 m
T ~1middot~~~~~~Imiddot~112Bmiddotmiddot3119~~ili1()middotBmiddot3119~i9iBI3i119Il8filiBmiddot31111i9~BI7B1i3iic1li9I~Iii-nuiigiiii1Iii19IIl5IBmiddot3~191~B4IBmiddot3i1ii19~B~3iBi3middot19IBili2BIllli311l9il1H~IOoi~i51i111middotIIBi)iIiI2RmiddotlI3231nmfuge iyen8 319W 319Microwave r- I I I
I 319BIOA I ~ 3215BLA 321BRA ~
1319B12A I 319B9A 3191l8A 319~7A 319116A 319B5A 319B4A 319B3A 319B2A319Sdnti amp I ~ 319B105 1319B9EI 319S~aker I U 319825J L321S~bull
I 321SA
1 bull ( l
~ ~ ~31amps(f) - ~~-JCit)
csect) e e reg etr)-~I J
(sectV ~
Hlt shy ~r Mtl~1 It~ -
JnA T1+ +rV+ oAr j Ii 8 el L (amp aor ~J U I 309BSC
Figure 1 Site Plan BioRelix
5 Science Park 3rd Floor New Haven CT
TRIUMVIRATE TRIUMVIRATE ENVIRONMENTAL INC
ENViRONMENTAL 200 Inner Belt Road Somerville MA 02143
(800) 966-9282 Fax (617) 628-8099
gt
1 UZlpound bull Ji
e LJ
rreg ~9 middotu
J J e
6
~ l nr Z 3 r l
~
( ~ e
e E
~ ~ ~i
0 1 rTl
l r rTl shy
Assay Definition-
Assay Description Wipe Test
Assay Type CPM Report Name Report1 Output Data Path CPackardTricarbResultswipe testwipe test20121015 1702 Raw Results Path CPackardTricarbResu1tswipe testwipe test20l21015 170220121015 1702results Comma-Delimited File Name CPackardTricarbResultswipe testwipe test201210 02Report1csv Assay File Name CPackardTriCarbAssayswipe testlsa
Count Conditions-
Nuclide 3H-14C-32P Quench Indicator tSIE External Std Terminator (sec) 05 2s Pre-Count Delay (min) 000
Quench Set na Count Time (min) 100 Count Mode Normal Assay Count Cycles 1 Sample Count 1 VialsSamp1e 1 Calculate Reference Off
Background Subtract Off Low CPM Threshold Off 2 Sigma Terminator Off
Regions LL UL A 00 120 B 120 1560 C 1560 17000
Count Corrections-
Static Controller On Luminescence Correction Off Colored na Heterogeneity Monitor na Coincidence Time (nsec) 18 Delay Before Burst (nsec) 75
Half Life-
Half Life Correction Off Regions Half Life Units Reference Date Reference Time A B
C
Cycle 1 Results S Count Time CPMA MESSAGES CPMB CPMC
1 1 00 20 14 7 2 1 00 18 7 4 3 1 00 20 14 2 4 1 00 18 12 7
5
10
15
20
25
30
35
40
45
50
55
60
1 00 14 l7 8 6 1 00 11 15 6 7 1 00 17 23 11 8 1 00 18 10 3 9 100 23 13 4
1 00 l3 20 5 11 1 00 12 8 8 12 1 00 15 11 6 l3 1 00 17 l7 6 14 1 00 14 l7 7
1 00 16 11 9 16 1 00 12 11 7 l7 100 19 15 5 18 1 00 20 11 12 19 1 00 19 12 10
1 00 12 14 10 21 1 00 16 15 5 22 1 00 12 8 12 23 1 00 19 18 12 24 1 00 5 l7 5
1 00 19 12 5 26 1 00 20 13 6 27 1 00 l7 14 9 28 100 16 17 6 29 1 00 19 9 3
1 00 25 13 6 31 1 00 14 13 5 32 1 00 14 7 5 33 1 00 9 20 6 34 1 00 13 9 10
1 00 20 28 8 36 100 31 24 10 37 1 00 19 20 5 38 1 00 19 11 9 39 1 00 568 l7 8
1 00 16 10 7 41 1 00 15 8 9 42 1 00 30 13 6 43 1 00 18 12 8 44 1 00 11 13 11
1 00 19 12 12 46 100 11 13 7 47 1 00 13 16 10 48 1 00 23 14 7 49 1 00 12 11 3
1 00 14 13 6 51 1 00 15 21 4 52 1 00 15 18 8 53 1 00 18 12 3 54 1 00 16 11 9
1 00 23 9 9 56 1 00 l7 11 6 57 1 00 21 23 4 58 1 00 15 13 10 59 100 15 11 6
1 00 11 20 10 61 1 00 23 7 8
62 1 00 63 1 00 64 1 00 65 1 00 66 1 00 67 1 00 68 1 00 69 1 00 70 1 00 71 1 00 72 1 00 73 1 00 74 1 00
19 25 20 11 25 13 18 13 27 22 17 20 19
12 5 12 4
9 3 13 4
7 7 17 5 12 14
7 9 12 9 17 7 19 5 12 4 19 4
Assay Definition-
Assay Description Wipe Test
Assay Type CPM Report Name Reportl Output Data Path CPackardTricarbResultswipe testwipe test20121018 1436 Raw Results Path CPackardTricarbResultswipe testwipe test20121018 143620121018 1436results Comma-Delimited File Name CPackardTricarbResultswipe testwipe test20121018 436Reportlcsv Assay File Name CPackardTriCarbAssayswipe testlsa
Count Conditions-
Nuclide 3H-14C-32P Quench Indicator tSIE External Std Terminator (sec) 05 2s Pre-Count Delay (min) 000
Quench Set na Count Time (min) 100 Count Mode Normal Assay Count Cycles 1 Repeat Sample Count 1 VialsSample 1 Calculate Reference Off
Background Subtract Off Low CPM Threshold Off 2 Sigma Terminator Off
Regions LL UL A 00 120 B 120 1560 C 1560 17000
Count Corrections-
Static Controller On Luminescence Correction Off Colored Samples na Heterogeneity Monitor na Coincidence Time (nsec) 18 Delay Before Burst (nsec) 75
Half Life-
Half Life Correction Off Regions Half Life Units Reference Date Reference Time A B C
Cycle 1 Results S Count Time CPMA MESSAGES CPMB CPMC
1 1 00 20 18 5 2 1 00 8 4 5 3 1 00 15 16 12
1
2 3
4
5
6
7
8
9
10 11
12 13
14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
34 35 36 37 38 39 40 41 42 43
SUMMARY OF SITE PLAN AND SWIPE TEST RESULTS
dpm H3 dpm C14 dpm P32 on the plan swipe sample cpmH3 cpm C14 cpm P32
31 15 7 316 18 7 4 background 20 14 7
28 7 4
318S 20 14 2 31 15 2 321SA 18 12 7 28 13 7
321BRA 14 17 8 22 18 8
321BRB 11 15 6 17 16 6
321Centrifuge 17 23 11 27 24 11 321Thermo 18 10 3 28 10 3
3215VWR 23 13 4 36 14 4
3215BlB 13 20 5 20 21 5
3215BLA 12 8 8 19 8 8
321SB 15 11 6 23 11 6
319Scint 17 17 6 27 18 6
319Hood 14 17 7 22 18 7
319B2A 16 11 9 25 11 9
319B2B 12 11 7 19 11 7
319B2S 19 15 5 30 16 5
319B3A 20 11 12 31 11 12 319B3B 19 12 10 30 13 10 319B4A 12 14 10 19 15 10
319B4B 16 15 5 25 16 5
319B5A 12 8 12 19 8 12 319B5B 19 18 12 30 19 12 319B6A 5 17 5 8 18 5
319B6B 19 12 5 30 13 5 319Ce ntrifuge 20 13 6 31 14 6 319Shaker 17 14 9 27 15 9
319B7A 16 17 6 25 18 6
319B7B 19 9 3 30 9 3 319B8A 25 13 6 39 14 6
319B8B 14 13 5 22 14 5 319B9E 14 7 5 22 7 5 319B9A 9 20 6 14 21 6 319B9B 13 9 10 20 9 10 319BlOA 20 28 8 31 29 8 319Microwave 31 24 10 48 25 10 319B10B 19 20 5 30 21 5
319B10S 19 11 9 30 11 9 319W 568 17 8 888 18 8 319B12A 16 10 7 25 10 7 319B12B 15 8 9 23 8 9 309B12E 30 13 6 47 14 6 309B12A 18 12 8 28 13 8
309B12B 44 11 13 11 17 14 11
309B11A 45 19 12 12 30 13 12
309B11B 46 11 13 7 17 14 7
309BlOE 47 13 16 10 20 17 10
309BlOA 48 23 14 7 36 15 7
309Bl0B 49 12 11 3 19 11 3
309B9A 50 14 13 6 22 14 6
309B9B 51 15 21 4 23 22 4
309B85 52 15 18 8 23 19 8
309B8A 53 18 12 3 28 13 3 309B8RS 54 16 11 9 25 11 9 309B7A 55 23 9 9 36 9 9 309B7B 56 17 11 6 27 11 6 309B6E 57 21 23 4 33 24 4 309B6A 58 15 13 10 23 14 10 309B6B 59 15 11 6 23 11 6 309B5A 60 11 20 10 17 21 10 309B5B 61 23 7 8 36 7 8 309B5C 62 19 12 5 30 13 5 309B4E 63 25 12 4 39 13 4 309B4A 64 20 9 3 31 9 3 309B4B 65 11 13 4 17 14 4 309B3A 66 25 7 7 39 7 7 309B3B 67 13 17 5 20 18 5 309B25 68 18 12 14 28 13 14 309B2 69 13 7 9 20 7 9 309B1A 70 27 12 9 42 13 9 309B1C 71 22 17 7 34 18 7 QAQC 72 17 19 5 27 20 5 QAQC 73 20 12 4 31 13 4 QAQC 74 19 19 4 30 20 4
Sample key 309 Room number e for 3H=064 dpm=cpme
Sample surface BshyB bench S-sink e for 14C=096 6 Bench number e for 32P=10
Description or E sequence
REPEAT OF THE RESULTS IN QUESTION
plan sample cpmH3 cpm C14 cpm P32 dpmH3 dpm C14 dpm P32 background 1 20 18 5 31 19 5 319Wa 2 8 4 5 13 4 5
319W b 3 15 16 12 23 17 12
Connecticut Department of Energy amp Environmental Protection Bureau of Air Management Radiation Division
Radioactive Material and Industrial X-Ray Device Registration
Please complete this form in accordance with the instructions (DEP-RAD-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation along with this form Please retain a copy of this completed form at your facility
Part I Registration Type
CPPU USE ONLY
App____________
Doc ______________
Check ____________
Program Radiation
Requested Year of Registration Period materials license termination
Registrations are based on the calendar year January 1st through December 31 stbull
Provide Permit Number (aka Facility ID see DEEP correspondence to
Check the appropriate box(es) identifying the registration type
D new registration (ie never registered with the DEEP) [221] registrant)
D new ownership [221] 01576
D renewal of an existing registration [221] If renewing or amending an existing
181 amendment to an existing registration [1467] registration please indicate any changes to tile existing registration information by using reel ink
Note If you are terminating your registration or removing a device(s) from registration refer to the registration instructions (DEP-RAD-INST-100) for required documentation necessary to comply with DEEP requirements
own I(here site is located New Haven
Part II Fee Information
An annual registration fee of $20000 is to be submitted by December 31 S with each registration and applies for the period covering the requested calendar year The fee is not pro-rated New registrants are required to pay the fee regardless of when they register with the DEEP There is no fee for amendments The registration will not be processed without the fee The fee shall be non-refundable and shall be paid by check or money order to the Department of Energy and Environmental Protection
Part III Registrant Information
bull If a registrant is a corporation limited liability company limited partnership limited liability partnership or a statutory trost it must be registered with the Secretary of State If applicable registrants name shall be stated exactly as it is registered with the Secretary of State Please note for those entities registered with the Secretary of State the registered name will be the name used by DEEP This information can be accessed at the Secretary of States database (CONCORD) (wwwconcord-sotsctgovICONCORDlindexjsp)
bull If a registrant is an individual provide the legal name (include suffix) in the following format First Name Middle Initial Last Name Suffix (Jr Sr II III etc)
DEP-RAD-REG-100 1 of 9 Rev 103112
Part III Registrant Information (continued)
1 Registrant Name BioRelix Inc
Mailing Address 5 Science Park (401 Winchester Avenue)
CitylTown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
Contact Person Izabela Puskarz Phone (203) 785-9282 ext 305
E-mail ipuskarzbiorelixcom
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from nctgov addresses Also please notify the department if your e-mail address changes
a) Registrant Type (check one) 0 individual [8J business entity o federal agency
o state agency o municipality tribal
If a business entity (If a business entity complete i through iii)
i) check type [8J corporation 0 limited liability company o limited partnership o Other ________o limited liability partnership 0 statutory trust
ii) provide Secretary of the State business ID ~08~67~696~___This information can be accessed at CONCORD
iii) 0 Check here if you are NOT registered with the SOTS
b) Registrants interest in property at which the proposed activity is to be located
o site owner 0 option holder [8J lessee 0 easement holder operator
o other (specify)
o Check here if any co-registrants If so attach additional sheet(s) with the required information as requested above
2 List billing contact if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
3 List primary contact for departmental cprrespondence and inquiries if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from ctgov addresses Also please notify the department if your e-mail address changes
DEP-RAD-REG-100 2of9 Rev 103112
---
Part III Registrant Information (continued)
4 List the Radiation Safety Officer (RSO) There must be one RSO listed per registration
Name Izabela J Puskarz
Direct Phone (203) 785-9282 ext 305 Fax (203) 785-8058
E-Mail Addressipuskarzbiorelixcom
24-Hour Emergency Phone ~---
List other contact people in the radiation safety section
Name Kenneth F Blount
Title Director of Biology
Direct Phone (203) 785-9282 ext 302 Fax (203) 785-8058
E-Mail Addresskblountbiorelixcom
24-Hour Emergency Pho
Name Brian R Dixon
Title President and CEO
Direct Phone (203) 785-9282 ext 303 Fax (203) 785-8058
E-Mail Addressbdizonbiorelixcom
24-Hour Emergency Phone
Part IV Site Information
1 Company Name BioRelix Inc
Site Name (if different)
Address 5 Science Park (401 Winchester Avenue)
Cityrrown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
2 Location of Material (if different than above)
Cityrrown State Zip Code
Part V NRC Licenses
For new licenses attach a copy of each license for renewals or modifications attach any amended pages of each license
06-31263-01 3 August 312017
DEP-RAD-REG-100 30f9 Rev 103112
Part VI Personnel Dosimetry
1 Indicate whether personnel dosimetry is performed at your facility Yes t8J No
2 If yes indicate the name of vendor that provides this service
Part VII Compliance
If you answer yes to any of the questions below you must complete Part VIII Table of Enforcement Actions as directed in the instructions for your registration
A During the five years immediately preceding submission of this registration has the registrant been convicted in any jurisdiction of a criminal violation of any environmental law
DYes t8J No
B During the five years immediately preceding submission of this registration has a civil penalty been imposed upon the registrant in any state including Connecticut or federal judicial proceeding for any other violation of an environmental law
DYes t8J No
C During the five years immediately preceding submission of this registration has a civil penalty exceeding five thousand dollars been imposed on the registrant in any state including Connecticut or federal administrative proceeding for any violation of an environmental law
DYes t8J No
D During the five years immediately preceding submission of this registration has any state including Connecticut or federal court issued any order or entered any judgment to the registrant concerning a violation of any environmental law
DYes t8J No
E During the five years immediately preceding submission of this registration has any state including Connecticut or federal administrative agency issued any order to the registrant concerning a violation of any environmental law
DYes t8J No
DEP-RAD-REG-100 4of9 Rev 103112
Part VIII Table of Enforcement Actions
Type of Action Type of Action Type of Action
Date Commenced Date Commenced Date Commenced
Date Terminated Date Terminated Date Terminated
Jurisdiction Jurisdiction Jurisdiction
CaselDocketlOrder Number CaselDocketlOrder Number CaseDocketlOrder Number
Description of Violation Description of Violation Description of Violation
D Check the box if additional sheets are attached Copies of this form may be duplicated for additional space
DEP-RAD-REG-100 50f9 Rev 1013112
For Parts IX through XVI you may hit the tab button at the end of each table in the last cell and create additional rows
Part IX Industrial X-Ray Equipment
Part X Analytic Equipment for Examination of Material
aXlimum mA
~~t JiUIp
(Including but not limited to X-ray diffraction units electron microscopes gauging devices spectroscopic equipment gas chromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or therapy)
MQttatltl I t
Serial Manufacturer r~ M~_ilil I Maximum mA
Part XI Industrial Radiographic Equipment
(For examination of structure with a sealed source)
I I TYRe Model ibmll Serial I Manufactu~middot l i i
Part XII Particle Accelerators
(Including but not limited to Van de Graffs Linacs Cyclotrons Electronic Beam Welders)
lI~f ler1 bull Ma~ufacturer p~Itf ii
DEP-RAD-REG-100 6 af9 Rev 103112
Part XIII Special Nuclear Material (Special nuclear material [SNM] refers to plutonium 233U uranium enriched in the isotope 233 or in the isotope 235 greater than its natural abundance and any other material which the US NRC pursuant to the provisions of Section 510f the Atomic Energy Act of 1954 determines to be special nuclear material SNM does not include source material)
Part XIV Source Material
(Source material [SM] refers to uranium or thorium or any combination thereof in any physical or chemical form or ores which contain at least 005 by weight uranium thorium or any combination thereof except when the material is designated as special nuclear material)
Part XV Sealed Sources
No1~er ofSikrcesltc
Part XVI Other Radioactive Materials (including medical isotopes)
3 Hydrogen 25mCi
33 Phosphorous 25mCi
DEP-RAD-REG-100 7of9 Rev 103112
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
Assay Definition-
Assay Description Wipe Test
Assay Type CPM Report Name Report1 Output Data Path CPackardTricarbResultswipe testwipe test20121015 1702 Raw Results Path CPackardTricarbResu1tswipe testwipe test20l21015 170220121015 1702results Comma-Delimited File Name CPackardTricarbResultswipe testwipe test201210 02Report1csv Assay File Name CPackardTriCarbAssayswipe testlsa
Count Conditions-
Nuclide 3H-14C-32P Quench Indicator tSIE External Std Terminator (sec) 05 2s Pre-Count Delay (min) 000
Quench Set na Count Time (min) 100 Count Mode Normal Assay Count Cycles 1 Sample Count 1 VialsSamp1e 1 Calculate Reference Off
Background Subtract Off Low CPM Threshold Off 2 Sigma Terminator Off
Regions LL UL A 00 120 B 120 1560 C 1560 17000
Count Corrections-
Static Controller On Luminescence Correction Off Colored na Heterogeneity Monitor na Coincidence Time (nsec) 18 Delay Before Burst (nsec) 75
Half Life-
Half Life Correction Off Regions Half Life Units Reference Date Reference Time A B
C
Cycle 1 Results S Count Time CPMA MESSAGES CPMB CPMC
1 1 00 20 14 7 2 1 00 18 7 4 3 1 00 20 14 2 4 1 00 18 12 7
5
10
15
20
25
30
35
40
45
50
55
60
1 00 14 l7 8 6 1 00 11 15 6 7 1 00 17 23 11 8 1 00 18 10 3 9 100 23 13 4
1 00 l3 20 5 11 1 00 12 8 8 12 1 00 15 11 6 l3 1 00 17 l7 6 14 1 00 14 l7 7
1 00 16 11 9 16 1 00 12 11 7 l7 100 19 15 5 18 1 00 20 11 12 19 1 00 19 12 10
1 00 12 14 10 21 1 00 16 15 5 22 1 00 12 8 12 23 1 00 19 18 12 24 1 00 5 l7 5
1 00 19 12 5 26 1 00 20 13 6 27 1 00 l7 14 9 28 100 16 17 6 29 1 00 19 9 3
1 00 25 13 6 31 1 00 14 13 5 32 1 00 14 7 5 33 1 00 9 20 6 34 1 00 13 9 10
1 00 20 28 8 36 100 31 24 10 37 1 00 19 20 5 38 1 00 19 11 9 39 1 00 568 l7 8
1 00 16 10 7 41 1 00 15 8 9 42 1 00 30 13 6 43 1 00 18 12 8 44 1 00 11 13 11
1 00 19 12 12 46 100 11 13 7 47 1 00 13 16 10 48 1 00 23 14 7 49 1 00 12 11 3
1 00 14 13 6 51 1 00 15 21 4 52 1 00 15 18 8 53 1 00 18 12 3 54 1 00 16 11 9
1 00 23 9 9 56 1 00 l7 11 6 57 1 00 21 23 4 58 1 00 15 13 10 59 100 15 11 6
1 00 11 20 10 61 1 00 23 7 8
62 1 00 63 1 00 64 1 00 65 1 00 66 1 00 67 1 00 68 1 00 69 1 00 70 1 00 71 1 00 72 1 00 73 1 00 74 1 00
19 25 20 11 25 13 18 13 27 22 17 20 19
12 5 12 4
9 3 13 4
7 7 17 5 12 14
7 9 12 9 17 7 19 5 12 4 19 4
Assay Definition-
Assay Description Wipe Test
Assay Type CPM Report Name Reportl Output Data Path CPackardTricarbResultswipe testwipe test20121018 1436 Raw Results Path CPackardTricarbResultswipe testwipe test20121018 143620121018 1436results Comma-Delimited File Name CPackardTricarbResultswipe testwipe test20121018 436Reportlcsv Assay File Name CPackardTriCarbAssayswipe testlsa
Count Conditions-
Nuclide 3H-14C-32P Quench Indicator tSIE External Std Terminator (sec) 05 2s Pre-Count Delay (min) 000
Quench Set na Count Time (min) 100 Count Mode Normal Assay Count Cycles 1 Repeat Sample Count 1 VialsSample 1 Calculate Reference Off
Background Subtract Off Low CPM Threshold Off 2 Sigma Terminator Off
Regions LL UL A 00 120 B 120 1560 C 1560 17000
Count Corrections-
Static Controller On Luminescence Correction Off Colored Samples na Heterogeneity Monitor na Coincidence Time (nsec) 18 Delay Before Burst (nsec) 75
Half Life-
Half Life Correction Off Regions Half Life Units Reference Date Reference Time A B C
Cycle 1 Results S Count Time CPMA MESSAGES CPMB CPMC
1 1 00 20 18 5 2 1 00 8 4 5 3 1 00 15 16 12
1
2 3
4
5
6
7
8
9
10 11
12 13
14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
34 35 36 37 38 39 40 41 42 43
SUMMARY OF SITE PLAN AND SWIPE TEST RESULTS
dpm H3 dpm C14 dpm P32 on the plan swipe sample cpmH3 cpm C14 cpm P32
31 15 7 316 18 7 4 background 20 14 7
28 7 4
318S 20 14 2 31 15 2 321SA 18 12 7 28 13 7
321BRA 14 17 8 22 18 8
321BRB 11 15 6 17 16 6
321Centrifuge 17 23 11 27 24 11 321Thermo 18 10 3 28 10 3
3215VWR 23 13 4 36 14 4
3215BlB 13 20 5 20 21 5
3215BLA 12 8 8 19 8 8
321SB 15 11 6 23 11 6
319Scint 17 17 6 27 18 6
319Hood 14 17 7 22 18 7
319B2A 16 11 9 25 11 9
319B2B 12 11 7 19 11 7
319B2S 19 15 5 30 16 5
319B3A 20 11 12 31 11 12 319B3B 19 12 10 30 13 10 319B4A 12 14 10 19 15 10
319B4B 16 15 5 25 16 5
319B5A 12 8 12 19 8 12 319B5B 19 18 12 30 19 12 319B6A 5 17 5 8 18 5
319B6B 19 12 5 30 13 5 319Ce ntrifuge 20 13 6 31 14 6 319Shaker 17 14 9 27 15 9
319B7A 16 17 6 25 18 6
319B7B 19 9 3 30 9 3 319B8A 25 13 6 39 14 6
319B8B 14 13 5 22 14 5 319B9E 14 7 5 22 7 5 319B9A 9 20 6 14 21 6 319B9B 13 9 10 20 9 10 319BlOA 20 28 8 31 29 8 319Microwave 31 24 10 48 25 10 319B10B 19 20 5 30 21 5
319B10S 19 11 9 30 11 9 319W 568 17 8 888 18 8 319B12A 16 10 7 25 10 7 319B12B 15 8 9 23 8 9 309B12E 30 13 6 47 14 6 309B12A 18 12 8 28 13 8
309B12B 44 11 13 11 17 14 11
309B11A 45 19 12 12 30 13 12
309B11B 46 11 13 7 17 14 7
309BlOE 47 13 16 10 20 17 10
309BlOA 48 23 14 7 36 15 7
309Bl0B 49 12 11 3 19 11 3
309B9A 50 14 13 6 22 14 6
309B9B 51 15 21 4 23 22 4
309B85 52 15 18 8 23 19 8
309B8A 53 18 12 3 28 13 3 309B8RS 54 16 11 9 25 11 9 309B7A 55 23 9 9 36 9 9 309B7B 56 17 11 6 27 11 6 309B6E 57 21 23 4 33 24 4 309B6A 58 15 13 10 23 14 10 309B6B 59 15 11 6 23 11 6 309B5A 60 11 20 10 17 21 10 309B5B 61 23 7 8 36 7 8 309B5C 62 19 12 5 30 13 5 309B4E 63 25 12 4 39 13 4 309B4A 64 20 9 3 31 9 3 309B4B 65 11 13 4 17 14 4 309B3A 66 25 7 7 39 7 7 309B3B 67 13 17 5 20 18 5 309B25 68 18 12 14 28 13 14 309B2 69 13 7 9 20 7 9 309B1A 70 27 12 9 42 13 9 309B1C 71 22 17 7 34 18 7 QAQC 72 17 19 5 27 20 5 QAQC 73 20 12 4 31 13 4 QAQC 74 19 19 4 30 20 4
Sample key 309 Room number e for 3H=064 dpm=cpme
Sample surface BshyB bench S-sink e for 14C=096 6 Bench number e for 32P=10
Description or E sequence
REPEAT OF THE RESULTS IN QUESTION
plan sample cpmH3 cpm C14 cpm P32 dpmH3 dpm C14 dpm P32 background 1 20 18 5 31 19 5 319Wa 2 8 4 5 13 4 5
319W b 3 15 16 12 23 17 12
Connecticut Department of Energy amp Environmental Protection Bureau of Air Management Radiation Division
Radioactive Material and Industrial X-Ray Device Registration
Please complete this form in accordance with the instructions (DEP-RAD-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation along with this form Please retain a copy of this completed form at your facility
Part I Registration Type
CPPU USE ONLY
App____________
Doc ______________
Check ____________
Program Radiation
Requested Year of Registration Period materials license termination
Registrations are based on the calendar year January 1st through December 31 stbull
Provide Permit Number (aka Facility ID see DEEP correspondence to
Check the appropriate box(es) identifying the registration type
D new registration (ie never registered with the DEEP) [221] registrant)
D new ownership [221] 01576
D renewal of an existing registration [221] If renewing or amending an existing
181 amendment to an existing registration [1467] registration please indicate any changes to tile existing registration information by using reel ink
Note If you are terminating your registration or removing a device(s) from registration refer to the registration instructions (DEP-RAD-INST-100) for required documentation necessary to comply with DEEP requirements
own I(here site is located New Haven
Part II Fee Information
An annual registration fee of $20000 is to be submitted by December 31 S with each registration and applies for the period covering the requested calendar year The fee is not pro-rated New registrants are required to pay the fee regardless of when they register with the DEEP There is no fee for amendments The registration will not be processed without the fee The fee shall be non-refundable and shall be paid by check or money order to the Department of Energy and Environmental Protection
Part III Registrant Information
bull If a registrant is a corporation limited liability company limited partnership limited liability partnership or a statutory trost it must be registered with the Secretary of State If applicable registrants name shall be stated exactly as it is registered with the Secretary of State Please note for those entities registered with the Secretary of State the registered name will be the name used by DEEP This information can be accessed at the Secretary of States database (CONCORD) (wwwconcord-sotsctgovICONCORDlindexjsp)
bull If a registrant is an individual provide the legal name (include suffix) in the following format First Name Middle Initial Last Name Suffix (Jr Sr II III etc)
DEP-RAD-REG-100 1 of 9 Rev 103112
Part III Registrant Information (continued)
1 Registrant Name BioRelix Inc
Mailing Address 5 Science Park (401 Winchester Avenue)
CitylTown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
Contact Person Izabela Puskarz Phone (203) 785-9282 ext 305
E-mail ipuskarzbiorelixcom
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from nctgov addresses Also please notify the department if your e-mail address changes
a) Registrant Type (check one) 0 individual [8J business entity o federal agency
o state agency o municipality tribal
If a business entity (If a business entity complete i through iii)
i) check type [8J corporation 0 limited liability company o limited partnership o Other ________o limited liability partnership 0 statutory trust
ii) provide Secretary of the State business ID ~08~67~696~___This information can be accessed at CONCORD
iii) 0 Check here if you are NOT registered with the SOTS
b) Registrants interest in property at which the proposed activity is to be located
o site owner 0 option holder [8J lessee 0 easement holder operator
o other (specify)
o Check here if any co-registrants If so attach additional sheet(s) with the required information as requested above
2 List billing contact if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
3 List primary contact for departmental cprrespondence and inquiries if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from ctgov addresses Also please notify the department if your e-mail address changes
DEP-RAD-REG-100 2of9 Rev 103112
---
Part III Registrant Information (continued)
4 List the Radiation Safety Officer (RSO) There must be one RSO listed per registration
Name Izabela J Puskarz
Direct Phone (203) 785-9282 ext 305 Fax (203) 785-8058
E-Mail Addressipuskarzbiorelixcom
24-Hour Emergency Phone ~---
List other contact people in the radiation safety section
Name Kenneth F Blount
Title Director of Biology
Direct Phone (203) 785-9282 ext 302 Fax (203) 785-8058
E-Mail Addresskblountbiorelixcom
24-Hour Emergency Pho
Name Brian R Dixon
Title President and CEO
Direct Phone (203) 785-9282 ext 303 Fax (203) 785-8058
E-Mail Addressbdizonbiorelixcom
24-Hour Emergency Phone
Part IV Site Information
1 Company Name BioRelix Inc
Site Name (if different)
Address 5 Science Park (401 Winchester Avenue)
Cityrrown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
2 Location of Material (if different than above)
Cityrrown State Zip Code
Part V NRC Licenses
For new licenses attach a copy of each license for renewals or modifications attach any amended pages of each license
06-31263-01 3 August 312017
DEP-RAD-REG-100 30f9 Rev 103112
Part VI Personnel Dosimetry
1 Indicate whether personnel dosimetry is performed at your facility Yes t8J No
2 If yes indicate the name of vendor that provides this service
Part VII Compliance
If you answer yes to any of the questions below you must complete Part VIII Table of Enforcement Actions as directed in the instructions for your registration
A During the five years immediately preceding submission of this registration has the registrant been convicted in any jurisdiction of a criminal violation of any environmental law
DYes t8J No
B During the five years immediately preceding submission of this registration has a civil penalty been imposed upon the registrant in any state including Connecticut or federal judicial proceeding for any other violation of an environmental law
DYes t8J No
C During the five years immediately preceding submission of this registration has a civil penalty exceeding five thousand dollars been imposed on the registrant in any state including Connecticut or federal administrative proceeding for any violation of an environmental law
DYes t8J No
D During the five years immediately preceding submission of this registration has any state including Connecticut or federal court issued any order or entered any judgment to the registrant concerning a violation of any environmental law
DYes t8J No
E During the five years immediately preceding submission of this registration has any state including Connecticut or federal administrative agency issued any order to the registrant concerning a violation of any environmental law
DYes t8J No
DEP-RAD-REG-100 4of9 Rev 103112
Part VIII Table of Enforcement Actions
Type of Action Type of Action Type of Action
Date Commenced Date Commenced Date Commenced
Date Terminated Date Terminated Date Terminated
Jurisdiction Jurisdiction Jurisdiction
CaselDocketlOrder Number CaselDocketlOrder Number CaseDocketlOrder Number
Description of Violation Description of Violation Description of Violation
D Check the box if additional sheets are attached Copies of this form may be duplicated for additional space
DEP-RAD-REG-100 50f9 Rev 1013112
For Parts IX through XVI you may hit the tab button at the end of each table in the last cell and create additional rows
Part IX Industrial X-Ray Equipment
Part X Analytic Equipment for Examination of Material
aXlimum mA
~~t JiUIp
(Including but not limited to X-ray diffraction units electron microscopes gauging devices spectroscopic equipment gas chromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or therapy)
MQttatltl I t
Serial Manufacturer r~ M~_ilil I Maximum mA
Part XI Industrial Radiographic Equipment
(For examination of structure with a sealed source)
I I TYRe Model ibmll Serial I Manufactu~middot l i i
Part XII Particle Accelerators
(Including but not limited to Van de Graffs Linacs Cyclotrons Electronic Beam Welders)
lI~f ler1 bull Ma~ufacturer p~Itf ii
DEP-RAD-REG-100 6 af9 Rev 103112
Part XIII Special Nuclear Material (Special nuclear material [SNM] refers to plutonium 233U uranium enriched in the isotope 233 or in the isotope 235 greater than its natural abundance and any other material which the US NRC pursuant to the provisions of Section 510f the Atomic Energy Act of 1954 determines to be special nuclear material SNM does not include source material)
Part XIV Source Material
(Source material [SM] refers to uranium or thorium or any combination thereof in any physical or chemical form or ores which contain at least 005 by weight uranium thorium or any combination thereof except when the material is designated as special nuclear material)
Part XV Sealed Sources
No1~er ofSikrcesltc
Part XVI Other Radioactive Materials (including medical isotopes)
3 Hydrogen 25mCi
33 Phosphorous 25mCi
DEP-RAD-REG-100 7of9 Rev 103112
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
5
10
15
20
25
30
35
40
45
50
55
60
1 00 14 l7 8 6 1 00 11 15 6 7 1 00 17 23 11 8 1 00 18 10 3 9 100 23 13 4
1 00 l3 20 5 11 1 00 12 8 8 12 1 00 15 11 6 l3 1 00 17 l7 6 14 1 00 14 l7 7
1 00 16 11 9 16 1 00 12 11 7 l7 100 19 15 5 18 1 00 20 11 12 19 1 00 19 12 10
1 00 12 14 10 21 1 00 16 15 5 22 1 00 12 8 12 23 1 00 19 18 12 24 1 00 5 l7 5
1 00 19 12 5 26 1 00 20 13 6 27 1 00 l7 14 9 28 100 16 17 6 29 1 00 19 9 3
1 00 25 13 6 31 1 00 14 13 5 32 1 00 14 7 5 33 1 00 9 20 6 34 1 00 13 9 10
1 00 20 28 8 36 100 31 24 10 37 1 00 19 20 5 38 1 00 19 11 9 39 1 00 568 l7 8
1 00 16 10 7 41 1 00 15 8 9 42 1 00 30 13 6 43 1 00 18 12 8 44 1 00 11 13 11
1 00 19 12 12 46 100 11 13 7 47 1 00 13 16 10 48 1 00 23 14 7 49 1 00 12 11 3
1 00 14 13 6 51 1 00 15 21 4 52 1 00 15 18 8 53 1 00 18 12 3 54 1 00 16 11 9
1 00 23 9 9 56 1 00 l7 11 6 57 1 00 21 23 4 58 1 00 15 13 10 59 100 15 11 6
1 00 11 20 10 61 1 00 23 7 8
62 1 00 63 1 00 64 1 00 65 1 00 66 1 00 67 1 00 68 1 00 69 1 00 70 1 00 71 1 00 72 1 00 73 1 00 74 1 00
19 25 20 11 25 13 18 13 27 22 17 20 19
12 5 12 4
9 3 13 4
7 7 17 5 12 14
7 9 12 9 17 7 19 5 12 4 19 4
Assay Definition-
Assay Description Wipe Test
Assay Type CPM Report Name Reportl Output Data Path CPackardTricarbResultswipe testwipe test20121018 1436 Raw Results Path CPackardTricarbResultswipe testwipe test20121018 143620121018 1436results Comma-Delimited File Name CPackardTricarbResultswipe testwipe test20121018 436Reportlcsv Assay File Name CPackardTriCarbAssayswipe testlsa
Count Conditions-
Nuclide 3H-14C-32P Quench Indicator tSIE External Std Terminator (sec) 05 2s Pre-Count Delay (min) 000
Quench Set na Count Time (min) 100 Count Mode Normal Assay Count Cycles 1 Repeat Sample Count 1 VialsSample 1 Calculate Reference Off
Background Subtract Off Low CPM Threshold Off 2 Sigma Terminator Off
Regions LL UL A 00 120 B 120 1560 C 1560 17000
Count Corrections-
Static Controller On Luminescence Correction Off Colored Samples na Heterogeneity Monitor na Coincidence Time (nsec) 18 Delay Before Burst (nsec) 75
Half Life-
Half Life Correction Off Regions Half Life Units Reference Date Reference Time A B C
Cycle 1 Results S Count Time CPMA MESSAGES CPMB CPMC
1 1 00 20 18 5 2 1 00 8 4 5 3 1 00 15 16 12
1
2 3
4
5
6
7
8
9
10 11
12 13
14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
34 35 36 37 38 39 40 41 42 43
SUMMARY OF SITE PLAN AND SWIPE TEST RESULTS
dpm H3 dpm C14 dpm P32 on the plan swipe sample cpmH3 cpm C14 cpm P32
31 15 7 316 18 7 4 background 20 14 7
28 7 4
318S 20 14 2 31 15 2 321SA 18 12 7 28 13 7
321BRA 14 17 8 22 18 8
321BRB 11 15 6 17 16 6
321Centrifuge 17 23 11 27 24 11 321Thermo 18 10 3 28 10 3
3215VWR 23 13 4 36 14 4
3215BlB 13 20 5 20 21 5
3215BLA 12 8 8 19 8 8
321SB 15 11 6 23 11 6
319Scint 17 17 6 27 18 6
319Hood 14 17 7 22 18 7
319B2A 16 11 9 25 11 9
319B2B 12 11 7 19 11 7
319B2S 19 15 5 30 16 5
319B3A 20 11 12 31 11 12 319B3B 19 12 10 30 13 10 319B4A 12 14 10 19 15 10
319B4B 16 15 5 25 16 5
319B5A 12 8 12 19 8 12 319B5B 19 18 12 30 19 12 319B6A 5 17 5 8 18 5
319B6B 19 12 5 30 13 5 319Ce ntrifuge 20 13 6 31 14 6 319Shaker 17 14 9 27 15 9
319B7A 16 17 6 25 18 6
319B7B 19 9 3 30 9 3 319B8A 25 13 6 39 14 6
319B8B 14 13 5 22 14 5 319B9E 14 7 5 22 7 5 319B9A 9 20 6 14 21 6 319B9B 13 9 10 20 9 10 319BlOA 20 28 8 31 29 8 319Microwave 31 24 10 48 25 10 319B10B 19 20 5 30 21 5
319B10S 19 11 9 30 11 9 319W 568 17 8 888 18 8 319B12A 16 10 7 25 10 7 319B12B 15 8 9 23 8 9 309B12E 30 13 6 47 14 6 309B12A 18 12 8 28 13 8
309B12B 44 11 13 11 17 14 11
309B11A 45 19 12 12 30 13 12
309B11B 46 11 13 7 17 14 7
309BlOE 47 13 16 10 20 17 10
309BlOA 48 23 14 7 36 15 7
309Bl0B 49 12 11 3 19 11 3
309B9A 50 14 13 6 22 14 6
309B9B 51 15 21 4 23 22 4
309B85 52 15 18 8 23 19 8
309B8A 53 18 12 3 28 13 3 309B8RS 54 16 11 9 25 11 9 309B7A 55 23 9 9 36 9 9 309B7B 56 17 11 6 27 11 6 309B6E 57 21 23 4 33 24 4 309B6A 58 15 13 10 23 14 10 309B6B 59 15 11 6 23 11 6 309B5A 60 11 20 10 17 21 10 309B5B 61 23 7 8 36 7 8 309B5C 62 19 12 5 30 13 5 309B4E 63 25 12 4 39 13 4 309B4A 64 20 9 3 31 9 3 309B4B 65 11 13 4 17 14 4 309B3A 66 25 7 7 39 7 7 309B3B 67 13 17 5 20 18 5 309B25 68 18 12 14 28 13 14 309B2 69 13 7 9 20 7 9 309B1A 70 27 12 9 42 13 9 309B1C 71 22 17 7 34 18 7 QAQC 72 17 19 5 27 20 5 QAQC 73 20 12 4 31 13 4 QAQC 74 19 19 4 30 20 4
Sample key 309 Room number e for 3H=064 dpm=cpme
Sample surface BshyB bench S-sink e for 14C=096 6 Bench number e for 32P=10
Description or E sequence
REPEAT OF THE RESULTS IN QUESTION
plan sample cpmH3 cpm C14 cpm P32 dpmH3 dpm C14 dpm P32 background 1 20 18 5 31 19 5 319Wa 2 8 4 5 13 4 5
319W b 3 15 16 12 23 17 12
Connecticut Department of Energy amp Environmental Protection Bureau of Air Management Radiation Division
Radioactive Material and Industrial X-Ray Device Registration
Please complete this form in accordance with the instructions (DEP-RAD-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation along with this form Please retain a copy of this completed form at your facility
Part I Registration Type
CPPU USE ONLY
App____________
Doc ______________
Check ____________
Program Radiation
Requested Year of Registration Period materials license termination
Registrations are based on the calendar year January 1st through December 31 stbull
Provide Permit Number (aka Facility ID see DEEP correspondence to
Check the appropriate box(es) identifying the registration type
D new registration (ie never registered with the DEEP) [221] registrant)
D new ownership [221] 01576
D renewal of an existing registration [221] If renewing or amending an existing
181 amendment to an existing registration [1467] registration please indicate any changes to tile existing registration information by using reel ink
Note If you are terminating your registration or removing a device(s) from registration refer to the registration instructions (DEP-RAD-INST-100) for required documentation necessary to comply with DEEP requirements
own I(here site is located New Haven
Part II Fee Information
An annual registration fee of $20000 is to be submitted by December 31 S with each registration and applies for the period covering the requested calendar year The fee is not pro-rated New registrants are required to pay the fee regardless of when they register with the DEEP There is no fee for amendments The registration will not be processed without the fee The fee shall be non-refundable and shall be paid by check or money order to the Department of Energy and Environmental Protection
Part III Registrant Information
bull If a registrant is a corporation limited liability company limited partnership limited liability partnership or a statutory trost it must be registered with the Secretary of State If applicable registrants name shall be stated exactly as it is registered with the Secretary of State Please note for those entities registered with the Secretary of State the registered name will be the name used by DEEP This information can be accessed at the Secretary of States database (CONCORD) (wwwconcord-sotsctgovICONCORDlindexjsp)
bull If a registrant is an individual provide the legal name (include suffix) in the following format First Name Middle Initial Last Name Suffix (Jr Sr II III etc)
DEP-RAD-REG-100 1 of 9 Rev 103112
Part III Registrant Information (continued)
1 Registrant Name BioRelix Inc
Mailing Address 5 Science Park (401 Winchester Avenue)
CitylTown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
Contact Person Izabela Puskarz Phone (203) 785-9282 ext 305
E-mail ipuskarzbiorelixcom
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from nctgov addresses Also please notify the department if your e-mail address changes
a) Registrant Type (check one) 0 individual [8J business entity o federal agency
o state agency o municipality tribal
If a business entity (If a business entity complete i through iii)
i) check type [8J corporation 0 limited liability company o limited partnership o Other ________o limited liability partnership 0 statutory trust
ii) provide Secretary of the State business ID ~08~67~696~___This information can be accessed at CONCORD
iii) 0 Check here if you are NOT registered with the SOTS
b) Registrants interest in property at which the proposed activity is to be located
o site owner 0 option holder [8J lessee 0 easement holder operator
o other (specify)
o Check here if any co-registrants If so attach additional sheet(s) with the required information as requested above
2 List billing contact if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
3 List primary contact for departmental cprrespondence and inquiries if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from ctgov addresses Also please notify the department if your e-mail address changes
DEP-RAD-REG-100 2of9 Rev 103112
---
Part III Registrant Information (continued)
4 List the Radiation Safety Officer (RSO) There must be one RSO listed per registration
Name Izabela J Puskarz
Direct Phone (203) 785-9282 ext 305 Fax (203) 785-8058
E-Mail Addressipuskarzbiorelixcom
24-Hour Emergency Phone ~---
List other contact people in the radiation safety section
Name Kenneth F Blount
Title Director of Biology
Direct Phone (203) 785-9282 ext 302 Fax (203) 785-8058
E-Mail Addresskblountbiorelixcom
24-Hour Emergency Pho
Name Brian R Dixon
Title President and CEO
Direct Phone (203) 785-9282 ext 303 Fax (203) 785-8058
E-Mail Addressbdizonbiorelixcom
24-Hour Emergency Phone
Part IV Site Information
1 Company Name BioRelix Inc
Site Name (if different)
Address 5 Science Park (401 Winchester Avenue)
Cityrrown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
2 Location of Material (if different than above)
Cityrrown State Zip Code
Part V NRC Licenses
For new licenses attach a copy of each license for renewals or modifications attach any amended pages of each license
06-31263-01 3 August 312017
DEP-RAD-REG-100 30f9 Rev 103112
Part VI Personnel Dosimetry
1 Indicate whether personnel dosimetry is performed at your facility Yes t8J No
2 If yes indicate the name of vendor that provides this service
Part VII Compliance
If you answer yes to any of the questions below you must complete Part VIII Table of Enforcement Actions as directed in the instructions for your registration
A During the five years immediately preceding submission of this registration has the registrant been convicted in any jurisdiction of a criminal violation of any environmental law
DYes t8J No
B During the five years immediately preceding submission of this registration has a civil penalty been imposed upon the registrant in any state including Connecticut or federal judicial proceeding for any other violation of an environmental law
DYes t8J No
C During the five years immediately preceding submission of this registration has a civil penalty exceeding five thousand dollars been imposed on the registrant in any state including Connecticut or federal administrative proceeding for any violation of an environmental law
DYes t8J No
D During the five years immediately preceding submission of this registration has any state including Connecticut or federal court issued any order or entered any judgment to the registrant concerning a violation of any environmental law
DYes t8J No
E During the five years immediately preceding submission of this registration has any state including Connecticut or federal administrative agency issued any order to the registrant concerning a violation of any environmental law
DYes t8J No
DEP-RAD-REG-100 4of9 Rev 103112
Part VIII Table of Enforcement Actions
Type of Action Type of Action Type of Action
Date Commenced Date Commenced Date Commenced
Date Terminated Date Terminated Date Terminated
Jurisdiction Jurisdiction Jurisdiction
CaselDocketlOrder Number CaselDocketlOrder Number CaseDocketlOrder Number
Description of Violation Description of Violation Description of Violation
D Check the box if additional sheets are attached Copies of this form may be duplicated for additional space
DEP-RAD-REG-100 50f9 Rev 1013112
For Parts IX through XVI you may hit the tab button at the end of each table in the last cell and create additional rows
Part IX Industrial X-Ray Equipment
Part X Analytic Equipment for Examination of Material
aXlimum mA
~~t JiUIp
(Including but not limited to X-ray diffraction units electron microscopes gauging devices spectroscopic equipment gas chromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or therapy)
MQttatltl I t
Serial Manufacturer r~ M~_ilil I Maximum mA
Part XI Industrial Radiographic Equipment
(For examination of structure with a sealed source)
I I TYRe Model ibmll Serial I Manufactu~middot l i i
Part XII Particle Accelerators
(Including but not limited to Van de Graffs Linacs Cyclotrons Electronic Beam Welders)
lI~f ler1 bull Ma~ufacturer p~Itf ii
DEP-RAD-REG-100 6 af9 Rev 103112
Part XIII Special Nuclear Material (Special nuclear material [SNM] refers to plutonium 233U uranium enriched in the isotope 233 or in the isotope 235 greater than its natural abundance and any other material which the US NRC pursuant to the provisions of Section 510f the Atomic Energy Act of 1954 determines to be special nuclear material SNM does not include source material)
Part XIV Source Material
(Source material [SM] refers to uranium or thorium or any combination thereof in any physical or chemical form or ores which contain at least 005 by weight uranium thorium or any combination thereof except when the material is designated as special nuclear material)
Part XV Sealed Sources
No1~er ofSikrcesltc
Part XVI Other Radioactive Materials (including medical isotopes)
3 Hydrogen 25mCi
33 Phosphorous 25mCi
DEP-RAD-REG-100 7of9 Rev 103112
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
62 1 00 63 1 00 64 1 00 65 1 00 66 1 00 67 1 00 68 1 00 69 1 00 70 1 00 71 1 00 72 1 00 73 1 00 74 1 00
19 25 20 11 25 13 18 13 27 22 17 20 19
12 5 12 4
9 3 13 4
7 7 17 5 12 14
7 9 12 9 17 7 19 5 12 4 19 4
Assay Definition-
Assay Description Wipe Test
Assay Type CPM Report Name Reportl Output Data Path CPackardTricarbResultswipe testwipe test20121018 1436 Raw Results Path CPackardTricarbResultswipe testwipe test20121018 143620121018 1436results Comma-Delimited File Name CPackardTricarbResultswipe testwipe test20121018 436Reportlcsv Assay File Name CPackardTriCarbAssayswipe testlsa
Count Conditions-
Nuclide 3H-14C-32P Quench Indicator tSIE External Std Terminator (sec) 05 2s Pre-Count Delay (min) 000
Quench Set na Count Time (min) 100 Count Mode Normal Assay Count Cycles 1 Repeat Sample Count 1 VialsSample 1 Calculate Reference Off
Background Subtract Off Low CPM Threshold Off 2 Sigma Terminator Off
Regions LL UL A 00 120 B 120 1560 C 1560 17000
Count Corrections-
Static Controller On Luminescence Correction Off Colored Samples na Heterogeneity Monitor na Coincidence Time (nsec) 18 Delay Before Burst (nsec) 75
Half Life-
Half Life Correction Off Regions Half Life Units Reference Date Reference Time A B C
Cycle 1 Results S Count Time CPMA MESSAGES CPMB CPMC
1 1 00 20 18 5 2 1 00 8 4 5 3 1 00 15 16 12
1
2 3
4
5
6
7
8
9
10 11
12 13
14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
34 35 36 37 38 39 40 41 42 43
SUMMARY OF SITE PLAN AND SWIPE TEST RESULTS
dpm H3 dpm C14 dpm P32 on the plan swipe sample cpmH3 cpm C14 cpm P32
31 15 7 316 18 7 4 background 20 14 7
28 7 4
318S 20 14 2 31 15 2 321SA 18 12 7 28 13 7
321BRA 14 17 8 22 18 8
321BRB 11 15 6 17 16 6
321Centrifuge 17 23 11 27 24 11 321Thermo 18 10 3 28 10 3
3215VWR 23 13 4 36 14 4
3215BlB 13 20 5 20 21 5
3215BLA 12 8 8 19 8 8
321SB 15 11 6 23 11 6
319Scint 17 17 6 27 18 6
319Hood 14 17 7 22 18 7
319B2A 16 11 9 25 11 9
319B2B 12 11 7 19 11 7
319B2S 19 15 5 30 16 5
319B3A 20 11 12 31 11 12 319B3B 19 12 10 30 13 10 319B4A 12 14 10 19 15 10
319B4B 16 15 5 25 16 5
319B5A 12 8 12 19 8 12 319B5B 19 18 12 30 19 12 319B6A 5 17 5 8 18 5
319B6B 19 12 5 30 13 5 319Ce ntrifuge 20 13 6 31 14 6 319Shaker 17 14 9 27 15 9
319B7A 16 17 6 25 18 6
319B7B 19 9 3 30 9 3 319B8A 25 13 6 39 14 6
319B8B 14 13 5 22 14 5 319B9E 14 7 5 22 7 5 319B9A 9 20 6 14 21 6 319B9B 13 9 10 20 9 10 319BlOA 20 28 8 31 29 8 319Microwave 31 24 10 48 25 10 319B10B 19 20 5 30 21 5
319B10S 19 11 9 30 11 9 319W 568 17 8 888 18 8 319B12A 16 10 7 25 10 7 319B12B 15 8 9 23 8 9 309B12E 30 13 6 47 14 6 309B12A 18 12 8 28 13 8
309B12B 44 11 13 11 17 14 11
309B11A 45 19 12 12 30 13 12
309B11B 46 11 13 7 17 14 7
309BlOE 47 13 16 10 20 17 10
309BlOA 48 23 14 7 36 15 7
309Bl0B 49 12 11 3 19 11 3
309B9A 50 14 13 6 22 14 6
309B9B 51 15 21 4 23 22 4
309B85 52 15 18 8 23 19 8
309B8A 53 18 12 3 28 13 3 309B8RS 54 16 11 9 25 11 9 309B7A 55 23 9 9 36 9 9 309B7B 56 17 11 6 27 11 6 309B6E 57 21 23 4 33 24 4 309B6A 58 15 13 10 23 14 10 309B6B 59 15 11 6 23 11 6 309B5A 60 11 20 10 17 21 10 309B5B 61 23 7 8 36 7 8 309B5C 62 19 12 5 30 13 5 309B4E 63 25 12 4 39 13 4 309B4A 64 20 9 3 31 9 3 309B4B 65 11 13 4 17 14 4 309B3A 66 25 7 7 39 7 7 309B3B 67 13 17 5 20 18 5 309B25 68 18 12 14 28 13 14 309B2 69 13 7 9 20 7 9 309B1A 70 27 12 9 42 13 9 309B1C 71 22 17 7 34 18 7 QAQC 72 17 19 5 27 20 5 QAQC 73 20 12 4 31 13 4 QAQC 74 19 19 4 30 20 4
Sample key 309 Room number e for 3H=064 dpm=cpme
Sample surface BshyB bench S-sink e for 14C=096 6 Bench number e for 32P=10
Description or E sequence
REPEAT OF THE RESULTS IN QUESTION
plan sample cpmH3 cpm C14 cpm P32 dpmH3 dpm C14 dpm P32 background 1 20 18 5 31 19 5 319Wa 2 8 4 5 13 4 5
319W b 3 15 16 12 23 17 12
Connecticut Department of Energy amp Environmental Protection Bureau of Air Management Radiation Division
Radioactive Material and Industrial X-Ray Device Registration
Please complete this form in accordance with the instructions (DEP-RAD-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation along with this form Please retain a copy of this completed form at your facility
Part I Registration Type
CPPU USE ONLY
App____________
Doc ______________
Check ____________
Program Radiation
Requested Year of Registration Period materials license termination
Registrations are based on the calendar year January 1st through December 31 stbull
Provide Permit Number (aka Facility ID see DEEP correspondence to
Check the appropriate box(es) identifying the registration type
D new registration (ie never registered with the DEEP) [221] registrant)
D new ownership [221] 01576
D renewal of an existing registration [221] If renewing or amending an existing
181 amendment to an existing registration [1467] registration please indicate any changes to tile existing registration information by using reel ink
Note If you are terminating your registration or removing a device(s) from registration refer to the registration instructions (DEP-RAD-INST-100) for required documentation necessary to comply with DEEP requirements
own I(here site is located New Haven
Part II Fee Information
An annual registration fee of $20000 is to be submitted by December 31 S with each registration and applies for the period covering the requested calendar year The fee is not pro-rated New registrants are required to pay the fee regardless of when they register with the DEEP There is no fee for amendments The registration will not be processed without the fee The fee shall be non-refundable and shall be paid by check or money order to the Department of Energy and Environmental Protection
Part III Registrant Information
bull If a registrant is a corporation limited liability company limited partnership limited liability partnership or a statutory trost it must be registered with the Secretary of State If applicable registrants name shall be stated exactly as it is registered with the Secretary of State Please note for those entities registered with the Secretary of State the registered name will be the name used by DEEP This information can be accessed at the Secretary of States database (CONCORD) (wwwconcord-sotsctgovICONCORDlindexjsp)
bull If a registrant is an individual provide the legal name (include suffix) in the following format First Name Middle Initial Last Name Suffix (Jr Sr II III etc)
DEP-RAD-REG-100 1 of 9 Rev 103112
Part III Registrant Information (continued)
1 Registrant Name BioRelix Inc
Mailing Address 5 Science Park (401 Winchester Avenue)
CitylTown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
Contact Person Izabela Puskarz Phone (203) 785-9282 ext 305
E-mail ipuskarzbiorelixcom
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from nctgov addresses Also please notify the department if your e-mail address changes
a) Registrant Type (check one) 0 individual [8J business entity o federal agency
o state agency o municipality tribal
If a business entity (If a business entity complete i through iii)
i) check type [8J corporation 0 limited liability company o limited partnership o Other ________o limited liability partnership 0 statutory trust
ii) provide Secretary of the State business ID ~08~67~696~___This information can be accessed at CONCORD
iii) 0 Check here if you are NOT registered with the SOTS
b) Registrants interest in property at which the proposed activity is to be located
o site owner 0 option holder [8J lessee 0 easement holder operator
o other (specify)
o Check here if any co-registrants If so attach additional sheet(s) with the required information as requested above
2 List billing contact if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
3 List primary contact for departmental cprrespondence and inquiries if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from ctgov addresses Also please notify the department if your e-mail address changes
DEP-RAD-REG-100 2of9 Rev 103112
---
Part III Registrant Information (continued)
4 List the Radiation Safety Officer (RSO) There must be one RSO listed per registration
Name Izabela J Puskarz
Direct Phone (203) 785-9282 ext 305 Fax (203) 785-8058
E-Mail Addressipuskarzbiorelixcom
24-Hour Emergency Phone ~---
List other contact people in the radiation safety section
Name Kenneth F Blount
Title Director of Biology
Direct Phone (203) 785-9282 ext 302 Fax (203) 785-8058
E-Mail Addresskblountbiorelixcom
24-Hour Emergency Pho
Name Brian R Dixon
Title President and CEO
Direct Phone (203) 785-9282 ext 303 Fax (203) 785-8058
E-Mail Addressbdizonbiorelixcom
24-Hour Emergency Phone
Part IV Site Information
1 Company Name BioRelix Inc
Site Name (if different)
Address 5 Science Park (401 Winchester Avenue)
Cityrrown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
2 Location of Material (if different than above)
Cityrrown State Zip Code
Part V NRC Licenses
For new licenses attach a copy of each license for renewals or modifications attach any amended pages of each license
06-31263-01 3 August 312017
DEP-RAD-REG-100 30f9 Rev 103112
Part VI Personnel Dosimetry
1 Indicate whether personnel dosimetry is performed at your facility Yes t8J No
2 If yes indicate the name of vendor that provides this service
Part VII Compliance
If you answer yes to any of the questions below you must complete Part VIII Table of Enforcement Actions as directed in the instructions for your registration
A During the five years immediately preceding submission of this registration has the registrant been convicted in any jurisdiction of a criminal violation of any environmental law
DYes t8J No
B During the five years immediately preceding submission of this registration has a civil penalty been imposed upon the registrant in any state including Connecticut or federal judicial proceeding for any other violation of an environmental law
DYes t8J No
C During the five years immediately preceding submission of this registration has a civil penalty exceeding five thousand dollars been imposed on the registrant in any state including Connecticut or federal administrative proceeding for any violation of an environmental law
DYes t8J No
D During the five years immediately preceding submission of this registration has any state including Connecticut or federal court issued any order or entered any judgment to the registrant concerning a violation of any environmental law
DYes t8J No
E During the five years immediately preceding submission of this registration has any state including Connecticut or federal administrative agency issued any order to the registrant concerning a violation of any environmental law
DYes t8J No
DEP-RAD-REG-100 4of9 Rev 103112
Part VIII Table of Enforcement Actions
Type of Action Type of Action Type of Action
Date Commenced Date Commenced Date Commenced
Date Terminated Date Terminated Date Terminated
Jurisdiction Jurisdiction Jurisdiction
CaselDocketlOrder Number CaselDocketlOrder Number CaseDocketlOrder Number
Description of Violation Description of Violation Description of Violation
D Check the box if additional sheets are attached Copies of this form may be duplicated for additional space
DEP-RAD-REG-100 50f9 Rev 1013112
For Parts IX through XVI you may hit the tab button at the end of each table in the last cell and create additional rows
Part IX Industrial X-Ray Equipment
Part X Analytic Equipment for Examination of Material
aXlimum mA
~~t JiUIp
(Including but not limited to X-ray diffraction units electron microscopes gauging devices spectroscopic equipment gas chromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or therapy)
MQttatltl I t
Serial Manufacturer r~ M~_ilil I Maximum mA
Part XI Industrial Radiographic Equipment
(For examination of structure with a sealed source)
I I TYRe Model ibmll Serial I Manufactu~middot l i i
Part XII Particle Accelerators
(Including but not limited to Van de Graffs Linacs Cyclotrons Electronic Beam Welders)
lI~f ler1 bull Ma~ufacturer p~Itf ii
DEP-RAD-REG-100 6 af9 Rev 103112
Part XIII Special Nuclear Material (Special nuclear material [SNM] refers to plutonium 233U uranium enriched in the isotope 233 or in the isotope 235 greater than its natural abundance and any other material which the US NRC pursuant to the provisions of Section 510f the Atomic Energy Act of 1954 determines to be special nuclear material SNM does not include source material)
Part XIV Source Material
(Source material [SM] refers to uranium or thorium or any combination thereof in any physical or chemical form or ores which contain at least 005 by weight uranium thorium or any combination thereof except when the material is designated as special nuclear material)
Part XV Sealed Sources
No1~er ofSikrcesltc
Part XVI Other Radioactive Materials (including medical isotopes)
3 Hydrogen 25mCi
33 Phosphorous 25mCi
DEP-RAD-REG-100 7of9 Rev 103112
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
Assay Definition-
Assay Description Wipe Test
Assay Type CPM Report Name Reportl Output Data Path CPackardTricarbResultswipe testwipe test20121018 1436 Raw Results Path CPackardTricarbResultswipe testwipe test20121018 143620121018 1436results Comma-Delimited File Name CPackardTricarbResultswipe testwipe test20121018 436Reportlcsv Assay File Name CPackardTriCarbAssayswipe testlsa
Count Conditions-
Nuclide 3H-14C-32P Quench Indicator tSIE External Std Terminator (sec) 05 2s Pre-Count Delay (min) 000
Quench Set na Count Time (min) 100 Count Mode Normal Assay Count Cycles 1 Repeat Sample Count 1 VialsSample 1 Calculate Reference Off
Background Subtract Off Low CPM Threshold Off 2 Sigma Terminator Off
Regions LL UL A 00 120 B 120 1560 C 1560 17000
Count Corrections-
Static Controller On Luminescence Correction Off Colored Samples na Heterogeneity Monitor na Coincidence Time (nsec) 18 Delay Before Burst (nsec) 75
Half Life-
Half Life Correction Off Regions Half Life Units Reference Date Reference Time A B C
Cycle 1 Results S Count Time CPMA MESSAGES CPMB CPMC
1 1 00 20 18 5 2 1 00 8 4 5 3 1 00 15 16 12
1
2 3
4
5
6
7
8
9
10 11
12 13
14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
34 35 36 37 38 39 40 41 42 43
SUMMARY OF SITE PLAN AND SWIPE TEST RESULTS
dpm H3 dpm C14 dpm P32 on the plan swipe sample cpmH3 cpm C14 cpm P32
31 15 7 316 18 7 4 background 20 14 7
28 7 4
318S 20 14 2 31 15 2 321SA 18 12 7 28 13 7
321BRA 14 17 8 22 18 8
321BRB 11 15 6 17 16 6
321Centrifuge 17 23 11 27 24 11 321Thermo 18 10 3 28 10 3
3215VWR 23 13 4 36 14 4
3215BlB 13 20 5 20 21 5
3215BLA 12 8 8 19 8 8
321SB 15 11 6 23 11 6
319Scint 17 17 6 27 18 6
319Hood 14 17 7 22 18 7
319B2A 16 11 9 25 11 9
319B2B 12 11 7 19 11 7
319B2S 19 15 5 30 16 5
319B3A 20 11 12 31 11 12 319B3B 19 12 10 30 13 10 319B4A 12 14 10 19 15 10
319B4B 16 15 5 25 16 5
319B5A 12 8 12 19 8 12 319B5B 19 18 12 30 19 12 319B6A 5 17 5 8 18 5
319B6B 19 12 5 30 13 5 319Ce ntrifuge 20 13 6 31 14 6 319Shaker 17 14 9 27 15 9
319B7A 16 17 6 25 18 6
319B7B 19 9 3 30 9 3 319B8A 25 13 6 39 14 6
319B8B 14 13 5 22 14 5 319B9E 14 7 5 22 7 5 319B9A 9 20 6 14 21 6 319B9B 13 9 10 20 9 10 319BlOA 20 28 8 31 29 8 319Microwave 31 24 10 48 25 10 319B10B 19 20 5 30 21 5
319B10S 19 11 9 30 11 9 319W 568 17 8 888 18 8 319B12A 16 10 7 25 10 7 319B12B 15 8 9 23 8 9 309B12E 30 13 6 47 14 6 309B12A 18 12 8 28 13 8
309B12B 44 11 13 11 17 14 11
309B11A 45 19 12 12 30 13 12
309B11B 46 11 13 7 17 14 7
309BlOE 47 13 16 10 20 17 10
309BlOA 48 23 14 7 36 15 7
309Bl0B 49 12 11 3 19 11 3
309B9A 50 14 13 6 22 14 6
309B9B 51 15 21 4 23 22 4
309B85 52 15 18 8 23 19 8
309B8A 53 18 12 3 28 13 3 309B8RS 54 16 11 9 25 11 9 309B7A 55 23 9 9 36 9 9 309B7B 56 17 11 6 27 11 6 309B6E 57 21 23 4 33 24 4 309B6A 58 15 13 10 23 14 10 309B6B 59 15 11 6 23 11 6 309B5A 60 11 20 10 17 21 10 309B5B 61 23 7 8 36 7 8 309B5C 62 19 12 5 30 13 5 309B4E 63 25 12 4 39 13 4 309B4A 64 20 9 3 31 9 3 309B4B 65 11 13 4 17 14 4 309B3A 66 25 7 7 39 7 7 309B3B 67 13 17 5 20 18 5 309B25 68 18 12 14 28 13 14 309B2 69 13 7 9 20 7 9 309B1A 70 27 12 9 42 13 9 309B1C 71 22 17 7 34 18 7 QAQC 72 17 19 5 27 20 5 QAQC 73 20 12 4 31 13 4 QAQC 74 19 19 4 30 20 4
Sample key 309 Room number e for 3H=064 dpm=cpme
Sample surface BshyB bench S-sink e for 14C=096 6 Bench number e for 32P=10
Description or E sequence
REPEAT OF THE RESULTS IN QUESTION
plan sample cpmH3 cpm C14 cpm P32 dpmH3 dpm C14 dpm P32 background 1 20 18 5 31 19 5 319Wa 2 8 4 5 13 4 5
319W b 3 15 16 12 23 17 12
Connecticut Department of Energy amp Environmental Protection Bureau of Air Management Radiation Division
Radioactive Material and Industrial X-Ray Device Registration
Please complete this form in accordance with the instructions (DEP-RAD-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation along with this form Please retain a copy of this completed form at your facility
Part I Registration Type
CPPU USE ONLY
App____________
Doc ______________
Check ____________
Program Radiation
Requested Year of Registration Period materials license termination
Registrations are based on the calendar year January 1st through December 31 stbull
Provide Permit Number (aka Facility ID see DEEP correspondence to
Check the appropriate box(es) identifying the registration type
D new registration (ie never registered with the DEEP) [221] registrant)
D new ownership [221] 01576
D renewal of an existing registration [221] If renewing or amending an existing
181 amendment to an existing registration [1467] registration please indicate any changes to tile existing registration information by using reel ink
Note If you are terminating your registration or removing a device(s) from registration refer to the registration instructions (DEP-RAD-INST-100) for required documentation necessary to comply with DEEP requirements
own I(here site is located New Haven
Part II Fee Information
An annual registration fee of $20000 is to be submitted by December 31 S with each registration and applies for the period covering the requested calendar year The fee is not pro-rated New registrants are required to pay the fee regardless of when they register with the DEEP There is no fee for amendments The registration will not be processed without the fee The fee shall be non-refundable and shall be paid by check or money order to the Department of Energy and Environmental Protection
Part III Registrant Information
bull If a registrant is a corporation limited liability company limited partnership limited liability partnership or a statutory trost it must be registered with the Secretary of State If applicable registrants name shall be stated exactly as it is registered with the Secretary of State Please note for those entities registered with the Secretary of State the registered name will be the name used by DEEP This information can be accessed at the Secretary of States database (CONCORD) (wwwconcord-sotsctgovICONCORDlindexjsp)
bull If a registrant is an individual provide the legal name (include suffix) in the following format First Name Middle Initial Last Name Suffix (Jr Sr II III etc)
DEP-RAD-REG-100 1 of 9 Rev 103112
Part III Registrant Information (continued)
1 Registrant Name BioRelix Inc
Mailing Address 5 Science Park (401 Winchester Avenue)
CitylTown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
Contact Person Izabela Puskarz Phone (203) 785-9282 ext 305
E-mail ipuskarzbiorelixcom
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from nctgov addresses Also please notify the department if your e-mail address changes
a) Registrant Type (check one) 0 individual [8J business entity o federal agency
o state agency o municipality tribal
If a business entity (If a business entity complete i through iii)
i) check type [8J corporation 0 limited liability company o limited partnership o Other ________o limited liability partnership 0 statutory trust
ii) provide Secretary of the State business ID ~08~67~696~___This information can be accessed at CONCORD
iii) 0 Check here if you are NOT registered with the SOTS
b) Registrants interest in property at which the proposed activity is to be located
o site owner 0 option holder [8J lessee 0 easement holder operator
o other (specify)
o Check here if any co-registrants If so attach additional sheet(s) with the required information as requested above
2 List billing contact if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
3 List primary contact for departmental cprrespondence and inquiries if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from ctgov addresses Also please notify the department if your e-mail address changes
DEP-RAD-REG-100 2of9 Rev 103112
---
Part III Registrant Information (continued)
4 List the Radiation Safety Officer (RSO) There must be one RSO listed per registration
Name Izabela J Puskarz
Direct Phone (203) 785-9282 ext 305 Fax (203) 785-8058
E-Mail Addressipuskarzbiorelixcom
24-Hour Emergency Phone ~---
List other contact people in the radiation safety section
Name Kenneth F Blount
Title Director of Biology
Direct Phone (203) 785-9282 ext 302 Fax (203) 785-8058
E-Mail Addresskblountbiorelixcom
24-Hour Emergency Pho
Name Brian R Dixon
Title President and CEO
Direct Phone (203) 785-9282 ext 303 Fax (203) 785-8058
E-Mail Addressbdizonbiorelixcom
24-Hour Emergency Phone
Part IV Site Information
1 Company Name BioRelix Inc
Site Name (if different)
Address 5 Science Park (401 Winchester Avenue)
Cityrrown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
2 Location of Material (if different than above)
Cityrrown State Zip Code
Part V NRC Licenses
For new licenses attach a copy of each license for renewals or modifications attach any amended pages of each license
06-31263-01 3 August 312017
DEP-RAD-REG-100 30f9 Rev 103112
Part VI Personnel Dosimetry
1 Indicate whether personnel dosimetry is performed at your facility Yes t8J No
2 If yes indicate the name of vendor that provides this service
Part VII Compliance
If you answer yes to any of the questions below you must complete Part VIII Table of Enforcement Actions as directed in the instructions for your registration
A During the five years immediately preceding submission of this registration has the registrant been convicted in any jurisdiction of a criminal violation of any environmental law
DYes t8J No
B During the five years immediately preceding submission of this registration has a civil penalty been imposed upon the registrant in any state including Connecticut or federal judicial proceeding for any other violation of an environmental law
DYes t8J No
C During the five years immediately preceding submission of this registration has a civil penalty exceeding five thousand dollars been imposed on the registrant in any state including Connecticut or federal administrative proceeding for any violation of an environmental law
DYes t8J No
D During the five years immediately preceding submission of this registration has any state including Connecticut or federal court issued any order or entered any judgment to the registrant concerning a violation of any environmental law
DYes t8J No
E During the five years immediately preceding submission of this registration has any state including Connecticut or federal administrative agency issued any order to the registrant concerning a violation of any environmental law
DYes t8J No
DEP-RAD-REG-100 4of9 Rev 103112
Part VIII Table of Enforcement Actions
Type of Action Type of Action Type of Action
Date Commenced Date Commenced Date Commenced
Date Terminated Date Terminated Date Terminated
Jurisdiction Jurisdiction Jurisdiction
CaselDocketlOrder Number CaselDocketlOrder Number CaseDocketlOrder Number
Description of Violation Description of Violation Description of Violation
D Check the box if additional sheets are attached Copies of this form may be duplicated for additional space
DEP-RAD-REG-100 50f9 Rev 1013112
For Parts IX through XVI you may hit the tab button at the end of each table in the last cell and create additional rows
Part IX Industrial X-Ray Equipment
Part X Analytic Equipment for Examination of Material
aXlimum mA
~~t JiUIp
(Including but not limited to X-ray diffraction units electron microscopes gauging devices spectroscopic equipment gas chromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or therapy)
MQttatltl I t
Serial Manufacturer r~ M~_ilil I Maximum mA
Part XI Industrial Radiographic Equipment
(For examination of structure with a sealed source)
I I TYRe Model ibmll Serial I Manufactu~middot l i i
Part XII Particle Accelerators
(Including but not limited to Van de Graffs Linacs Cyclotrons Electronic Beam Welders)
lI~f ler1 bull Ma~ufacturer p~Itf ii
DEP-RAD-REG-100 6 af9 Rev 103112
Part XIII Special Nuclear Material (Special nuclear material [SNM] refers to plutonium 233U uranium enriched in the isotope 233 or in the isotope 235 greater than its natural abundance and any other material which the US NRC pursuant to the provisions of Section 510f the Atomic Energy Act of 1954 determines to be special nuclear material SNM does not include source material)
Part XIV Source Material
(Source material [SM] refers to uranium or thorium or any combination thereof in any physical or chemical form or ores which contain at least 005 by weight uranium thorium or any combination thereof except when the material is designated as special nuclear material)
Part XV Sealed Sources
No1~er ofSikrcesltc
Part XVI Other Radioactive Materials (including medical isotopes)
3 Hydrogen 25mCi
33 Phosphorous 25mCi
DEP-RAD-REG-100 7of9 Rev 103112
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
1
2 3
4
5
6
7
8
9
10 11
12 13
14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
34 35 36 37 38 39 40 41 42 43
SUMMARY OF SITE PLAN AND SWIPE TEST RESULTS
dpm H3 dpm C14 dpm P32 on the plan swipe sample cpmH3 cpm C14 cpm P32
31 15 7 316 18 7 4 background 20 14 7
28 7 4
318S 20 14 2 31 15 2 321SA 18 12 7 28 13 7
321BRA 14 17 8 22 18 8
321BRB 11 15 6 17 16 6
321Centrifuge 17 23 11 27 24 11 321Thermo 18 10 3 28 10 3
3215VWR 23 13 4 36 14 4
3215BlB 13 20 5 20 21 5
3215BLA 12 8 8 19 8 8
321SB 15 11 6 23 11 6
319Scint 17 17 6 27 18 6
319Hood 14 17 7 22 18 7
319B2A 16 11 9 25 11 9
319B2B 12 11 7 19 11 7
319B2S 19 15 5 30 16 5
319B3A 20 11 12 31 11 12 319B3B 19 12 10 30 13 10 319B4A 12 14 10 19 15 10
319B4B 16 15 5 25 16 5
319B5A 12 8 12 19 8 12 319B5B 19 18 12 30 19 12 319B6A 5 17 5 8 18 5
319B6B 19 12 5 30 13 5 319Ce ntrifuge 20 13 6 31 14 6 319Shaker 17 14 9 27 15 9
319B7A 16 17 6 25 18 6
319B7B 19 9 3 30 9 3 319B8A 25 13 6 39 14 6
319B8B 14 13 5 22 14 5 319B9E 14 7 5 22 7 5 319B9A 9 20 6 14 21 6 319B9B 13 9 10 20 9 10 319BlOA 20 28 8 31 29 8 319Microwave 31 24 10 48 25 10 319B10B 19 20 5 30 21 5
319B10S 19 11 9 30 11 9 319W 568 17 8 888 18 8 319B12A 16 10 7 25 10 7 319B12B 15 8 9 23 8 9 309B12E 30 13 6 47 14 6 309B12A 18 12 8 28 13 8
309B12B 44 11 13 11 17 14 11
309B11A 45 19 12 12 30 13 12
309B11B 46 11 13 7 17 14 7
309BlOE 47 13 16 10 20 17 10
309BlOA 48 23 14 7 36 15 7
309Bl0B 49 12 11 3 19 11 3
309B9A 50 14 13 6 22 14 6
309B9B 51 15 21 4 23 22 4
309B85 52 15 18 8 23 19 8
309B8A 53 18 12 3 28 13 3 309B8RS 54 16 11 9 25 11 9 309B7A 55 23 9 9 36 9 9 309B7B 56 17 11 6 27 11 6 309B6E 57 21 23 4 33 24 4 309B6A 58 15 13 10 23 14 10 309B6B 59 15 11 6 23 11 6 309B5A 60 11 20 10 17 21 10 309B5B 61 23 7 8 36 7 8 309B5C 62 19 12 5 30 13 5 309B4E 63 25 12 4 39 13 4 309B4A 64 20 9 3 31 9 3 309B4B 65 11 13 4 17 14 4 309B3A 66 25 7 7 39 7 7 309B3B 67 13 17 5 20 18 5 309B25 68 18 12 14 28 13 14 309B2 69 13 7 9 20 7 9 309B1A 70 27 12 9 42 13 9 309B1C 71 22 17 7 34 18 7 QAQC 72 17 19 5 27 20 5 QAQC 73 20 12 4 31 13 4 QAQC 74 19 19 4 30 20 4
Sample key 309 Room number e for 3H=064 dpm=cpme
Sample surface BshyB bench S-sink e for 14C=096 6 Bench number e for 32P=10
Description or E sequence
REPEAT OF THE RESULTS IN QUESTION
plan sample cpmH3 cpm C14 cpm P32 dpmH3 dpm C14 dpm P32 background 1 20 18 5 31 19 5 319Wa 2 8 4 5 13 4 5
319W b 3 15 16 12 23 17 12
Connecticut Department of Energy amp Environmental Protection Bureau of Air Management Radiation Division
Radioactive Material and Industrial X-Ray Device Registration
Please complete this form in accordance with the instructions (DEP-RAD-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation along with this form Please retain a copy of this completed form at your facility
Part I Registration Type
CPPU USE ONLY
App____________
Doc ______________
Check ____________
Program Radiation
Requested Year of Registration Period materials license termination
Registrations are based on the calendar year January 1st through December 31 stbull
Provide Permit Number (aka Facility ID see DEEP correspondence to
Check the appropriate box(es) identifying the registration type
D new registration (ie never registered with the DEEP) [221] registrant)
D new ownership [221] 01576
D renewal of an existing registration [221] If renewing or amending an existing
181 amendment to an existing registration [1467] registration please indicate any changes to tile existing registration information by using reel ink
Note If you are terminating your registration or removing a device(s) from registration refer to the registration instructions (DEP-RAD-INST-100) for required documentation necessary to comply with DEEP requirements
own I(here site is located New Haven
Part II Fee Information
An annual registration fee of $20000 is to be submitted by December 31 S with each registration and applies for the period covering the requested calendar year The fee is not pro-rated New registrants are required to pay the fee regardless of when they register with the DEEP There is no fee for amendments The registration will not be processed without the fee The fee shall be non-refundable and shall be paid by check or money order to the Department of Energy and Environmental Protection
Part III Registrant Information
bull If a registrant is a corporation limited liability company limited partnership limited liability partnership or a statutory trost it must be registered with the Secretary of State If applicable registrants name shall be stated exactly as it is registered with the Secretary of State Please note for those entities registered with the Secretary of State the registered name will be the name used by DEEP This information can be accessed at the Secretary of States database (CONCORD) (wwwconcord-sotsctgovICONCORDlindexjsp)
bull If a registrant is an individual provide the legal name (include suffix) in the following format First Name Middle Initial Last Name Suffix (Jr Sr II III etc)
DEP-RAD-REG-100 1 of 9 Rev 103112
Part III Registrant Information (continued)
1 Registrant Name BioRelix Inc
Mailing Address 5 Science Park (401 Winchester Avenue)
CitylTown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
Contact Person Izabela Puskarz Phone (203) 785-9282 ext 305
E-mail ipuskarzbiorelixcom
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from nctgov addresses Also please notify the department if your e-mail address changes
a) Registrant Type (check one) 0 individual [8J business entity o federal agency
o state agency o municipality tribal
If a business entity (If a business entity complete i through iii)
i) check type [8J corporation 0 limited liability company o limited partnership o Other ________o limited liability partnership 0 statutory trust
ii) provide Secretary of the State business ID ~08~67~696~___This information can be accessed at CONCORD
iii) 0 Check here if you are NOT registered with the SOTS
b) Registrants interest in property at which the proposed activity is to be located
o site owner 0 option holder [8J lessee 0 easement holder operator
o other (specify)
o Check here if any co-registrants If so attach additional sheet(s) with the required information as requested above
2 List billing contact if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
3 List primary contact for departmental cprrespondence and inquiries if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from ctgov addresses Also please notify the department if your e-mail address changes
DEP-RAD-REG-100 2of9 Rev 103112
---
Part III Registrant Information (continued)
4 List the Radiation Safety Officer (RSO) There must be one RSO listed per registration
Name Izabela J Puskarz
Direct Phone (203) 785-9282 ext 305 Fax (203) 785-8058
E-Mail Addressipuskarzbiorelixcom
24-Hour Emergency Phone ~---
List other contact people in the radiation safety section
Name Kenneth F Blount
Title Director of Biology
Direct Phone (203) 785-9282 ext 302 Fax (203) 785-8058
E-Mail Addresskblountbiorelixcom
24-Hour Emergency Pho
Name Brian R Dixon
Title President and CEO
Direct Phone (203) 785-9282 ext 303 Fax (203) 785-8058
E-Mail Addressbdizonbiorelixcom
24-Hour Emergency Phone
Part IV Site Information
1 Company Name BioRelix Inc
Site Name (if different)
Address 5 Science Park (401 Winchester Avenue)
Cityrrown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
2 Location of Material (if different than above)
Cityrrown State Zip Code
Part V NRC Licenses
For new licenses attach a copy of each license for renewals or modifications attach any amended pages of each license
06-31263-01 3 August 312017
DEP-RAD-REG-100 30f9 Rev 103112
Part VI Personnel Dosimetry
1 Indicate whether personnel dosimetry is performed at your facility Yes t8J No
2 If yes indicate the name of vendor that provides this service
Part VII Compliance
If you answer yes to any of the questions below you must complete Part VIII Table of Enforcement Actions as directed in the instructions for your registration
A During the five years immediately preceding submission of this registration has the registrant been convicted in any jurisdiction of a criminal violation of any environmental law
DYes t8J No
B During the five years immediately preceding submission of this registration has a civil penalty been imposed upon the registrant in any state including Connecticut or federal judicial proceeding for any other violation of an environmental law
DYes t8J No
C During the five years immediately preceding submission of this registration has a civil penalty exceeding five thousand dollars been imposed on the registrant in any state including Connecticut or federal administrative proceeding for any violation of an environmental law
DYes t8J No
D During the five years immediately preceding submission of this registration has any state including Connecticut or federal court issued any order or entered any judgment to the registrant concerning a violation of any environmental law
DYes t8J No
E During the five years immediately preceding submission of this registration has any state including Connecticut or federal administrative agency issued any order to the registrant concerning a violation of any environmental law
DYes t8J No
DEP-RAD-REG-100 4of9 Rev 103112
Part VIII Table of Enforcement Actions
Type of Action Type of Action Type of Action
Date Commenced Date Commenced Date Commenced
Date Terminated Date Terminated Date Terminated
Jurisdiction Jurisdiction Jurisdiction
CaselDocketlOrder Number CaselDocketlOrder Number CaseDocketlOrder Number
Description of Violation Description of Violation Description of Violation
D Check the box if additional sheets are attached Copies of this form may be duplicated for additional space
DEP-RAD-REG-100 50f9 Rev 1013112
For Parts IX through XVI you may hit the tab button at the end of each table in the last cell and create additional rows
Part IX Industrial X-Ray Equipment
Part X Analytic Equipment for Examination of Material
aXlimum mA
~~t JiUIp
(Including but not limited to X-ray diffraction units electron microscopes gauging devices spectroscopic equipment gas chromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or therapy)
MQttatltl I t
Serial Manufacturer r~ M~_ilil I Maximum mA
Part XI Industrial Radiographic Equipment
(For examination of structure with a sealed source)
I I TYRe Model ibmll Serial I Manufactu~middot l i i
Part XII Particle Accelerators
(Including but not limited to Van de Graffs Linacs Cyclotrons Electronic Beam Welders)
lI~f ler1 bull Ma~ufacturer p~Itf ii
DEP-RAD-REG-100 6 af9 Rev 103112
Part XIII Special Nuclear Material (Special nuclear material [SNM] refers to plutonium 233U uranium enriched in the isotope 233 or in the isotope 235 greater than its natural abundance and any other material which the US NRC pursuant to the provisions of Section 510f the Atomic Energy Act of 1954 determines to be special nuclear material SNM does not include source material)
Part XIV Source Material
(Source material [SM] refers to uranium or thorium or any combination thereof in any physical or chemical form or ores which contain at least 005 by weight uranium thorium or any combination thereof except when the material is designated as special nuclear material)
Part XV Sealed Sources
No1~er ofSikrcesltc
Part XVI Other Radioactive Materials (including medical isotopes)
3 Hydrogen 25mCi
33 Phosphorous 25mCi
DEP-RAD-REG-100 7of9 Rev 103112
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
309B12B 44 11 13 11 17 14 11
309B11A 45 19 12 12 30 13 12
309B11B 46 11 13 7 17 14 7
309BlOE 47 13 16 10 20 17 10
309BlOA 48 23 14 7 36 15 7
309Bl0B 49 12 11 3 19 11 3
309B9A 50 14 13 6 22 14 6
309B9B 51 15 21 4 23 22 4
309B85 52 15 18 8 23 19 8
309B8A 53 18 12 3 28 13 3 309B8RS 54 16 11 9 25 11 9 309B7A 55 23 9 9 36 9 9 309B7B 56 17 11 6 27 11 6 309B6E 57 21 23 4 33 24 4 309B6A 58 15 13 10 23 14 10 309B6B 59 15 11 6 23 11 6 309B5A 60 11 20 10 17 21 10 309B5B 61 23 7 8 36 7 8 309B5C 62 19 12 5 30 13 5 309B4E 63 25 12 4 39 13 4 309B4A 64 20 9 3 31 9 3 309B4B 65 11 13 4 17 14 4 309B3A 66 25 7 7 39 7 7 309B3B 67 13 17 5 20 18 5 309B25 68 18 12 14 28 13 14 309B2 69 13 7 9 20 7 9 309B1A 70 27 12 9 42 13 9 309B1C 71 22 17 7 34 18 7 QAQC 72 17 19 5 27 20 5 QAQC 73 20 12 4 31 13 4 QAQC 74 19 19 4 30 20 4
Sample key 309 Room number e for 3H=064 dpm=cpme
Sample surface BshyB bench S-sink e for 14C=096 6 Bench number e for 32P=10
Description or E sequence
REPEAT OF THE RESULTS IN QUESTION
plan sample cpmH3 cpm C14 cpm P32 dpmH3 dpm C14 dpm P32 background 1 20 18 5 31 19 5 319Wa 2 8 4 5 13 4 5
319W b 3 15 16 12 23 17 12
Connecticut Department of Energy amp Environmental Protection Bureau of Air Management Radiation Division
Radioactive Material and Industrial X-Ray Device Registration
Please complete this form in accordance with the instructions (DEP-RAD-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation along with this form Please retain a copy of this completed form at your facility
Part I Registration Type
CPPU USE ONLY
App____________
Doc ______________
Check ____________
Program Radiation
Requested Year of Registration Period materials license termination
Registrations are based on the calendar year January 1st through December 31 stbull
Provide Permit Number (aka Facility ID see DEEP correspondence to
Check the appropriate box(es) identifying the registration type
D new registration (ie never registered with the DEEP) [221] registrant)
D new ownership [221] 01576
D renewal of an existing registration [221] If renewing or amending an existing
181 amendment to an existing registration [1467] registration please indicate any changes to tile existing registration information by using reel ink
Note If you are terminating your registration or removing a device(s) from registration refer to the registration instructions (DEP-RAD-INST-100) for required documentation necessary to comply with DEEP requirements
own I(here site is located New Haven
Part II Fee Information
An annual registration fee of $20000 is to be submitted by December 31 S with each registration and applies for the period covering the requested calendar year The fee is not pro-rated New registrants are required to pay the fee regardless of when they register with the DEEP There is no fee for amendments The registration will not be processed without the fee The fee shall be non-refundable and shall be paid by check or money order to the Department of Energy and Environmental Protection
Part III Registrant Information
bull If a registrant is a corporation limited liability company limited partnership limited liability partnership or a statutory trost it must be registered with the Secretary of State If applicable registrants name shall be stated exactly as it is registered with the Secretary of State Please note for those entities registered with the Secretary of State the registered name will be the name used by DEEP This information can be accessed at the Secretary of States database (CONCORD) (wwwconcord-sotsctgovICONCORDlindexjsp)
bull If a registrant is an individual provide the legal name (include suffix) in the following format First Name Middle Initial Last Name Suffix (Jr Sr II III etc)
DEP-RAD-REG-100 1 of 9 Rev 103112
Part III Registrant Information (continued)
1 Registrant Name BioRelix Inc
Mailing Address 5 Science Park (401 Winchester Avenue)
CitylTown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
Contact Person Izabela Puskarz Phone (203) 785-9282 ext 305
E-mail ipuskarzbiorelixcom
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from nctgov addresses Also please notify the department if your e-mail address changes
a) Registrant Type (check one) 0 individual [8J business entity o federal agency
o state agency o municipality tribal
If a business entity (If a business entity complete i through iii)
i) check type [8J corporation 0 limited liability company o limited partnership o Other ________o limited liability partnership 0 statutory trust
ii) provide Secretary of the State business ID ~08~67~696~___This information can be accessed at CONCORD
iii) 0 Check here if you are NOT registered with the SOTS
b) Registrants interest in property at which the proposed activity is to be located
o site owner 0 option holder [8J lessee 0 easement holder operator
o other (specify)
o Check here if any co-registrants If so attach additional sheet(s) with the required information as requested above
2 List billing contact if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
3 List primary contact for departmental cprrespondence and inquiries if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from ctgov addresses Also please notify the department if your e-mail address changes
DEP-RAD-REG-100 2of9 Rev 103112
---
Part III Registrant Information (continued)
4 List the Radiation Safety Officer (RSO) There must be one RSO listed per registration
Name Izabela J Puskarz
Direct Phone (203) 785-9282 ext 305 Fax (203) 785-8058
E-Mail Addressipuskarzbiorelixcom
24-Hour Emergency Phone ~---
List other contact people in the radiation safety section
Name Kenneth F Blount
Title Director of Biology
Direct Phone (203) 785-9282 ext 302 Fax (203) 785-8058
E-Mail Addresskblountbiorelixcom
24-Hour Emergency Pho
Name Brian R Dixon
Title President and CEO
Direct Phone (203) 785-9282 ext 303 Fax (203) 785-8058
E-Mail Addressbdizonbiorelixcom
24-Hour Emergency Phone
Part IV Site Information
1 Company Name BioRelix Inc
Site Name (if different)
Address 5 Science Park (401 Winchester Avenue)
Cityrrown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
2 Location of Material (if different than above)
Cityrrown State Zip Code
Part V NRC Licenses
For new licenses attach a copy of each license for renewals or modifications attach any amended pages of each license
06-31263-01 3 August 312017
DEP-RAD-REG-100 30f9 Rev 103112
Part VI Personnel Dosimetry
1 Indicate whether personnel dosimetry is performed at your facility Yes t8J No
2 If yes indicate the name of vendor that provides this service
Part VII Compliance
If you answer yes to any of the questions below you must complete Part VIII Table of Enforcement Actions as directed in the instructions for your registration
A During the five years immediately preceding submission of this registration has the registrant been convicted in any jurisdiction of a criminal violation of any environmental law
DYes t8J No
B During the five years immediately preceding submission of this registration has a civil penalty been imposed upon the registrant in any state including Connecticut or federal judicial proceeding for any other violation of an environmental law
DYes t8J No
C During the five years immediately preceding submission of this registration has a civil penalty exceeding five thousand dollars been imposed on the registrant in any state including Connecticut or federal administrative proceeding for any violation of an environmental law
DYes t8J No
D During the five years immediately preceding submission of this registration has any state including Connecticut or federal court issued any order or entered any judgment to the registrant concerning a violation of any environmental law
DYes t8J No
E During the five years immediately preceding submission of this registration has any state including Connecticut or federal administrative agency issued any order to the registrant concerning a violation of any environmental law
DYes t8J No
DEP-RAD-REG-100 4of9 Rev 103112
Part VIII Table of Enforcement Actions
Type of Action Type of Action Type of Action
Date Commenced Date Commenced Date Commenced
Date Terminated Date Terminated Date Terminated
Jurisdiction Jurisdiction Jurisdiction
CaselDocketlOrder Number CaselDocketlOrder Number CaseDocketlOrder Number
Description of Violation Description of Violation Description of Violation
D Check the box if additional sheets are attached Copies of this form may be duplicated for additional space
DEP-RAD-REG-100 50f9 Rev 1013112
For Parts IX through XVI you may hit the tab button at the end of each table in the last cell and create additional rows
Part IX Industrial X-Ray Equipment
Part X Analytic Equipment for Examination of Material
aXlimum mA
~~t JiUIp
(Including but not limited to X-ray diffraction units electron microscopes gauging devices spectroscopic equipment gas chromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or therapy)
MQttatltl I t
Serial Manufacturer r~ M~_ilil I Maximum mA
Part XI Industrial Radiographic Equipment
(For examination of structure with a sealed source)
I I TYRe Model ibmll Serial I Manufactu~middot l i i
Part XII Particle Accelerators
(Including but not limited to Van de Graffs Linacs Cyclotrons Electronic Beam Welders)
lI~f ler1 bull Ma~ufacturer p~Itf ii
DEP-RAD-REG-100 6 af9 Rev 103112
Part XIII Special Nuclear Material (Special nuclear material [SNM] refers to plutonium 233U uranium enriched in the isotope 233 or in the isotope 235 greater than its natural abundance and any other material which the US NRC pursuant to the provisions of Section 510f the Atomic Energy Act of 1954 determines to be special nuclear material SNM does not include source material)
Part XIV Source Material
(Source material [SM] refers to uranium or thorium or any combination thereof in any physical or chemical form or ores which contain at least 005 by weight uranium thorium or any combination thereof except when the material is designated as special nuclear material)
Part XV Sealed Sources
No1~er ofSikrcesltc
Part XVI Other Radioactive Materials (including medical isotopes)
3 Hydrogen 25mCi
33 Phosphorous 25mCi
DEP-RAD-REG-100 7of9 Rev 103112
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
319W b 3 15 16 12 23 17 12
Connecticut Department of Energy amp Environmental Protection Bureau of Air Management Radiation Division
Radioactive Material and Industrial X-Ray Device Registration
Please complete this form in accordance with the instructions (DEP-RAD-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation along with this form Please retain a copy of this completed form at your facility
Part I Registration Type
CPPU USE ONLY
App____________
Doc ______________
Check ____________
Program Radiation
Requested Year of Registration Period materials license termination
Registrations are based on the calendar year January 1st through December 31 stbull
Provide Permit Number (aka Facility ID see DEEP correspondence to
Check the appropriate box(es) identifying the registration type
D new registration (ie never registered with the DEEP) [221] registrant)
D new ownership [221] 01576
D renewal of an existing registration [221] If renewing or amending an existing
181 amendment to an existing registration [1467] registration please indicate any changes to tile existing registration information by using reel ink
Note If you are terminating your registration or removing a device(s) from registration refer to the registration instructions (DEP-RAD-INST-100) for required documentation necessary to comply with DEEP requirements
own I(here site is located New Haven
Part II Fee Information
An annual registration fee of $20000 is to be submitted by December 31 S with each registration and applies for the period covering the requested calendar year The fee is not pro-rated New registrants are required to pay the fee regardless of when they register with the DEEP There is no fee for amendments The registration will not be processed without the fee The fee shall be non-refundable and shall be paid by check or money order to the Department of Energy and Environmental Protection
Part III Registrant Information
bull If a registrant is a corporation limited liability company limited partnership limited liability partnership or a statutory trost it must be registered with the Secretary of State If applicable registrants name shall be stated exactly as it is registered with the Secretary of State Please note for those entities registered with the Secretary of State the registered name will be the name used by DEEP This information can be accessed at the Secretary of States database (CONCORD) (wwwconcord-sotsctgovICONCORDlindexjsp)
bull If a registrant is an individual provide the legal name (include suffix) in the following format First Name Middle Initial Last Name Suffix (Jr Sr II III etc)
DEP-RAD-REG-100 1 of 9 Rev 103112
Part III Registrant Information (continued)
1 Registrant Name BioRelix Inc
Mailing Address 5 Science Park (401 Winchester Avenue)
CitylTown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
Contact Person Izabela Puskarz Phone (203) 785-9282 ext 305
E-mail ipuskarzbiorelixcom
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from nctgov addresses Also please notify the department if your e-mail address changes
a) Registrant Type (check one) 0 individual [8J business entity o federal agency
o state agency o municipality tribal
If a business entity (If a business entity complete i through iii)
i) check type [8J corporation 0 limited liability company o limited partnership o Other ________o limited liability partnership 0 statutory trust
ii) provide Secretary of the State business ID ~08~67~696~___This information can be accessed at CONCORD
iii) 0 Check here if you are NOT registered with the SOTS
b) Registrants interest in property at which the proposed activity is to be located
o site owner 0 option holder [8J lessee 0 easement holder operator
o other (specify)
o Check here if any co-registrants If so attach additional sheet(s) with the required information as requested above
2 List billing contact if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
3 List primary contact for departmental cprrespondence and inquiries if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from ctgov addresses Also please notify the department if your e-mail address changes
DEP-RAD-REG-100 2of9 Rev 103112
---
Part III Registrant Information (continued)
4 List the Radiation Safety Officer (RSO) There must be one RSO listed per registration
Name Izabela J Puskarz
Direct Phone (203) 785-9282 ext 305 Fax (203) 785-8058
E-Mail Addressipuskarzbiorelixcom
24-Hour Emergency Phone ~---
List other contact people in the radiation safety section
Name Kenneth F Blount
Title Director of Biology
Direct Phone (203) 785-9282 ext 302 Fax (203) 785-8058
E-Mail Addresskblountbiorelixcom
24-Hour Emergency Pho
Name Brian R Dixon
Title President and CEO
Direct Phone (203) 785-9282 ext 303 Fax (203) 785-8058
E-Mail Addressbdizonbiorelixcom
24-Hour Emergency Phone
Part IV Site Information
1 Company Name BioRelix Inc
Site Name (if different)
Address 5 Science Park (401 Winchester Avenue)
Cityrrown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
2 Location of Material (if different than above)
Cityrrown State Zip Code
Part V NRC Licenses
For new licenses attach a copy of each license for renewals or modifications attach any amended pages of each license
06-31263-01 3 August 312017
DEP-RAD-REG-100 30f9 Rev 103112
Part VI Personnel Dosimetry
1 Indicate whether personnel dosimetry is performed at your facility Yes t8J No
2 If yes indicate the name of vendor that provides this service
Part VII Compliance
If you answer yes to any of the questions below you must complete Part VIII Table of Enforcement Actions as directed in the instructions for your registration
A During the five years immediately preceding submission of this registration has the registrant been convicted in any jurisdiction of a criminal violation of any environmental law
DYes t8J No
B During the five years immediately preceding submission of this registration has a civil penalty been imposed upon the registrant in any state including Connecticut or federal judicial proceeding for any other violation of an environmental law
DYes t8J No
C During the five years immediately preceding submission of this registration has a civil penalty exceeding five thousand dollars been imposed on the registrant in any state including Connecticut or federal administrative proceeding for any violation of an environmental law
DYes t8J No
D During the five years immediately preceding submission of this registration has any state including Connecticut or federal court issued any order or entered any judgment to the registrant concerning a violation of any environmental law
DYes t8J No
E During the five years immediately preceding submission of this registration has any state including Connecticut or federal administrative agency issued any order to the registrant concerning a violation of any environmental law
DYes t8J No
DEP-RAD-REG-100 4of9 Rev 103112
Part VIII Table of Enforcement Actions
Type of Action Type of Action Type of Action
Date Commenced Date Commenced Date Commenced
Date Terminated Date Terminated Date Terminated
Jurisdiction Jurisdiction Jurisdiction
CaselDocketlOrder Number CaselDocketlOrder Number CaseDocketlOrder Number
Description of Violation Description of Violation Description of Violation
D Check the box if additional sheets are attached Copies of this form may be duplicated for additional space
DEP-RAD-REG-100 50f9 Rev 1013112
For Parts IX through XVI you may hit the tab button at the end of each table in the last cell and create additional rows
Part IX Industrial X-Ray Equipment
Part X Analytic Equipment for Examination of Material
aXlimum mA
~~t JiUIp
(Including but not limited to X-ray diffraction units electron microscopes gauging devices spectroscopic equipment gas chromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or therapy)
MQttatltl I t
Serial Manufacturer r~ M~_ilil I Maximum mA
Part XI Industrial Radiographic Equipment
(For examination of structure with a sealed source)
I I TYRe Model ibmll Serial I Manufactu~middot l i i
Part XII Particle Accelerators
(Including but not limited to Van de Graffs Linacs Cyclotrons Electronic Beam Welders)
lI~f ler1 bull Ma~ufacturer p~Itf ii
DEP-RAD-REG-100 6 af9 Rev 103112
Part XIII Special Nuclear Material (Special nuclear material [SNM] refers to plutonium 233U uranium enriched in the isotope 233 or in the isotope 235 greater than its natural abundance and any other material which the US NRC pursuant to the provisions of Section 510f the Atomic Energy Act of 1954 determines to be special nuclear material SNM does not include source material)
Part XIV Source Material
(Source material [SM] refers to uranium or thorium or any combination thereof in any physical or chemical form or ores which contain at least 005 by weight uranium thorium or any combination thereof except when the material is designated as special nuclear material)
Part XV Sealed Sources
No1~er ofSikrcesltc
Part XVI Other Radioactive Materials (including medical isotopes)
3 Hydrogen 25mCi
33 Phosphorous 25mCi
DEP-RAD-REG-100 7of9 Rev 103112
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
Connecticut Department of Energy amp Environmental Protection Bureau of Air Management Radiation Division
Radioactive Material and Industrial X-Ray Device Registration
Please complete this form in accordance with the instructions (DEP-RAD-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation along with this form Please retain a copy of this completed form at your facility
Part I Registration Type
CPPU USE ONLY
App____________
Doc ______________
Check ____________
Program Radiation
Requested Year of Registration Period materials license termination
Registrations are based on the calendar year January 1st through December 31 stbull
Provide Permit Number (aka Facility ID see DEEP correspondence to
Check the appropriate box(es) identifying the registration type
D new registration (ie never registered with the DEEP) [221] registrant)
D new ownership [221] 01576
D renewal of an existing registration [221] If renewing or amending an existing
181 amendment to an existing registration [1467] registration please indicate any changes to tile existing registration information by using reel ink
Note If you are terminating your registration or removing a device(s) from registration refer to the registration instructions (DEP-RAD-INST-100) for required documentation necessary to comply with DEEP requirements
own I(here site is located New Haven
Part II Fee Information
An annual registration fee of $20000 is to be submitted by December 31 S with each registration and applies for the period covering the requested calendar year The fee is not pro-rated New registrants are required to pay the fee regardless of when they register with the DEEP There is no fee for amendments The registration will not be processed without the fee The fee shall be non-refundable and shall be paid by check or money order to the Department of Energy and Environmental Protection
Part III Registrant Information
bull If a registrant is a corporation limited liability company limited partnership limited liability partnership or a statutory trost it must be registered with the Secretary of State If applicable registrants name shall be stated exactly as it is registered with the Secretary of State Please note for those entities registered with the Secretary of State the registered name will be the name used by DEEP This information can be accessed at the Secretary of States database (CONCORD) (wwwconcord-sotsctgovICONCORDlindexjsp)
bull If a registrant is an individual provide the legal name (include suffix) in the following format First Name Middle Initial Last Name Suffix (Jr Sr II III etc)
DEP-RAD-REG-100 1 of 9 Rev 103112
Part III Registrant Information (continued)
1 Registrant Name BioRelix Inc
Mailing Address 5 Science Park (401 Winchester Avenue)
CitylTown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
Contact Person Izabela Puskarz Phone (203) 785-9282 ext 305
E-mail ipuskarzbiorelixcom
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from nctgov addresses Also please notify the department if your e-mail address changes
a) Registrant Type (check one) 0 individual [8J business entity o federal agency
o state agency o municipality tribal
If a business entity (If a business entity complete i through iii)
i) check type [8J corporation 0 limited liability company o limited partnership o Other ________o limited liability partnership 0 statutory trust
ii) provide Secretary of the State business ID ~08~67~696~___This information can be accessed at CONCORD
iii) 0 Check here if you are NOT registered with the SOTS
b) Registrants interest in property at which the proposed activity is to be located
o site owner 0 option holder [8J lessee 0 easement holder operator
o other (specify)
o Check here if any co-registrants If so attach additional sheet(s) with the required information as requested above
2 List billing contact if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
3 List primary contact for departmental cprrespondence and inquiries if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from ctgov addresses Also please notify the department if your e-mail address changes
DEP-RAD-REG-100 2of9 Rev 103112
---
Part III Registrant Information (continued)
4 List the Radiation Safety Officer (RSO) There must be one RSO listed per registration
Name Izabela J Puskarz
Direct Phone (203) 785-9282 ext 305 Fax (203) 785-8058
E-Mail Addressipuskarzbiorelixcom
24-Hour Emergency Phone ~---
List other contact people in the radiation safety section
Name Kenneth F Blount
Title Director of Biology
Direct Phone (203) 785-9282 ext 302 Fax (203) 785-8058
E-Mail Addresskblountbiorelixcom
24-Hour Emergency Pho
Name Brian R Dixon
Title President and CEO
Direct Phone (203) 785-9282 ext 303 Fax (203) 785-8058
E-Mail Addressbdizonbiorelixcom
24-Hour Emergency Phone
Part IV Site Information
1 Company Name BioRelix Inc
Site Name (if different)
Address 5 Science Park (401 Winchester Avenue)
Cityrrown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
2 Location of Material (if different than above)
Cityrrown State Zip Code
Part V NRC Licenses
For new licenses attach a copy of each license for renewals or modifications attach any amended pages of each license
06-31263-01 3 August 312017
DEP-RAD-REG-100 30f9 Rev 103112
Part VI Personnel Dosimetry
1 Indicate whether personnel dosimetry is performed at your facility Yes t8J No
2 If yes indicate the name of vendor that provides this service
Part VII Compliance
If you answer yes to any of the questions below you must complete Part VIII Table of Enforcement Actions as directed in the instructions for your registration
A During the five years immediately preceding submission of this registration has the registrant been convicted in any jurisdiction of a criminal violation of any environmental law
DYes t8J No
B During the five years immediately preceding submission of this registration has a civil penalty been imposed upon the registrant in any state including Connecticut or federal judicial proceeding for any other violation of an environmental law
DYes t8J No
C During the five years immediately preceding submission of this registration has a civil penalty exceeding five thousand dollars been imposed on the registrant in any state including Connecticut or federal administrative proceeding for any violation of an environmental law
DYes t8J No
D During the five years immediately preceding submission of this registration has any state including Connecticut or federal court issued any order or entered any judgment to the registrant concerning a violation of any environmental law
DYes t8J No
E During the five years immediately preceding submission of this registration has any state including Connecticut or federal administrative agency issued any order to the registrant concerning a violation of any environmental law
DYes t8J No
DEP-RAD-REG-100 4of9 Rev 103112
Part VIII Table of Enforcement Actions
Type of Action Type of Action Type of Action
Date Commenced Date Commenced Date Commenced
Date Terminated Date Terminated Date Terminated
Jurisdiction Jurisdiction Jurisdiction
CaselDocketlOrder Number CaselDocketlOrder Number CaseDocketlOrder Number
Description of Violation Description of Violation Description of Violation
D Check the box if additional sheets are attached Copies of this form may be duplicated for additional space
DEP-RAD-REG-100 50f9 Rev 1013112
For Parts IX through XVI you may hit the tab button at the end of each table in the last cell and create additional rows
Part IX Industrial X-Ray Equipment
Part X Analytic Equipment for Examination of Material
aXlimum mA
~~t JiUIp
(Including but not limited to X-ray diffraction units electron microscopes gauging devices spectroscopic equipment gas chromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or therapy)
MQttatltl I t
Serial Manufacturer r~ M~_ilil I Maximum mA
Part XI Industrial Radiographic Equipment
(For examination of structure with a sealed source)
I I TYRe Model ibmll Serial I Manufactu~middot l i i
Part XII Particle Accelerators
(Including but not limited to Van de Graffs Linacs Cyclotrons Electronic Beam Welders)
lI~f ler1 bull Ma~ufacturer p~Itf ii
DEP-RAD-REG-100 6 af9 Rev 103112
Part XIII Special Nuclear Material (Special nuclear material [SNM] refers to plutonium 233U uranium enriched in the isotope 233 or in the isotope 235 greater than its natural abundance and any other material which the US NRC pursuant to the provisions of Section 510f the Atomic Energy Act of 1954 determines to be special nuclear material SNM does not include source material)
Part XIV Source Material
(Source material [SM] refers to uranium or thorium or any combination thereof in any physical or chemical form or ores which contain at least 005 by weight uranium thorium or any combination thereof except when the material is designated as special nuclear material)
Part XV Sealed Sources
No1~er ofSikrcesltc
Part XVI Other Radioactive Materials (including medical isotopes)
3 Hydrogen 25mCi
33 Phosphorous 25mCi
DEP-RAD-REG-100 7of9 Rev 103112
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
Part III Registrant Information (continued)
1 Registrant Name BioRelix Inc
Mailing Address 5 Science Park (401 Winchester Avenue)
CitylTown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
Contact Person Izabela Puskarz Phone (203) 785-9282 ext 305
E-mail ipuskarzbiorelixcom
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from nctgov addresses Also please notify the department if your e-mail address changes
a) Registrant Type (check one) 0 individual [8J business entity o federal agency
o state agency o municipality tribal
If a business entity (If a business entity complete i through iii)
i) check type [8J corporation 0 limited liability company o limited partnership o Other ________o limited liability partnership 0 statutory trust
ii) provide Secretary of the State business ID ~08~67~696~___This information can be accessed at CONCORD
iii) 0 Check here if you are NOT registered with the SOTS
b) Registrants interest in property at which the proposed activity is to be located
o site owner 0 option holder [8J lessee 0 easement holder operator
o other (specify)
o Check here if any co-registrants If so attach additional sheet(s) with the required information as requested above
2 List billing contact if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
3 List primary contact for departmental cprrespondence and inquiries if different than the registrant
Name
Mailing Address
CitylTown State Zip Code
Business Phone ext
Contact Person Phone ext
By providing this e-mail address you are agreeing to receive official correspondence from the department at this electronic address concerning the subject registration Please remember to check your security settings to be sure you can receive e-mails from ctgov addresses Also please notify the department if your e-mail address changes
DEP-RAD-REG-100 2of9 Rev 103112
---
Part III Registrant Information (continued)
4 List the Radiation Safety Officer (RSO) There must be one RSO listed per registration
Name Izabela J Puskarz
Direct Phone (203) 785-9282 ext 305 Fax (203) 785-8058
E-Mail Addressipuskarzbiorelixcom
24-Hour Emergency Phone ~---
List other contact people in the radiation safety section
Name Kenneth F Blount
Title Director of Biology
Direct Phone (203) 785-9282 ext 302 Fax (203) 785-8058
E-Mail Addresskblountbiorelixcom
24-Hour Emergency Pho
Name Brian R Dixon
Title President and CEO
Direct Phone (203) 785-9282 ext 303 Fax (203) 785-8058
E-Mail Addressbdizonbiorelixcom
24-Hour Emergency Phone
Part IV Site Information
1 Company Name BioRelix Inc
Site Name (if different)
Address 5 Science Park (401 Winchester Avenue)
Cityrrown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
2 Location of Material (if different than above)
Cityrrown State Zip Code
Part V NRC Licenses
For new licenses attach a copy of each license for renewals or modifications attach any amended pages of each license
06-31263-01 3 August 312017
DEP-RAD-REG-100 30f9 Rev 103112
Part VI Personnel Dosimetry
1 Indicate whether personnel dosimetry is performed at your facility Yes t8J No
2 If yes indicate the name of vendor that provides this service
Part VII Compliance
If you answer yes to any of the questions below you must complete Part VIII Table of Enforcement Actions as directed in the instructions for your registration
A During the five years immediately preceding submission of this registration has the registrant been convicted in any jurisdiction of a criminal violation of any environmental law
DYes t8J No
B During the five years immediately preceding submission of this registration has a civil penalty been imposed upon the registrant in any state including Connecticut or federal judicial proceeding for any other violation of an environmental law
DYes t8J No
C During the five years immediately preceding submission of this registration has a civil penalty exceeding five thousand dollars been imposed on the registrant in any state including Connecticut or federal administrative proceeding for any violation of an environmental law
DYes t8J No
D During the five years immediately preceding submission of this registration has any state including Connecticut or federal court issued any order or entered any judgment to the registrant concerning a violation of any environmental law
DYes t8J No
E During the five years immediately preceding submission of this registration has any state including Connecticut or federal administrative agency issued any order to the registrant concerning a violation of any environmental law
DYes t8J No
DEP-RAD-REG-100 4of9 Rev 103112
Part VIII Table of Enforcement Actions
Type of Action Type of Action Type of Action
Date Commenced Date Commenced Date Commenced
Date Terminated Date Terminated Date Terminated
Jurisdiction Jurisdiction Jurisdiction
CaselDocketlOrder Number CaselDocketlOrder Number CaseDocketlOrder Number
Description of Violation Description of Violation Description of Violation
D Check the box if additional sheets are attached Copies of this form may be duplicated for additional space
DEP-RAD-REG-100 50f9 Rev 1013112
For Parts IX through XVI you may hit the tab button at the end of each table in the last cell and create additional rows
Part IX Industrial X-Ray Equipment
Part X Analytic Equipment for Examination of Material
aXlimum mA
~~t JiUIp
(Including but not limited to X-ray diffraction units electron microscopes gauging devices spectroscopic equipment gas chromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or therapy)
MQttatltl I t
Serial Manufacturer r~ M~_ilil I Maximum mA
Part XI Industrial Radiographic Equipment
(For examination of structure with a sealed source)
I I TYRe Model ibmll Serial I Manufactu~middot l i i
Part XII Particle Accelerators
(Including but not limited to Van de Graffs Linacs Cyclotrons Electronic Beam Welders)
lI~f ler1 bull Ma~ufacturer p~Itf ii
DEP-RAD-REG-100 6 af9 Rev 103112
Part XIII Special Nuclear Material (Special nuclear material [SNM] refers to plutonium 233U uranium enriched in the isotope 233 or in the isotope 235 greater than its natural abundance and any other material which the US NRC pursuant to the provisions of Section 510f the Atomic Energy Act of 1954 determines to be special nuclear material SNM does not include source material)
Part XIV Source Material
(Source material [SM] refers to uranium or thorium or any combination thereof in any physical or chemical form or ores which contain at least 005 by weight uranium thorium or any combination thereof except when the material is designated as special nuclear material)
Part XV Sealed Sources
No1~er ofSikrcesltc
Part XVI Other Radioactive Materials (including medical isotopes)
3 Hydrogen 25mCi
33 Phosphorous 25mCi
DEP-RAD-REG-100 7of9 Rev 103112
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
---
Part III Registrant Information (continued)
4 List the Radiation Safety Officer (RSO) There must be one RSO listed per registration
Name Izabela J Puskarz
Direct Phone (203) 785-9282 ext 305 Fax (203) 785-8058
E-Mail Addressipuskarzbiorelixcom
24-Hour Emergency Phone ~---
List other contact people in the radiation safety section
Name Kenneth F Blount
Title Director of Biology
Direct Phone (203) 785-9282 ext 302 Fax (203) 785-8058
E-Mail Addresskblountbiorelixcom
24-Hour Emergency Pho
Name Brian R Dixon
Title President and CEO
Direct Phone (203) 785-9282 ext 303 Fax (203) 785-8058
E-Mail Addressbdizonbiorelixcom
24-Hour Emergency Phone
Part IV Site Information
1 Company Name BioRelix Inc
Site Name (if different)
Address 5 Science Park (401 Winchester Avenue)
Cityrrown New Haven State CT Zip Code 06511
Business Phone (203) 785-9282 ext
2 Location of Material (if different than above)
Cityrrown State Zip Code
Part V NRC Licenses
For new licenses attach a copy of each license for renewals or modifications attach any amended pages of each license
06-31263-01 3 August 312017
DEP-RAD-REG-100 30f9 Rev 103112
Part VI Personnel Dosimetry
1 Indicate whether personnel dosimetry is performed at your facility Yes t8J No
2 If yes indicate the name of vendor that provides this service
Part VII Compliance
If you answer yes to any of the questions below you must complete Part VIII Table of Enforcement Actions as directed in the instructions for your registration
A During the five years immediately preceding submission of this registration has the registrant been convicted in any jurisdiction of a criminal violation of any environmental law
DYes t8J No
B During the five years immediately preceding submission of this registration has a civil penalty been imposed upon the registrant in any state including Connecticut or federal judicial proceeding for any other violation of an environmental law
DYes t8J No
C During the five years immediately preceding submission of this registration has a civil penalty exceeding five thousand dollars been imposed on the registrant in any state including Connecticut or federal administrative proceeding for any violation of an environmental law
DYes t8J No
D During the five years immediately preceding submission of this registration has any state including Connecticut or federal court issued any order or entered any judgment to the registrant concerning a violation of any environmental law
DYes t8J No
E During the five years immediately preceding submission of this registration has any state including Connecticut or federal administrative agency issued any order to the registrant concerning a violation of any environmental law
DYes t8J No
DEP-RAD-REG-100 4of9 Rev 103112
Part VIII Table of Enforcement Actions
Type of Action Type of Action Type of Action
Date Commenced Date Commenced Date Commenced
Date Terminated Date Terminated Date Terminated
Jurisdiction Jurisdiction Jurisdiction
CaselDocketlOrder Number CaselDocketlOrder Number CaseDocketlOrder Number
Description of Violation Description of Violation Description of Violation
D Check the box if additional sheets are attached Copies of this form may be duplicated for additional space
DEP-RAD-REG-100 50f9 Rev 1013112
For Parts IX through XVI you may hit the tab button at the end of each table in the last cell and create additional rows
Part IX Industrial X-Ray Equipment
Part X Analytic Equipment for Examination of Material
aXlimum mA
~~t JiUIp
(Including but not limited to X-ray diffraction units electron microscopes gauging devices spectroscopic equipment gas chromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or therapy)
MQttatltl I t
Serial Manufacturer r~ M~_ilil I Maximum mA
Part XI Industrial Radiographic Equipment
(For examination of structure with a sealed source)
I I TYRe Model ibmll Serial I Manufactu~middot l i i
Part XII Particle Accelerators
(Including but not limited to Van de Graffs Linacs Cyclotrons Electronic Beam Welders)
lI~f ler1 bull Ma~ufacturer p~Itf ii
DEP-RAD-REG-100 6 af9 Rev 103112
Part XIII Special Nuclear Material (Special nuclear material [SNM] refers to plutonium 233U uranium enriched in the isotope 233 or in the isotope 235 greater than its natural abundance and any other material which the US NRC pursuant to the provisions of Section 510f the Atomic Energy Act of 1954 determines to be special nuclear material SNM does not include source material)
Part XIV Source Material
(Source material [SM] refers to uranium or thorium or any combination thereof in any physical or chemical form or ores which contain at least 005 by weight uranium thorium or any combination thereof except when the material is designated as special nuclear material)
Part XV Sealed Sources
No1~er ofSikrcesltc
Part XVI Other Radioactive Materials (including medical isotopes)
3 Hydrogen 25mCi
33 Phosphorous 25mCi
DEP-RAD-REG-100 7of9 Rev 103112
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
Part VI Personnel Dosimetry
1 Indicate whether personnel dosimetry is performed at your facility Yes t8J No
2 If yes indicate the name of vendor that provides this service
Part VII Compliance
If you answer yes to any of the questions below you must complete Part VIII Table of Enforcement Actions as directed in the instructions for your registration
A During the five years immediately preceding submission of this registration has the registrant been convicted in any jurisdiction of a criminal violation of any environmental law
DYes t8J No
B During the five years immediately preceding submission of this registration has a civil penalty been imposed upon the registrant in any state including Connecticut or federal judicial proceeding for any other violation of an environmental law
DYes t8J No
C During the five years immediately preceding submission of this registration has a civil penalty exceeding five thousand dollars been imposed on the registrant in any state including Connecticut or federal administrative proceeding for any violation of an environmental law
DYes t8J No
D During the five years immediately preceding submission of this registration has any state including Connecticut or federal court issued any order or entered any judgment to the registrant concerning a violation of any environmental law
DYes t8J No
E During the five years immediately preceding submission of this registration has any state including Connecticut or federal administrative agency issued any order to the registrant concerning a violation of any environmental law
DYes t8J No
DEP-RAD-REG-100 4of9 Rev 103112
Part VIII Table of Enforcement Actions
Type of Action Type of Action Type of Action
Date Commenced Date Commenced Date Commenced
Date Terminated Date Terminated Date Terminated
Jurisdiction Jurisdiction Jurisdiction
CaselDocketlOrder Number CaselDocketlOrder Number CaseDocketlOrder Number
Description of Violation Description of Violation Description of Violation
D Check the box if additional sheets are attached Copies of this form may be duplicated for additional space
DEP-RAD-REG-100 50f9 Rev 1013112
For Parts IX through XVI you may hit the tab button at the end of each table in the last cell and create additional rows
Part IX Industrial X-Ray Equipment
Part X Analytic Equipment for Examination of Material
aXlimum mA
~~t JiUIp
(Including but not limited to X-ray diffraction units electron microscopes gauging devices spectroscopic equipment gas chromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or therapy)
MQttatltl I t
Serial Manufacturer r~ M~_ilil I Maximum mA
Part XI Industrial Radiographic Equipment
(For examination of structure with a sealed source)
I I TYRe Model ibmll Serial I Manufactu~middot l i i
Part XII Particle Accelerators
(Including but not limited to Van de Graffs Linacs Cyclotrons Electronic Beam Welders)
lI~f ler1 bull Ma~ufacturer p~Itf ii
DEP-RAD-REG-100 6 af9 Rev 103112
Part XIII Special Nuclear Material (Special nuclear material [SNM] refers to plutonium 233U uranium enriched in the isotope 233 or in the isotope 235 greater than its natural abundance and any other material which the US NRC pursuant to the provisions of Section 510f the Atomic Energy Act of 1954 determines to be special nuclear material SNM does not include source material)
Part XIV Source Material
(Source material [SM] refers to uranium or thorium or any combination thereof in any physical or chemical form or ores which contain at least 005 by weight uranium thorium or any combination thereof except when the material is designated as special nuclear material)
Part XV Sealed Sources
No1~er ofSikrcesltc
Part XVI Other Radioactive Materials (including medical isotopes)
3 Hydrogen 25mCi
33 Phosphorous 25mCi
DEP-RAD-REG-100 7of9 Rev 103112
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
Part VIII Table of Enforcement Actions
Type of Action Type of Action Type of Action
Date Commenced Date Commenced Date Commenced
Date Terminated Date Terminated Date Terminated
Jurisdiction Jurisdiction Jurisdiction
CaselDocketlOrder Number CaselDocketlOrder Number CaseDocketlOrder Number
Description of Violation Description of Violation Description of Violation
D Check the box if additional sheets are attached Copies of this form may be duplicated for additional space
DEP-RAD-REG-100 50f9 Rev 1013112
For Parts IX through XVI you may hit the tab button at the end of each table in the last cell and create additional rows
Part IX Industrial X-Ray Equipment
Part X Analytic Equipment for Examination of Material
aXlimum mA
~~t JiUIp
(Including but not limited to X-ray diffraction units electron microscopes gauging devices spectroscopic equipment gas chromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or therapy)
MQttatltl I t
Serial Manufacturer r~ M~_ilil I Maximum mA
Part XI Industrial Radiographic Equipment
(For examination of structure with a sealed source)
I I TYRe Model ibmll Serial I Manufactu~middot l i i
Part XII Particle Accelerators
(Including but not limited to Van de Graffs Linacs Cyclotrons Electronic Beam Welders)
lI~f ler1 bull Ma~ufacturer p~Itf ii
DEP-RAD-REG-100 6 af9 Rev 103112
Part XIII Special Nuclear Material (Special nuclear material [SNM] refers to plutonium 233U uranium enriched in the isotope 233 or in the isotope 235 greater than its natural abundance and any other material which the US NRC pursuant to the provisions of Section 510f the Atomic Energy Act of 1954 determines to be special nuclear material SNM does not include source material)
Part XIV Source Material
(Source material [SM] refers to uranium or thorium or any combination thereof in any physical or chemical form or ores which contain at least 005 by weight uranium thorium or any combination thereof except when the material is designated as special nuclear material)
Part XV Sealed Sources
No1~er ofSikrcesltc
Part XVI Other Radioactive Materials (including medical isotopes)
3 Hydrogen 25mCi
33 Phosphorous 25mCi
DEP-RAD-REG-100 7of9 Rev 103112
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
For Parts IX through XVI you may hit the tab button at the end of each table in the last cell and create additional rows
Part IX Industrial X-Ray Equipment
Part X Analytic Equipment for Examination of Material
aXlimum mA
~~t JiUIp
(Including but not limited to X-ray diffraction units electron microscopes gauging devices spectroscopic equipment gas chromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or therapy)
MQttatltl I t
Serial Manufacturer r~ M~_ilil I Maximum mA
Part XI Industrial Radiographic Equipment
(For examination of structure with a sealed source)
I I TYRe Model ibmll Serial I Manufactu~middot l i i
Part XII Particle Accelerators
(Including but not limited to Van de Graffs Linacs Cyclotrons Electronic Beam Welders)
lI~f ler1 bull Ma~ufacturer p~Itf ii
DEP-RAD-REG-100 6 af9 Rev 103112
Part XIII Special Nuclear Material (Special nuclear material [SNM] refers to plutonium 233U uranium enriched in the isotope 233 or in the isotope 235 greater than its natural abundance and any other material which the US NRC pursuant to the provisions of Section 510f the Atomic Energy Act of 1954 determines to be special nuclear material SNM does not include source material)
Part XIV Source Material
(Source material [SM] refers to uranium or thorium or any combination thereof in any physical or chemical form or ores which contain at least 005 by weight uranium thorium or any combination thereof except when the material is designated as special nuclear material)
Part XV Sealed Sources
No1~er ofSikrcesltc
Part XVI Other Radioactive Materials (including medical isotopes)
3 Hydrogen 25mCi
33 Phosphorous 25mCi
DEP-RAD-REG-100 7of9 Rev 103112
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
Part XIII Special Nuclear Material (Special nuclear material [SNM] refers to plutonium 233U uranium enriched in the isotope 233 or in the isotope 235 greater than its natural abundance and any other material which the US NRC pursuant to the provisions of Section 510f the Atomic Energy Act of 1954 determines to be special nuclear material SNM does not include source material)
Part XIV Source Material
(Source material [SM] refers to uranium or thorium or any combination thereof in any physical or chemical form or ores which contain at least 005 by weight uranium thorium or any combination thereof except when the material is designated as special nuclear material)
Part XV Sealed Sources
No1~er ofSikrcesltc
Part XVI Other Radioactive Materials (including medical isotopes)
3 Hydrogen 25mCi
33 Phosphorous 25mCi
DEP-RAD-REG-100 7of9 Rev 103112
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
o o
o W 0 C ~ a w o
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
Part XVII Waste Disposal
Does your facility generate llRW which will require disposal by burial DYes 181 No
Does your facility generate short half-life radioactive waste DYes 181 No
Does your facility dispose of radioactive waste to a sanitary sewer DYes 181 No
Remarks or Comments materials license tennination
Part XVIII Registration Certification
The company executive with overall responsibility for the facility and the individuals) responsible for actually preparing the registration must sign this part A registration will be considered incomplete unless all required signatures are provided
I have personally examined and am familiar with the information submitted in this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individuals responsible for obtaining the information the submitted information is true accurate and complete to the best of my knowledge and belief
I certify that this registration is on complete and accurate forms as prescribed by the commissioner without alteration of the text
I understand that a false statement in the submitted information may be punishable as a criminal offense in accordance with section 22a-6 of the G r Statutes pursuant to section 53a-157b of the General Statutes and in accordance with any other a ble statut
Date
Brian R Dixon President and CEO Name of Company Executive (print or type) Title (if applicable) _ ~ PlLlt~CUL- 1012shy
Signature of Preparer
Izabela J Puskarz Lab Mana er Name of Preparer (print or type) Title (if applicable)
o Check here if additional signatures are required If so please reproduce this sheet and attach signed copies to this sheet
Note Please submit the following C8l a completed registration form
o fee (paid by check or money order to the Department of Energy and Environmental Protection)
o copy of each NRC license or amended pages of NRC licenses
C8l supporting documentation as indicated in the instructions for terminating a registration or removing a device(s) from registration
to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION 79 ELM ST HARTFORD CT 061~5127
An out of state registrant planning to make a site visit to Connecticut shall submit an additional form the Temporary Use Notification (DEP-RAD-REG-101) at least three days prior to entering the state informing the department of their activities within Connecticut The Radioactive Materials and Industrial X-Ray Devices Registration Form must have been previously submitted before filing a Temporary Use Notification
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
UNITED STATES Click-N-ShipregPOSTAL SERVICE reg
tlspscom 9405503699300331 216049005050001001 9406 p $505
US POSTAGEIIII~ ~ 111111 Commercial Base Pricing
022413 0 Ib 10 oz Mailed from 06119 062S0000001310 I----~-~-
USPS PRIORITY MAIL reg 0006IZABELA PUSKARZ
4 GIFFORD RD WEST HARTFORD CT 06119-2206
S~6 ELIZABETH ULLRICH US NRC REGION I
2100 RENAISSANCE BLVD
KNG OF PRUSSA PA 19406-2723
USPSTM TRACKING
I 1111 II 111111 420194069405503699300331 216049
Electronic Rate Approved 038555749
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader
This is to acknowledge the receipt of your lette~ated
oZ - oS- 3 and to inform you that the initial processing which includes an administrative review has been performed
-r~ 010- 3dLto3 -0[if There were no administrative omissions Your application was assigned to a
technical reviewer Please note that the technical review may identify additional omissions or require additional information
o Please provide to this office within 30 days of your receipt of this ca~d
A copy of your action has been forwarded to our License Fee amp Accounts Receivable Branch who will contact you separately if there is a fee issue involved
Your action has been assigned Mail Control Number bull ITo Lfj When calling to inquire about this action please refer to this control nu ber You may call us on (610) 337-5398 or 337-5260
NRC FORM 532 (RI) Sincerely (6middot9)) Licensing Assistance Team Leader