north kansas city hospital, request to amend license number … · 2019. 12. 27. · certificate of...
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CERTIFICATE OF DISPOSITIO OF MATERIALS 1 ’ ICENSEE NAME AND ADDRESS
I M ~ r t t a ~ Halrh Corporadon 2790 Clny Edwards Drive., Suits 520 North Kansus City, MO 64116
A. LI ENSEISTATUS (Check 2 This license has expired. This l i c & t has not yet explred, plc E. D18P6SAL OF RADIOAI
check the #mpd=te boxee end ccunpla ea notuvry . IfeWtimwispace k ha: licensee. or any indlvldual executing thla csrtitificate on behalf of the lice
I
1 No radloaetlve materials have ever b
0 b. Dispofal of radioactive materials: 1. DIrectly by the licensee:
24-32275-01 Lh&&tkj73674 UCENSE EXPIRATION DATE
I OlNlL2Oll
2. By Ilcensed dispoeal site: 1
c] 3. By waste contractor:
0 c. All radioactive materials have been such that any rem ining residual radioadvity is withln the limits of l o CFR Part 20. Subpart E, and is ALARA.
1. ~radlatlonsurveywasconduCted
0 b. that any rernalnlng residual
a. is attached; or b. is not
#24-18628-01, North Kansas City 0. the absence of licensed radioactive rimrials
2. A copy of the radiation sumy results:
pns 3. A mdlatbn survey is not
I I he person to be contacted regarding the informstfan prodidsd on thls form: 1 AME I 1 ITELEPHONE h % d t 3 A m c o d s l (E-MAIL ADDRESS
le appmptlata box) ne terminate it.
rivE MTERIAL iudd, prod& atlecltments) Be, cefflfles that: 1 the licensee vlder this license.
flue materials procured and/or possessed by the limngee I followlng mmner.
; Phone 116-691-5343 or Cell #913-70&9200
PRI- ON RECYCLED PAPER RC FQRM 314 (MW)
TOTRL P.02
Toye L. Simmons Materials Licensing Branc'i, 2443 Warrenville Rd Suite Lisle, lllinols 005332-4352
S in ce rely,
Region Ill 210 1
North Kansas City MO 6
816 691 5343 Departme
Radiation Safety Officer
913 706 9200 Cell 816 346 7869 Fax