lli lll 1 ii111 1111 iiiii i1i111111111 iiiii 11i11 111111 ... · 11/03/2015 nrc form 664 07 -2015...

llI lll II111 1 IIIII 1111 I1I111111111 IIIII 11I11 111111 11111 IIIIIll I 111lHiii11 ti 11111IIIt III! lll l liltIIIGL-705530-2011/03/2015

NRC FORM 664

07 - 201510 CFR 31.5

APPROVED BY 0MB" NO. 31 50-01 98

SECTION 1PAGE 1 of 2

U.S. NUCLEAR REGULATORY COMMISSION

GENERAL LICENSEE REGISTRATION

EXPIRES: 04/30/2016

Estimated burden per response to comply with this mandatory collection request: 20 minutes. NRC will use this information to track general licensees and their devices toensure a higher level of device accountability. Send comments regarding burden estimate to the FOIA, Privacy, and Information Collections Branch (T-5 F53), U. S. NuclearRegulatory Commission, Washington, DC 20555-0001, or by internet e-mail to Infocollects.Resource~nrc.gov, and to the Desk Officer, Office of Information and RegulatoryAffairs, NEOB-1 0202, (3150-0198), Office of Management and Budget, Washington, DC 20503. If a means used to impose an information collection does not display acurrently valid 0MB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.

Complete all six sections of this registration form. If any of the preprinted information is incorrect, provide thechanges in the applicable boxes. USE CAPITAL LETTERS.

General LicenseRegistration NumberGL-705530-20

SECTION 1 - GENERAL LICENSEE INFORMATION

Enter the company name and the street add resslphysical location of use for your device(s). Forportable devices, specify the primary storage location. Do not use a P.O. Box address.

Company Name: MARYSVI LLE HYDROCARBONS

Department: HEALTH AND SAFETY

Address Line 1: 2510 BUSHA HIGHWAY

Address Line 2:

City: MARYSVI LLE

State: Ml Zip Code: 48040 -1904 I 'Lw:For NRC Use Only. cateor'

...... ,,i: :Packet Rece~ipt Date (MMDDYYY): i:

Accesio Nuber

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SECTION 1PAGE 2 of 2

SECTION 1 - GENERAL LICENSEE INFORMATION (Continued)Enter the name, teleiphone number and title of the person who is the responsible individual for the device(s).

Last Name: HALLIGAN

First Name: DENNIS Middle Initial: P

Telephone: (810) 388-2084 Extension:

Title: SENIOR HEALTH & SAFETY CO

s~lPJ-AM• sQuP Rk>V)JS•

Enter the mailing address where correspondence regarding your device(s) should be sent.This address should be specific to the use or storage location of your device(s).

Department: ADMINISTRATION

Address Line 1.: 2510 BUSHA HIGHWAY

Address Line 2:

City: MARYSVILLE

Stt:M I Zr Zi Coe:484I-90

A A

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11/03/2015 SECTION 2 -DEVICES SUBJECT TO REGISTRATION SECTION 2

Our records indicate that you have these devices. Please update the information as necessary. PAGE 1 of 14

NRC Device Key 591333 (Internal Control Number)

Distributor/Distributed By: KAY-RAY/SENSALL, INC.

Distributor License Number: IL-01010-02

Manufacturer Name: KAY-RAY/SENSALL, INC.

Device Model (Not Source Model): 7063P

Device Serial Number: $98F0503

Transfer Date (Receipt Date): 05/I5 119 9 8

I I [•• • • L•Not in possession of device (AlsoD] complete Section 4.)

MM DD YYYY

Isotope (e.g. AM241) Activity (e.g. 100) Unit (e.g. mCi)

1 CS137 500.000000000

ED2

3

4

5

6

A

mCi

DIIDIIDIDDIEDIEDIE

A

IIIIIIII 1111 111 11111 11111 11111 IIII I liU 111111 11111111 III III11I i11111 IIII BIII 1111 IIII IIIlGL-705530-2011/03/2015 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2



Distributor/Distributed By: KAY-RAY/SENSALL, I NC.




Device Serial Number: S98M2904

Transfer Date (Receipt Date): 11/1 5/1 998I I II I I INot in possession of device (AlsoD] complete Section 4.)

MM DD YYYY


1 CS137 200.000000000

2

3

4

5

6

K~Ih

A

mCi

DIDDiiDiiDiiDiiDID

A

GL-705530-2011/0312015 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2




Distributor License Number: .I L-01 010-02



Device Serial Number: $98M2905

Transfer Date (Receipt Date): 11/15/1998l__ • l 1 • • •Not in possession ofdevice (Also

D] complete Section 4.)ED Di Dii

MM DD YYYY


1 CS137 200.000000000 mCi

2

3

4

5

6

Dii

DiiDiiDiiDiiDiiDii

A

GL-705530-20

11/03/2015 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SEC

Our records indicate that you have these devices. Please update the information as necessary. PAGE





- Device Modei (Not Source Model): 7063P


Transfer Date (Receipt Date): 11/1 5/1 998I I E__MZ JNotin possession ofdeviceo(Also

D] complete Section 4.)

MM DD YYYY

IDIhIIIII.3TION 2

4 4of14

Isotope (e.g. AM241 )

1 CS137

2

3

WEW I4

5

6

Activity (e.g. 100)

200.000000000

Unit (e.g. mCi)

mCi

WE_[

WEU

WEU

A A

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Our records indicate that you have these devices. Please update the information as necessary.



Distributor License Number: I L-01 010-02




Transfer Date (Receipt Date): 11/1 5/1 998Not in possession of devicII I IkJ2JD complete Section4.)

MM DD YYYY

III nnll miI niI IIIISECTION 2

PAGE 5 of 14

L

1

ii:e (Also

Isotope (e.g. AM241)

1 CS137

2

3

4

5

6

Activity (e.g. 100)

200.000000000

Unit (e.g. mCi)

mCi

LW•

A A

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11/03/2015 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2






Device Model (Not Source Model): 7062BP

Device Serial Number: $99G0102

Transfer Date (Receipt Date): 08/15/1999• [___• • ___• ~ m• •Not in possession of device (Also


MM DD YYYY


1 CS137 100.000000000

2

3

4

5

6

,A

mCi

Diiiiiiiiiiii

A

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NRC Device Key 591317 (internal Control Number)





Device Serial Number: S99G0103

Transfer Date (Receipt Date): 08/15/1999Not in possession of device (Also

I--D complete Section 4.)

MM DD YYYY


1 CS137 100.000000000

2

3

4

5J

6

WEIE

A

mCi

WEWEWEWEWEWE

A

GL-705530-20





Distributor License N umber: IL-Cl1010-02




Transfer Date (Receipt Date): 08/1 5/1 999Not in possession of device (AlsoI 1 11 1 •D complee Seoction4.)

MM DD YYYY

Isotope (e.g. AM241)

1 CS137

2

3

4

5

6

Activity (e.g. 100)

100.000000000

Unit (e.g. mCi)

mCi

EmDDEEWDDEDDEDDE

A A

GL-705530-20





I I I I L I

Distributor License Number: IL-Ol1010-02



Device Serial Number: $00C1301

Transfer Date (Receipt Date): 03/16/2000L___• •-• •Not in possession of device (Also

[]complete Section 4.)

MM DD YYYY


1 CS137

2

3

4

5 zww6 Dfflw

A

100.0000000Imi WEWEWEWEWEWE

A

1111iil1111I1I1i11I111111111111I1111I11I11I111 I I ll II 1IIIII 1111 111 IIfIlII IIIl III III III IIIIGL-705530-2011/03/2015 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2





Manufacturer Name:


Device Serial Number: S00D2703

Transfer Date (Receipt Date): 05/1 5/2000• __J • • • • L•Not in possession of device (Also


MM DD YYYY


1 CS137 200.000000000

2

3

~ii

4

5

6

,A

mCi

DiiDiiDiiDiiDiiDii

A

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11/03/2015 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2Our records indicate that you have these devices. Please update the information as necessary. PAGE 11 of 14

NRC Device Key 667443 (Internal Control Number) 4,=--


Distributor License Number: IL-O01010-02



Device Serial Number: B79

Transfer Date (Receipt Date): 03/22/2001• ._j _• •Not in possession of device (AlsoLII complete Section 4.)

MM DD YYYY


1 0S137 100.000000000

2

3

4

5

6

mCi

DiiDiiDiiDiiDiiDiD

A

GL-705530-20*11/03/2015 SECTION 2 - DEVICES SUBJECT TO REGISTRATION

Our records indicate that you have these devices. Please update the information as necessary.


Distributor/Distributed By: TH-ERMO FISCHER SCIENTIFIC

Distributor License Number: L03524

Manufacturer Name: THERMO MEASURETECH



Transfer Date (Receipt Date): 05/25/2004I I I •Not in possession of de

El complete Section 4.)

MM DD YYYY

IIIIIIIIII iIIIIII IISECTION 2

PAGE 12 of 14

]

]

]

.vice (Also


1 CS137

2

3

4

5

6

Activity (e.g. 100)

50.000000000

Unit (e.g. mCi)

mCi

WEL

WEU

A A

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Distributor/Distributed By: THERMO FISCHER SCIENTIFIC


Manufacturer Name: THERMO MEASURETECH


Device Serial Number: $98F2509

Transfer Date (Receipt Date): 05/25/2004[ • Not in possession of device (Also


MM DD YYYY


1 CS137 50.000000000 mCi

2

3

4

5

6

A

WirDiiI

Diil

A

GL-705530-20




Distributor/Distributed By: TH ERMO FISCH ER SCIENTI FIC


Manufacturer Name: TH ERMO MEASURETECH

Device Model (Not Source Model): 5202"

Device Serial Number: B2798

Transfer Date (Receipt Date): 12/15/2004I I LN ot in possesson ofdevie,(Also


•MM DD YYYY


1 CS137

2

4

5

6

A

200.000000000mi

DiiDiiDiiDiiiDiDii

A

I IIII IIIIi II~ I I III ~IIDIII 1111111 IIIIIi IIIIIi ilIII IIII 11111IIIII IIIIIII! 11 IIII IIIGL-705530-2011/03/2015 SECTION 3

SECTION 3 - ADDITIONAL DEVICES SUBJECT TO REGISTRATION PAGE 1 of 1Provide information about other devices you have that are subject to registration. Do not report specifically licensed devices.

Manufacturer Name

Initial Transferor Name

Initial Transferor License Number (if known)

Device Model Number (Not Source Modei)

Device Serial Number

II

I

0 Manufacturer/initial Transferor listed aboveHow acquired and date (e.g.,from a distributor/manufacturer, 0 Other General Licensee Date Transferred: L71_J L i K ulhi

oteOiese ohrsuc) Other Source (Received) MM DD YYYY

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.


W~IE

KKKKKKKK

Activity (e.g. 100)

I I I I

[ I I I

I I I

Activity (e.g. 100)

I I I

I I I

wIEDlIIIIEDIIDEDlEDI

I I

I I

I I

r I

I I

ilIIIIII

LIIIIIII

Unit (e.g. mCi)

WELWDIDLWWEWEWEWEWEWE

i i i i I I I

I I I I

I I I I I I

I I I [

I I [ I I I

I I Im I I I I I

A A

GL-705530-20 SECTION 4 - NOT IN POSSESSION OF DEVICE SECTION 41110312015Provide information about devices listed in Section 2 or 6, but no longer in your possession. PAGE 1 of 1

Part 1 Transfer Date:

NRC Device Key: _ L L•

(from Section 2 or 6) E D WlMM DD YYYY

Location of the Device:

O Whereabouts Unknown (complete Part 1 only) 0 Transferred to another general licensee (complete Parts 2 and 3)

o Never Possessed the Device (complete Part 1 only) 0 Transferred to a Specific Licensee (Not the manufacturer)

O Returned to Manufacturer (complete Part 1 only) (complete Part 2)

Part 2 License Number of Recipient (if transferred to a specific licensee):

Company Name:

Department:

Adrs Line 1:

Address Line 2:

City:

State: Zip Code: WIDE - EEPart 3 Enter the name of the individual responsible for this device:

Last Name:

First Name: Middle Initial:

Title:

A A

I11111111IIi]llIIIIIIIII Oi i Ii 11111l11111II1011I1I11 II111I11 liiii11IIIIIIIIII 1110111IGL-705530-20 SECTION 5 - CERTIFICATION SECTION 511/03/2015 PAGE 1 of 1

I hereby certify that:

A. All information contained in this registration is true and complete to the best of my knowledge and belief.

B. A physical inventory of the devices subject to registration has been completed, and the device information on

this form has been checked against the device labeling.

C. I am aware of the requirements of the general license, provided in 10 CFR 31.5.(Copies of pl ble regul tor s may be viewed at the NRC websiteat

http/ .n v/e in r oc-o oscr

SIGNATURE - E-SPONS L INDIVIDUAL (Listed in Section 1) DATE

WARNING: FALSE STATEMENTS MAY BE SUBJECT TO CIVILAND/OR CRIMINAL PENALTIES. NRC

REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRC BE COMPLETE AND ACCURATE IN ALL

MATERIALASPECTS. 18 U.S.C. SECTION 1001 MAKES ITA CRIMINAL OFFENSE TO MAKEAWILLFULLY

WRONG STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED

STATES AS TO ANY MATTER IN ITS JURISDICTION.

A A

GL-705530-20

11/03/2015 SECTION 6 - DEVICES NOT SUBJECT TO REGISTRATION SECTION 6

PAGE 1 of I

NRC Device Key: Manufacturer License No:

Manufacturer Name:

Model Number: Serial #: Transfer Date:

lli lll 1 ii111 1111 iiiii i1i111111111 iiiii 11i11 111111 ... · 11/03/2015 nrc form 664 07 -2015...

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