Sent By: K; 41 06652074;. .. . ... . ---- . - - --- .....

qRc FpRM 2A14r NUCLEAR, REG3ULATOR~Y COMMISSION-

-REPORT OF PROPOSED ACTMTIES IN

NONAGREEMENT STATES, R9EAS.OF EXCLUSIVE

FEDERAL JURISDICTION, OR OFFSHORE WATERS. .. .. : - : .- ' $X th t+^

I

May-15-03 14:01; Pace 6/10

_A~pROV9 ISY 0MEB: No. 31 SO-0018 T~01120bu~s r~flflto Y M fwith oft Inandstory Ods

EW-111 " ".tmmon.is requuired so thatNC

schedulE Inspofio of the ffiownlaS etwar UitIWV or andue60ewdon09' wift rH4UIrtM-ft5 tr Pmoleulon of the publthatl n

aelty Sed omnafis tnrdln burden 0410ma1D toteRe0 dMarm~mentitranh {T8~WI~U.S.Near Rugulaloly Cnal.iA~

nndto~obeak Dftoar Ollos filomto.ali En ReglI cgiycI.

on des ot I~pY1 urrntly'mid OIO ontol umber, theNRC~ ~ ~ ~ ~ ~ ~~~~Tu rdaoraosrtda roni o eured to

(Please road the InstiuctiomOffoDrai =11OTIPY 6 115 ... /~~ resnon M. um e-

7wmh l uc~s 'Ap 'D'fmjv 2. TYPIE OF RPR

Krueger-Gil~bert Health Pkhysics ;--Inc .INITIAL RVSN CLRCATIO

3. f~ssOF JC~8~ M~Iil9 4drI~ OIW~II WIWW OE1W WyM iinadJ4. L!CESN3 CONTACT AND liTLE

D-onna Thim/Health Physicist

BaltimerSe MaryJTFUafla 21234 B "M

7. ACImfTES"TD9E CONDUCTED)UNDER THE 0!NRAL UCENBE GIVEN IN 10 CFR 160.20

DWELL LOGGING LEAKTESTING AND/OR CALIBRATIONS TELETHERAPY1I1RRADIATOR SERVICE

D PORTABLE GAUGES E OTHE-R. (Spec"f) ' ______________________

RADIOGRAPH4Y ~ ~ POA C11Al P~C U

BCWr NME, S.C~~ ~~C~NISAE PDC =A ~~IP0M. AD~ CITWOiK LOCAI1O9

Mol.ecul~ar lma~ging Services'"'eas#613 High StreetSeaford, DYE 19973

lo. a~mNwrB')0C NtAS 11. WO0K LOCATlON2.eLPkwWENumCsR

302-629-9099306299

- 2 AE C4UWDWORK DAYS ADD 09WEE REFERS1CE NUM1BER

13. NUIAEROP 14 1ff 1R ToC tiOASIIONSD BY NRC

/ Xjh 4 / o./ 3 ( ec 3 NIMETB

LIST fDfITONP.L WOKsTSMSON SEPARATE SHMTs To INCLUDE ALL INPCRATONCONTAINED [INN rffEMMS BUIS ABOVE.

Cs-137 ICN MLDO1#30 9 3 8 9 ', 250uCi .(11/23/87)

Cs-1 37 INAS MED 3550 #A.73:80, 1B2..5 uCi (11/1/97)

ASVEMcoopowr~otwu M 045-1 01 _ D ,30/00

-. AY~fkl 21L-prhffN7TE0YAFPPUCAWD

I, THS UNMU51niql, 110t!Y CMTIFY ThAT: .

* All lrt rIWBIOUI lin NC report Is ~Uin- *I coIIp4Ilm

IL I have rend end gndasizid the provision of the, genenl Ijcrfls 10 CT'R '180) mreprted an the insrafudlons of' min lorm; wndI umdhrsbrnd that I ant

raquIred to seYMpy w"ith fise provisotia as tp alm byproduct, acurca,' or mpecWa nudeai wate"Ial which~ I Possess etid mehI nonmAgrhUDUt SUatOf

ot~shomu waters under the genera ties for wih tis np~hl Ifiledi WMt We U.S. Nuclea Retulatory CQMtolmllnl

~. uneraiti tht atXVES.Iriludig otq cuniltedletImnAgreiI~lttens.pnde geera Ucne 10 CPR 10f0 erM lUMit to tatafl of 190 days

I~ calergdatw yecr.wit[ theseplutip tors", condUctSd IN ht~lort Aters.b wltito Ia authoutkw! Wo an unlimIted period of "Me In the cajender Year.

d. I mUfltst~ltnd UtnatI may be InaPeodW by NXtC At the above lIsled work shte lo-ftkrn end at the Uicaerie borne oateic addres for act"Ivis prformed In

h~f.Ag3Sl~Ottstaesor offshore waters.

*.I understand ttia owdut ofIany nenvales not dencrhed ashe"', IneWding conduct of actvllieu an dates r ocafflons dlfferen fromn theN' described

above Or wi tho bx Nff4_ wtutn NR= iutorusioda VW to enforceeinat atown, Winui eNi rcinlw ed

CI1R~t~Q4'FC5~ P3 or .IseoviniMRwwE~l~ pini nd T.) .D7-

heabsc oC IeJiOifgh - R .mideanl..-.--Ir

E l-J9S.I. E~t*7

WA7NYFle~~l~Uii- iB~et~l¶0 nkaW ciNPnE raflontS 10 Widk & warmuuriy .. to

IWAMONG! Palm VDIMMIN W ""m "' " __ ____ -- .�Aocflon 1001 Innitleg wil clirmnal 0"allas TO TMOM 0 W]"Huly- - -. 1 �riftrtc_ 12 U-9 4090. , -.. . ,

tuNRC be convwtft m11IN accuFUKe ml- G.--- .- ,.--- --* - f~nMumcetatriuit o ftp~gaittltI~t o an de~tiwat r aenc tthe triltod States asr to Any inwttor wti t~lt

I1 aePWROAL .TE. TCTALUGQE- YSTOOAr

FORA

41 06652074; May-15-03 13:59; Page 2

4106652074;Sent By: K; May-15-03 13:59; Pace 2

NR FR 21us. NUCLEAR REGULATORY COMMISSION AP bY=OM-T NO. n. i 81E0.COII E(PIRE5 -7120bure r ' t talh m

'law) :lreouest 15 minulus. T notlolin b requird o tot NRC ma

.whadule irpeatnon Of he ft vills to en of they rte rllaihat ndiaccordncian with reqidreflen'ts for Proilsotlfiof h ufU a n

REPORT OF PROPOSED ACTMTIES IN d IU7 Nuclar egulaitory Co-misaihim,siena -melt 10 1@nrl .gO..

NON-AGREEMENT STATES, AREAS OF EXCLUSIVE in hmeekDkmnat 0110ofmtort and Raguy A ar

FEDERAL JURISDICTION, OR OFFSHORE WATERS W-o5 rdgon,6 2c D d003 a0mmo use Oo MP040 On irafnIcollection does not dlspluy n OurrslntlY vftid OMBI control number, the

(Pono ea heinst~cJfl b fr cmpetngtisftlf) NRC may not gocdl or spno.adaperson Is not required lto(Please read the inwiructionis dbefr completing this form) _ aon =o h g n

1 NAME OF UCI4SIM ON"ac of rpm pFwcu1 to = VW WW11Y88 dOnOed bob) 2. TYPE OF REPo T

Krueger:Gilbert Health Physics, Inc INITIAL E REVISION CLARIFICATION

A, 7RES OF LICZNSEE (Uiagl eddre or - -=R icent11 may ) 4 LrEN9EE CON TACT AND TITLE

3E.01 E. Joppa Road ,~Ar~ L$~/ealth Physic

Baltimdre, Maryland 2123 4 EH0NE ER Fa. FCIMLE NUMBER

410-665-5447 1410-665-2074

7. ACTIVITIES T ONDUCTED UNDER THE OENERAL UCENSE GIVEN IN 10 CFR 15020

D WELL LOGGING LEAK TESTING AND/OR CALIBRATIONS D TELETHERAPYJlRRADIATOR SERVICE

D PORTABLE GAUGES j OTHER (Specify) -'I_

REGISTERED ,AS USER OF PACK(AGING ICERTIr-CATES OF COM4PLANCE NUMSERS)

RADIOGRAPHY K ___ _ _ _ __._ _ _ _ _ __ _ _ _ _ __ _ _ _ _ _

8. CUENT NAME. AODRESS, CCTYICOUNTY, STATE. ZDP CODE a. AUAL F'ECAL AIODESS OF WORK LOCATION(3&J .0 Nn~b.' oVe JCUO. n'..5 n et .nddmuu or diSrtdOO5 4u pa~l

Nanticoke Memorial Hospital

801 Middleford Road same as 8

Seaford, DE 19973

IQ CLIENT tlOPINE NUMBER 1t. WORKLOCATIOELEPHONE NlIJNSR

.302-629-6615 302-629-661513 15R F iI. 16. LOCATION

12. DATE SCNEDULf1. NUBDEROF 14 t. 1. M1ZDTSSHDLDWORX DAYS ADD DELETE RE1IERt2NCE NUMBER

FROM TONUMBER TO BEROM To ASSIGNED BY NRC

_=R A E sH5$->951!EE S 0,TON CONTAINED IN9 IEMS 9-16 A BNOVE. _

LIST ADDITIONAL WORK SITES ON SEPARAT SEE STO INCLUDE ALIFRAINCNANDI VM -SAOE

17. LIST kADIOACTIVE MIATERIAL WHICH WILL BE POSSES1lED, USED, INSTALLED. SERVICED, OR TEMTE

inew wsorbofn ofwop and quw of adwamemW Ineforth aw-ito oweA. of dwess toa Leu)

Cs-137 ICN MLD-01#30 9 3 8 9 , 25OuCi (11/23/87)

Cs-137 NAS MED 3550 #A7380, 182.5 uCi (111197)

tc. A 'S NWKA AE ELITHSSAM Ec UOR AL%4ERO TO CONDCT L CENSE N -MBER 20 0AE 3I

A&MK R 19FO LCERTIOOFICSATIO SPECIFE IN r-T9rAl= DYor_.AOE otro'9oflepCfCtnouticrrp=y theJnMWNRC PFOin 241.) IMD- 05-101-1 MP 6/36/2003'-....- ~.. ... nc ^^"cifD =Tt=f mYV A P ICAMT)

.st

I, THE UNDERSIGNED. HEREBY CERTIFY THAT:

All Infoynatlon In this report Is true and comrVlete.

b I have road ant undeastand the provision otAthe general llcense 10 CPR 16c.20 reprinted on the InsutiOtions of thisto;nn and I undbastandthat I am

required to comply with these provisions as to all byproduct, sOUTCe, or special nuclear miterial which I possess and use In non-AgtIment States or

offshore wates under the general license toI Ir which ttis report Is flled with the U.S. 5 Nulear Regutotoay ComolssIO.

I underdtand that activities, Including storage, conducted In non-Agmft Stae und r genral lrcense 10 CFR 10.20 are lUmned to a cotal of 1WO days

In calendar year. Wth the exception of work conducted In off-shore waters. which Is LuthBriz-d for an unlimited pefloti 1tme In the calandr year

d. i understand tisna I may be Inspected by NYG at the above listed work sIte locations and at the License" home office address for activlties perfomned In

norrlAgf ement Staes or offshore Water.

e I understand that conduct of any activitIes ict described above, Including conduct of activities on das or locations different trorn those descrfled

above or without NRC auttiorizatlonn may *4bjart me to enforcement actilon Includeg civil or efimI penaltles

CERTIFNG OFFICEA - PSO or MarageflwJ opmaarw Nam* awWTnd T.) SIGN E

' 1. ILK] hnellor crirnanf Vena es. NRC regulations require Ihat submissions to

WARNING:' False statements in tirs ceraruni tMay un - K smnlofes omk ~ llyMthe NRC be complte and accurate in all irmterial respects. 1B U.S. action 1001 makes i~e crininal ofhnse to rake a WiIIIlllyuise

statement or representatIon lo ary department.o' agency of the United States as to any miter within Its jurisdiction.I -, ITOTAL USAGL-- DAYS TO DATE

1241 (7-1O0) I

C-nt Ru1 6e, 41 06652074;3 klay-15-03 13:59; Pace 3OCi I,

NRr- FORM 241 U.S. NUCLEAR REGULATORY COMMISSION .APOE Y0R-N. 002 V]:OIbuw ndawry oolbo. w

-1 eu:15 mInUgs Iltu is retuin go that llRC: may:sts.dui Lntpewdon of f *rJ to enst tat tthey are onductd Ina*crdan~e vfth requiresmrd for pruadlon of kha publiic health r nd

REPORT OF PROPOSED ACTIVITIES IN roty. Sand tooc rStSrdfl b~burden asibenat to the iaorti

MAn ment Smac iT-Jv UA. Nuclear Reagulatory Comnisslonl,IIl. DC 20~5-0OO., or by mwr*o

NON-AGREEMENT STATES, AREAS OF EXCLUSIVE and to 1n k Oe ereo ffice ofIfotrmation and R jI

FEDERAL JURISDICTION, OR OFFSHORE WATERS wahingon, 2080. vd MB cOntr endbeud

.oolnrdlon dooe not di ousnil O

(P/awo moad the Insirucmlons befwr completing this form) R no = duot

t NAME OF LICENSEE fP~onn a, &m p omiU b cuct the iVl&hW a crd Miwbiw 2. TYPE OF REPOWT

Krueger-Gilbert Health Physics,_ Inc INITIAL | REVISION ,CLARIFICATION

S ADDRESS OF LICENSES 4. L1 d~iS a a on wfle'O //o may hee W) . LCENSEEoNr AND oTnLS

Donna Thim /Health Physic3601 E. Joppa RoadBaltimdre, Maryland 21234 s. TELENE MW. mom

410-665-5447 410 665-2074

7. ACTIVITIES TO BE CONDUCTED UNDER THE GENERAL LICENSE GIVEN IN 10 CFR 180.20

WELL LOGGING LEAK tESTING AND/OR CALIBRATIONS 2 TELETHERAPYJIRRADIATOR SERVICE

[ PORTABLE GAUGES U OTHER (Spewl*y __

REGISTERAED AS USER Of PACKAOING LCRTFICATES OF COMPLIANCE NUMBERS)

L RADIOGRAPHY ___

B. CLIENT NAME. ADDRESS. CrrY/COUNTY, STATE, DP COOE G. ACTuAL PWFAL AODRESS OF WORK LOCATION

:~~ a.'~d NUmbr oIhJ;b2I eEA. .w s~u n ~da a dsdnsa psiJu,

- Bayhealth Medical Center same as #8Kent General Hospital64D South State StreetDover, Delaware 19901 io. N t1.WORKLOCATlON TEL.p141ENUMBER

302-674-4700 302-674-470013. NUMBER OF 14. 11.LS LOCATION

12. DATSS SCHEDULED WORK DAYS ADD DELST RFFMCENUMBER

FROM O II :UMBER

TO BE

(ajio s /d/0 / 6½/a/.3 47o-/7 _

LIST ADDITIONAL WORK STTES ON SEPARATE SHEET(S) TO INCLUDE ALL INFORMATION CONTAINED IN ITEMS 9.18 ABOVE.

17. LIST RA OACflV! MATERIAL, WN1I4s WIL. Be POSSEssED. USED, IUSTALLED, SERV2C!D. OR TEtTED

rlnchu deorden of roe nc quI~ cant iSoce noit~ erle1dse oewoeft at dewe b .&

Cs-137 ICN MLD-01#309 389 , 250uCi (11/23/87)Cs-137 NAS MED 3550 A73B0, 182.5 uCi (11/1/97)

E S PfLNSICENSE NUMBER A STATE EXPIRA1loN DATE

ACUA N WWHIR ~EWTEPCALAEE POR LOCAn N OF IJSE, A SPE JnR

ABOVE, (Durcopi- ofMe Mc /k-lis t G=Mpony o I1-1 MN r F U rU0/2003

1S. ficrilrI. I iJ{I~ (VI.JI , -. ~, -.- -_

I, THE UNDERSIGND, HREMY CERTIFY THAT:

r All Informnatlon In thbl repol Is true and comolete.

b I have read and understand the provision of the general lIcense 10 CFR '1020 reprInted on the Inatuctions of this form; and I understand that I m

nequIred to comply wtth th-e provisions as lo all byproduct, tourct, or sp elW nuclesr manterlil which I porsr*1 and use In non.AgraeImrlt Sttes or

offshore waters under the genenrl license forwhlch thIs report Is filed with the U.S, Nurhear Regulatory CommissIon.

c I undersand that actvflateS Including storage, conducted In nont.Areernet States under general lIcense 10 CFR 130.20 are limited to a total at 1ao dayp

In cahntdar year. WIth the exceplton ot work conducted In off-shore waters, whlch Is auth~dor d for in unlimited period of time in the calendar year.

d I understand that I may be Inspected by NRC, at the above lilsted work ste locatloruz end at the Licensee home offlce address for ectivItIes performed In

non-Atreement States or off shore watera.

I understand that conduc of any actvlties not descrlbed above, Induding conduct of actititea on dates or locatlons diffruht from those described

above or without NRC authorlStiion, may subject me to entorcement actione lnciulpg cIvil cr criminal penales.I Inky% ,-7 j

I

Sent By: K;

NRr, FORM 241M. I awl.131

41 06652074;-

U.S. NUCLEAR. REGULATORY COMMISSION

IIs

REPORT OF PROPOSED ACTMTIES IN

NON-AGREEMENT STATES, AREAS OF EXCLUSIVEFEDERAL JURISDICTION, OR OFFSHORE WATERS

j r_ Va ;hmfrira rnmnbifiinn fhhs forml

M~ay-15-03 14:00; Page 5/10APPROVED BlY 0MB: NO. 31 b0-OOS PIMRES: 07J~r1g

atnpty vith Ihix r andto collo ionr' asnu,. Wijno'cation is reured so kiat NR~r, ,-

acl w ule lvaper-tric of the, so~vibe to .isuueO they mer conduct6 inmocosdanne with requlremerits for protectioni of the publiO health andBuafty. San~d comrnents regarding burden eutlimate to the Revcords

Man gem nt ranh (-6 M , U .S Nuclear Rsgukalory CoarmisioN5W~iI n~lf ii OC 055 Da00 , or by Internet &-am il to bIel nr-.O v.

and to th D oak C s o z ffo f I fo i. a d e u a oy A falrm,NE05-1 0202 Z1 50-0013) 01110 of Manaparanifl and Bd at.

-A _-st-lptn- _ 10503 L M eagna USed to impose an tnlr roalocoIlection does not display a currenlya YalId 0MB control number, eN R C n.yt o o d c , o s o s r n . p m z a n ot required t

(rJ"OU Dutm di A rospon l I thp II11~HflIun~ f 00.

1. NPAE OF LICENSEE fPr~m 0FAn 5VcOing b, " andut v/wviVN" iwyabed hnw) 2. TYPE OF REPO~

Krueger-Gilbert Health Physics, Inc NITIAL ZiREVISION _[CLARIMCATION

a. ADORES0f OF LICENSEE (M iftaddlw rodda d hOVO A. LI OI*~*JOWJ 4CE SEE CONTACT AND 1TTLE

Donna Thim ./Health Physici3601 E. Joppa Road3altirmdre, Maryland 21234 e. I MLENeRI

7. ACTIVITIES TO BE CONDUCTED UNDER TiE GENERAL LICENSE GIVEN IN 10 CFR 110a20

D WELL LOGGING LEAKTESTING AND/OR CALIBRATIONS 2 TELETHERAPYAIRRADIATOR SERVICE

| PORTABLE GAUGES OTHER (Spaciy)

_E-ISTERMs AS USM OF PACKASIN1 jIC0flMEa'OF CMWAUANCE NUMEME;3

RADIOGRAPHY 1 _

_. CLiENT NAMr ADoRE, crryxovJU7, STATE, zip CODE D. ACTUlJ. PWISICAL AODMS3 OF WOW LOCA-TON...;.wt vtd Nmih ohwicaa t Cr. or wn tes an edrw a d-k- p-vbrj

- Bay>ealth Medical Center same as #8'Kent Geberal tacicer cbhter

793 S. Queen StreetDover, Delaware 19904 1 =. C/TE-LM'OWE HUMmER 11. WO j:C HELEONUMSER

: (302) 674-4401 _(302) 674-44L111. UN WR9OF 1415 IQ. L.OCAT"O

12. D^IES9CHEDULED WORK DAYS ADD DE LT 16R.W NUMBER

IROM TO NUMWER lOBEFROMINI RY NM C

UST ADDmONAL WORK SrTES ON SEPARATE SHElET(S) TO INCLUDE ALL INFORMATION CONTAINED IN ITEMS 5-16 ABOVE.

17. LIST RADIOACTIVX MAI!RIAL. WHICH WILL SEP101 EDS US21. IWSTALLZ, SERIYiCD, OR YE3 TI. pnct d a re n cI~e end q W v e t ,uduad ls, n t ~ .a n aurus . or d~t ee o be aad.)

Cs-137 ICN MLD-01#309389, 250uCi (11/23/87)Cs-137 NAS MED 3550 #A7380,. 182.5 uCi (11/1/97)

IS l / I LI~eL3E NuNw IiSTA-M PIW A1I DATE

~e v . Furc ~ ee o u~ p am ic n e min a a p ny V n r r al R Fo m241.) M Dx - o 5 - i 0 1 -0 1 Im D) 6i L3 0 L2 0 0 3:S E T 1 A I N I L ~ u * r ~ I L .I . ..A.JL ~ I _-

.IS. CEF.KIF CA;I ON pM1J"U&T UUP~U~t

1, THE UNDERS1ONED, HERE.Y C&RlKfY ThAT;

, All Informaiton In tihi repart Is tUf and COmpl0 .. ,

b. I have read and understand the provinton of the general license 10 CFR 180.0 reprinted an the Instructions of thin fam; and I undrimand lhi I am

required to comply wth these proVisons as to all byproduct tource, or special nucltar matrial which I posses and us i non-Agreerent atates or

ofshore waers untlerthe general license for whIch this report is flied wvth the U.. Nuclear Regulatory Commlssion.

,I undarsand that activiltes, Including starage. conducted Ill nin-Agreenent States under general Ecenee I ' CFR 150i0 art Ilnilteto a total of 180 days

In calentur year. Wfit 1he exception of work conducted In ofn-ehor waters, which It tMnoned for an unilmired peartd of Zone In the calendar year.

d I understatnd that I may be Inspected by NRC at the above listed work dtte locatios end art the Licensee home osilc addess for activties performed In

non..Agreearnit MSse or offshore waters.

a. I unerstand that conduct e at any astvesi nqt deecrewd above, Including conduct of activites on dates or bocetaons dmrmnr from those 0aslibod

abnve or without NRC uuthorization, mny aukdect me to orfemntM action, ndg civil w crimlirn txlls.

CElRlFYINtl Of PICER - RSO or Mmieerne~t Rr gmip~t d (N~lie an 77W 7 G * I DA m

Ri.nnt 'r Kr L L1c R ( a SWARJING: false In this curtlficate way be subject to colkind/lr cirenal pneas.. NRC regulations require t*at submIsslons t4

the NRC be complete and accurate in all mnterial respects. 11 US.CADctUon 1001 makes a Cr., imnsl offense to nmka a w4Muy faise

statement or representation to any deparbtmnt or agency of the United Stats as to any matter within ts jurwkdlo#

OFOR NRC I RMdEAEe TOW) FFICNITURAL . DA1E lytrUSAGE - 0 DATE

USE ONLY T.p alS 3v4(,C . o 1W-.PRB4flD ON RWYCLEDi PAP;A I

MCIFORM 241 (I-100 'l I ' '-47) Id) U' - .. . _ -,

Sent By: K; 41 06652074; May-15-03 14:03; Page 10/10

NR~C FORM 241 U.S. NUCLEAR REGULATORY COMMISSION APr-OIWED BY 0MB3: NO- 3150-0013 XIE:072lf0Esiimwaad burden Per masponsa to comply with this artiodutory collioiIonreutiLst: 15 mim aes. This notIfloallon la remquird so that NRC mays=hvdule Inapection of the ativitl= s to ensuru that they are snducte4d In

acoordanco vwtI requirements for prDIOteCto Of the PUblIC 114l1tl and

REPORT OF PROPOSED ACTIVITIES IN r fe". Sen cornments r rdina burden estimate to the RcorfdSMarnang Drnc oo Nuolear Regulatory CommissiIon,l\I s ingron, DC 200 ,o yId tV4ml ~IQr~o,

NON-GREMEN STTES ARES O EXLUSVE nd to tira Deck Offloor Office of Information antd Regu story. Affahr,NS-10202. (36-dI1 Office of manotpernant and Budget,

FEDERAL JURISDICTION, OR OFFSHORE WATERS G.0n,9on, DC 2OSO. It S mefnS uced tOiMB an Informalioncollsotlon dosntdslyacurrently valid MBcontrol number, Ilhe

(Plevse road the Instructions before cornplutna this form) NRC jty not conduct r sponsor, and a person i not required io

1t NMEOFUICENSEE fwnrempmpengecUieclyrsa a.wibcdboWr) 2. TYPE OF REPORT

Krueger-Gilbert Health Physics, Inc INITIAL L] REVISION Y CLARIFICATION

i. ADDRE OF LCCNM (MaRM w other locatiov WAw liveaw m.l ba ted) 4. UCENSCE CONTACT AND TITLE HealthMalek Daneshvar PhysiciSt

3601 E. Joppa RoadBaltimore, Maryland 21234 sB. ToEHONE NecnR 6.F ACX1MI5 ENUMBER

410-665-5447 41 0-665-20747. ACTIVITIES TO BE CtONDUCTED UNDER THE GENERAL LICENSE GIVEN IN 10 CFR 150.2D

D WELL LOGGING LEAKTEST!NG ANDIOR CALIBRA71ONS D TELETHERAPYAIRRADIATOR SERVICE

I] PORTABLE GAUGES OTHER (Specify ;=

REGISTERED AS USER OF PACKAI<ING (CExflFicA1tS OF _OtiPUACE NuM BERS)U RADIOGRAPHY >4>

8. CUENT NAME. ADDRESS. CfTY/GOUN'T. STATE. ZIP CODE: ACrUAL PHYSICAL ADOFRES OF WORK LOCATON~~. 11wd Nwtrnhafo!hrk'tlt~f. GShee comtpe*l. e aarea o:rdhutw eoaulblJo

Delaware Diagnostic Service, Inc. same as #8Community Imaging Center:1941 Limestone Road, Suite 214Wilmington, Delaware 1988 8 O

10. CUENTTELOHNE WlUlEU 1 WORK llCTON TELEPHONE NUM8ER(AelW9 Al Cod.) friaree ArmI Ceej

302- 892- 6200 302-892-6200

12. DATESCHZDLEG 138 NUMBEROF 1AD 8 18. LOCATION12WAE CH~LDj ORK DAYS ADD DELr.EE RE"RNCS MUMBElt

FROM T NUMBER TO BE_________________________|_ rASSIGNED BY NRC

LIST ADDITIONALW ORK SITES ON SEPARATE SHEET S) TO INCLUDE ALL INFORMATIONCO1 AINED IN ITEMS S.16 ABOVE.

17. ST RADIOACTIVY MAMTRI~AL WNICH WILL UNEPSSES$EO, USED. INSTALE3.L sERVCZD*, OR'STEDr~ ."rj ecDon of tpr fe endqrlr~Dndeulfrn ,ner., a*esiedutrc.A, oraere to Se u:ds)

Cs-137 ICN MLD-01#309389, 25OuCi (11/23/87)

Cs-137 NAS MED 3550 #A7380, 182.5 uCi (11/1/97)

1A. ACRIf TATE SECIEIC UCF!NSE PWICH AU7HOReES 0 IDAS TO CLNDUr |ICENSE NUMP STATE |PIRATION DATEACnRIM WIH ARE T AML EXC FOR LOCAUTlN OF 5S IEZ IN l^ 5. I , IAOVE. 1/30/2003

19. CERTIFICATION (MUSTBE COMPLETED BYAPPU>CAA1)1, THE UNDERSIGNED. HEREBY CERTIFY THAT:

, All Inf ormnation In Inin report Is true and complete,

b I have read and understand the provt~lon of Ile general license 1D rFRISO.20 rapiIntad on the instructlonl Dtthis form; and I understand that I am

required to comply with thest psovlslona a to all byproduct , aourco, or sp4ilal nuclear material which I possets and use In non-Agreement States or

offshore waters under the generst license lo? which this report Is fl ed with the U.S. Nuclear Regulatory Commission.

c. I understand that activltles, Including storagfe, conducted In non.Apgrtement Stmtnu under general lIcens* 10 CPR I BO.20 are limited to a total of 180 daysIn calendar year. 'Mtl the exceptlon of work conducted In of-shore waters, which Is authorized for in unlImIted perIod of time In the calendar yesr.

d. I understand that I may be Inspected by NRC Bt the above listed work sIte location; ant at trne Icenee home offIce address for activitIes performed innon-AgrtemtlNnt Statet or oftahote waters.

-I uJnderstand 1that conducta of any actIvItIes not desctibed above, IncludIng eonduct ot actvItIes on dates or locatIons dIferent from those descrlbedsbnr.' t hr wIthout NRC authorization, may subject nne to enforctmerrt actIon, inclurt; civil or crlminpi penaltIes. f

C~WtrdG F~ER - RSO er Mg arsue nt Iiaprosanttfvo (Mnwm andl TI0.) ao Nc' FYTN(t -MPrP

-

WARNING: False statenents In this otiftificate arrts be subject to c~VI~ndlor enrninal penaloes. NRC regulations requir mhatsurlslons. tothe NRC be complete and accurate In all rrmterLal respects. 18 U.S&USection 1001 makes IWa criminal offense to make a wifliully falsestatenent or representation to any department or ugency orthe UnIted States as to any matter wIthin ItsJurlfdiction.

FOR NRC IREVIEWINGOFFiCLAL rrypttradmand T71w DATE TOTAL uSA DAYS TO DATE

USE ONLY [ P a X' -w--A, L' 4 7tLs _

NRCFORM241 (7-19K

(p,FIWTrw UN KLa;rs

eAr- V � rsqatiP At t-�t erE ear DED

Sent By: K;

. FOR 24gm.9A

4106652074;

U.S. NUCLEAR REGULATORY COMMiSSION

REPORT OF PROPOSED ACTIVITIES IN

NON-AGREEMENT STATES, AREAS OF EXCLUSVE

FEDERAL JURISDICTION, OR OFFSHORE WATERS-i -_ _ o-- l iUofll ramDkef/na Ihis form)

Mvay-15-03 14:02; Page 7/10

APPROVED OYO MB: NO. 316"0-Sl ri:u3as'~1 ~ n~ d bur entn wmn p y wffb 1hi nm nr II V c lc iiad n

rua elt Q i~n ta. *T~n , tffcsl onIs taq~rsd no thatl NRC nm yshftIrmpentlo(n Ur the usIovltlm t mmurt e ihy fire Wniuda ta

movaonlero wfth requirementsi tr Protetonl of the Puiblic hiellth mind

safety. Sernd cammenis reo rdnO balarti) mummte to lile RecordsMan~ ene t ruicl ~ EE . .S Nuolear Rau llory, Commiasian,Wuat rrPC C~DO , orbvl, ntarril8'-nmi~l

t o lb~,Ai rc.ov,and O lice Offsa O ifl~t~ atIofl and Itopu a woy Aff a a~.N E O B 1 0 2 0 , ~ i O - o i a ~ . O ffl n of M ai an rn a fit O r d a u d g u t,

Waebr~lfl~ 00 2~ D ~ a m ar3used to irri ose an inform uuot%'coleot~ f do s lab db pht a aui un y v lW OM B cantral rum tar. theN R C ay iot ond ci o sp nsor urd a p er uo i Is not req u ilrud tIi

~re~~~ilet eathys~s IcINMAL F1 REVISION __CLARIFICATION

3601E. opp2~oa 1fl4 rA2C~~f'Health Physicist

BaJltima-Xe, m~aryl~and 21234 ~~ AI~UE

410-665-5447 04 -665-2074

7. ACTIVITES TO BE CONDUCTEDUNDER THE GENERAL LICENSE (3rtIN IN ID CFR 160.21

DWELL I.CzGING LEAK TESTING ANDIOR CAUBRATIONS D TFLETHERZAPoYJRRAOIATOR SER1.1CE

D POR.TAOLE GAUGES. o THER i(Specif:V _ _ _ __ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _

G2ITV= ASiUSWR ClfPA~CKA0NQ(Va1WICATM Of COMPUANCE NUMeE0a)

D R A D iO G R A P HY - R_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

B cu~e Tr NAtAL AaD przs, Yicrr U IY, STATE, Zip~ .A1 A.Pt ~ b -DDE B 1 O 1iVO 1bK 0 CAI1D

Habib Boluxtchi, M.D. (an~s~8

4'503 XHIg-hway 'oneRehoboth, D..E. 19971

* ~0 ~ &~HON2 UM0II. W ORKLMATlOt100 .&B ONE NUMBE..

30.2-645-7671 F30f2-645-76711.NUMBER~ OF `14. ii *i. L.OCA71ION

IZ- DATES SCH=tL R AY=D P1.rm REFEUNCE NUMBER~

LIST ADDITONAL WORK SITES ON SEPARATE SHEFT(S) TO INCLUDE AIL INFORMATION-CONTAINED IN ITEMS 0-46 ABOVEL

17. LIST KADMAt7T1VE MATIDUAI., WhIJ= WILLM. U PO8Mh~IS, URMD INXTALI-RA MWICIM, OR T==t

#MwAM w~da mpdai erbs's andASWUV' ?E 0F1U&0eV- Wf je AGSW& d*M Ar" ~as W bo ~mud,

Cs-1 37 ICN MrLD-01 #30938 9 , 250uCi (1 1/23/87)

Cs-1.37 NAS MED 3550 #A7380, 182.5 uCi (11/l/.57)

A W TA 7 licD1Sm NutAB STATE EXPIRAflON DATE

A VVL CH Al05 10E 91W L6

/0/2V0- 11. O MII5,LLA1IN .malJm " Lumhm I e.'J

ITHE UNDSMRBIOIW, H!RUY CURTIPY THAT:

IL Al Infrmtioon lIi tImls, rapit Is.ftre and wDMPlete

b Iha e adand understand the ProVtilof of nt~ general limene lo cpR 180.20 raprlnled -n the umtucvdon ofti fo m n I undA utan thIt " Om

b, I u he rd toc mwltt a provisfrm as ato all bypraduc4 sourct, or apracia nuclear trinaruhel whic~h IlPORLae and use In nonAt IUl St eso

offahone wmte untdarfthe Ven"n~ license for whIch this repal¶ Wfiled With 1110 U.S. Nuclear ReputniafY COmmS~

c. I understu etha tactivities, Intludlfg stenhga, jOfdueM In flur.Agft Mhif SW =in under gmefeul l1cmnse 10 CFR 150.2D t m st oa oft10cy

in cae1na.r year. With the exception of work wnfducted In of-shore waicre, whchiti k uthatuAd lot an wiIlrafltad period ofthria In Ithe calendmryaar.

. lunderstnd thati maYke inxPechd by NRCatthie abovb h edwork site o~tlons cnn tIM i? censeehome oflce s~lnr oiradictlv OSptllonmad I

liar)Agrieleflt Staev at offshore walemS

I Underaftad that CrntdUd Of any adctttma riot U.acribe4 mbovs, Incudmino conducd of meivtban on datat or iocutions different trom those oescr~bed

above or vothout NRr, awthortzatiot. may subject met to enforcetmat nction. lntiuc~v IdVII or criminal Penuiltas.

ASOl or M ii . L.AI..*. m

hins UIjftEZIOdS t

I

WARN NG: alim stwitements lin oft or tlmfic=10mnltiy be subject to t'flkodtar cr~rnmat pn~ b. nrt-y u

ututvnont or representuton to any dePzfftme`l or. agency of the Untted Stata as to any matte withlin It ju isdclienfl.A

USE ON LY -, .~J0 O ~ 0~ P P

pe.J.WM jwaIRWV h' PAM

r4KU; FEW, m1 -lI . . ... 1. I kJ

Rpnt Pvx- K- 4106652074; May-15-03 14:00; Page 4/10OU11 g

NCFRM21U.S. NUCLEAR REGULATORY COMMISSION AP90,VED bYrd OMfl: No. 21850-0013 EXPIRES: 0741i202

ruquest 16 minu,. ss.`esr= `Wn I. squired o Iha NRC amay

.adus Inspection of the ACt ls to encurc tha they a3r oOnductnd tn

: nssocrtanwo with roquiremetria for prolsollont of Ins public hezlth sn I

REPORT OF PROPOSED ACTIVITIES IN ntt aend e t in1eSrdif budrde stimate °t the RecordsMatnagemen Broic (T8~UA Nucler Reguimoy. Camfnmislo"VilE Wiuhittglfl DC 055- l or by l nterrrmt e-maIl to bj al rgov.

NON-AGREEMENT STATES, AREAS OF EXCLUSIVE awnthre ndek Officer. Off20 e of lnlornation and Rgulstaor AftiarNECB-10202 J3150-00131, Office of Manatoorient and Budgjst.

FEDERAL JURISDICTION, OR OFFSHORE WATERS Washington25 2s05. ° a3nearm u¢sd to iposean informatlartcatleelon does rsct display a currentlyvalitd OMB confrol number, t16

(Plewse raad the InstructIons before complialng this form) NRC may not conduct or sporaor, and a person is not required to

1= NAME Of LcSA (PWV00 W ff/M Pmpo-v to cmnu 1 gm ac*Th0a d;%a bewj 2. TYPE OF REPo T

Krueger-Cilbert Health Physics, Inc INITIAL REVISION CLARIFICATION

AmssOFuCrNsEE (iti l' r w hy bW 4. UNSEEOOTACTAND TITLE

3601 E. Joppa Road onna Thim 'Health Physicist

Baltimdre, Maryland 21234 -fbTEaMIiF teC M /F/ACO E NUMBE

410-665-5447 1410-665-2074

7. ACTIVTIES TO BE CONDUCTED UNDER THE GENERAL LICENSE GIVEN IN 10 CFR 16G0.20

D WELL LOGGING LEAK TESTINGAND/OR CALIBRATIONS C TELErHERAPYiIRRADIATOR SERVICE

PORTABLE GAUGES O 0THER (Specl t _

PEGtSTERED AS USER OF PACKAFING (CERTIFICATES OF COMPUAk4CE NUMBERS)

F7RADIOGRAPHY ________________________

& CUEN NAME, ADORESS, ClTYICOUNTY, STATI. ZI COD D. ACTUAL PHYOCAL ADDRESS OF WORK LOCAM_

Milford Memorial Hospital same as #8

21 W. Clark AvenueMilford, DE 19963

10. CUFRTWPlS E NUMOER 11. WORKLOCATIONMEPHONENUMBER.rq Ci d. (k64 Am o-

302-422-3311 302-422-3311

1.DTSSHDLD13. NUMBER OF 14. is. j 16. LOCATION12. DATES 5CHEULED |1.N DAYS ADD DELETE REFERENCE _UMBLR

FROM To NUMBER TO B

. l7O/3 | . | AS/NED BY NRC

1S4 J)3 .// & ,o 0

UST ADDITIONAL WORK SITES ON SEPARATE SHEET(S) TO INCLUDE ALL INFORMATION CONTAINED IN ITMS 8-16 ABOVE.

17. LIST RADIOACTIVE MATERIAL. WHICH WLL BE POSSESSED. USED, INS7ALLED, SERVICMD, OR TESTED

pneldt aerWtJ ertyp SlQd anmyUV orm"Mneaw.nw sawdsovr, erd5yorl w o ha &a ac)

Cs-137 ICN MLD-01#309 3 8 9 , 25OuCi (11/23/87)

Cs-137 NAS MED 3550 #A7380, 182.5 uCi (11/1/97)

STATE SPECIFIC UCENS Lfl4 E lA NESGE 0COARE TSEE TICE UNDERS. 0 s CRrDUC | LICENSE NUMBER |TATE | PIRAT1ON DATE

A lvriwWHICtl ARE THE SAMMEINWHTW ON OF USEA PS PECIRlED IN S. I 0

ABOVE fFouTCps cffe sp. lo mmt acco slrerfa the Uff r IFo 241F) - 5- 1- 6 / O / 20 3

1S1.1.r.MJ I JW11 IM16f- I �� -- - ' ' -- ' -- - - I

i, THE UNDERSIGNED, HEREBY CERTWlY THAT:

All Infoainrt on In this report Is true and complete.

b I have reed end understand the provilon of the general l1cense 10 CPA 180.20 reprinted on the Instructions of this form; and 1 understand that I am

required to comply wIM Itese provisions as to all byproduct, source, or upecinl nlucIer material whictt I possess and use In non.Agreemtmn States or

otfshore waters under We general license f1rwhich this report is filed wlh the U.S. Nuclear negulatory Commrlislon.

c. I understand that activitles, including storage, conducted In non.Abratmant States under general lIcense 10 CFR 150.20 are l1mitd lo a total of 0 Dodays

In calendar year. With th. axceptbon Of worh Conducted In otf-short waters, which Ls authorized for an unlImited period of time In the calender year.

d I understand that I may be Inspected by NRC: t the above lsted work aste locatons and at the Ucensee hbonme orice addrees for activIties performed In

nongreemurt states or oft hoce waters.

g. I understand that conduct of any acUvItIes not deacribed above, Including conduct of ecthl~vts on dates or locations different from those described

above or without NRC tuthorliatlon, mey subject me to enforcement action, Includ civil or criminal penatties.

CERMFYING OFFICE RSr1 nd 77W SiXr £ lim a T O RE

WANIN:False xtatements In this certificat' may be subject to c I ndlor crimina pens es. NRC regutat uim I .t xubm-ssonS to

tha NRC be complete and accurate In all muterial respects. 1R U.S. t ectlon 1001 makes a criminal offense to make a willfully false

statemelt or representation to any depftffant or agency ot the United States mg to any mraner wlthin Kts jurIsdiction.

-- I-OnNATlJRF A -. DATE TOTAL UsBAAjAYS TO DATE

FOR NRC IREVIENGEOFFlICAI. ir. ... ~usUSE ONL -,K =--H NP m\Ld I 440

� 1 J z/ 0. = ON PAPEFI

NRC FORM 241 (7.1r9 &

Sent By: K; 4106652074;U.S. NUCLEAR REGULATORY COMMISSIONNRC FORM 241

.1(7IM

REPORT OF PROPOSED ACTIVITIES IN

NON-AGREEMENT STATES, AREAS OF EXCLUSIVEFEDERAL JURISDICTION, OR OFFSHORE WATERS

i. e a who Instryfion~s hafarD cormnpflona this form)

May-15-03 14:03; Page 9/10APPROVED BY 0MS: NO. 2180D0012 EKPIRES: 97J31i=flfEctffrwundbijrd~ or rearrmi to compl4y wfth IN. n'wdaft c09flI0On

igmTIsnottflostlon is required so that NRC MAYiria.peclor of Inae aca4ttz in enaumeta they mu tnthU*d In

acoartignc wit h roultomentu for PreOlaub" Of the Publ~ haalth andsufety. Siard DorniMarrIig T rding byrdan eathimal to Iat Rwoords

Wm' e ti l~~nn~c ,US Nimlaur Repuiatory cotniusalon.VV N," R 2 6 , Irteryniemt .- mnidl to br1@nro-gov.

Ba~d to he D~ank Offic-sr. Cflia of wnormation ancf Requ xaary AIairm.NEOB.-1020Z, pi15O0C0i3) ofrios of Manopsmrntand udaWashingtno1n, ioc 20503. If mealr iedito rmol anoualladion doe. not diaptiy a ourrntly vaid OMB colral rarmbez, lhe

F*C ayfb conduct or sonaor, and a person Ls not required id

1. NqAME oF u ?3C Pi- A7'NU.0STUM~ 2. TYPME OF REPO

Krueg exr-Cilbert Hiealth Physiacs, Inc INITIAL L7 REVISION CLAR[FICATION

1~A0DREESOFUC(Wt.gJ44Eh Fobot~brJi., aMJfd 4. UCgN= co7CT ~AND TrrLE

3601 E. Joppa Road i47&c2$/e .tPhsisB a.Itimr ~er Maryland 21234

7. ACTIVITIES TO BIE CONDUCTED UNDER THE GENERAL UCENSE- QIVEN IN 10 CFR ¶50.20

DWELL LOGGING LEAKTE-s-lING. ANDIOR CAUBRA-noNs .TELETHPRAPYARRADLALTOR SERVICE

PORTABLE GAUGES OTHERI(Spectfy) ~ ________________________

REGISTMIE AS USM OF PACKAGING (CT1FICAT; OF COM ANCE NUMODRw

Li RADIOGRAPHY __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

8. CUIE47 NAME. ADRE, CrYCLJY TT PCD . ACTUAL Pt1CI ACRlS FWR LC7O(Ef~twiJsd M~nwc mise bew) m C" . G =r R~wpj0M a Aflddf0ilO VROU Aitdin &~PDUh)

The.Cardiovaz'cular QGroup, PC. Same as 8

130 Pak'Y'Street, ..S.E, -Suite 100Vienna, Virginia ..221 80

* 10. =~TELEPHONE NUM6ER Ii. WORK( LCJCAMON11~.WONE NUMBER

7-03-281-1265 703-2B1-1265I.DT&SMUL)12. NUNME OF iL. its. IL I.CC.AT1ON

VMAAES5MDU~WIK DAYS ADM DELLT MP8EMtNCE NUMBER9

Ut¶ AnbIffIONAL WORIO M!S NSPAWA!SHI-IETI&TO INCLUE ALL INF0RMA1ION co rAJNED INI"MS 3-15 ABOVE,

17. USjjATKACT1Vz mATmxL41-. WI4IC14 WILL 130 POSSMBSM, USED. DIXTALLED, SttRlCI, OR~ TESTED

fin.*M. aw o~~efpl oet, ad z'of lswadsorUo ffwW $a& maimsw or dwm.4 tabs tmsdj

C6-137 ICN MLD-01#309389,: 25OUCi (11/23187)CS-137 NAS MED 3550 #A7380, 1 82. S uCi (11I/1 /97)

1C ItAI~1 fL1M ~ LL CEN±MJ NUT ArJ1JL10JYI)

I, THE UNDEMOINED, HqMRM CZKT)`Y TMAT:.

'All Informnation Iin IjtW report Istrue and compitlL

b. I rum vx td and understxnd the provision of thm general liceselIO CFX 150-20 ruprire don thoInstrctinsof lSthis form; andiundwirond thatlIarnrequired to comply wftfu mesa provisions as to all byproduc¶ source, or specila rnutlmar mebtrial wticll I possane and use in non.Agrbalimat swa1s or

uffahore wrterja under theC genaral 11cenma for witich Ihis report Is fliled with the U.s. Nuzlear RAsulirtory Commission.

I understand maI ac0Yitlo, lncluitngf stomMU~ toda~ucftd In norr-AgremWiet Startes under getteral] llcanne 1 0 ClRf 1ISO= ame limitd to a total of 180o days

in cmlandnr year. Wltt the. exception of work courtduted In otT-shors Wutorr, which Ia a uthorizod for ane unlirmitad period ofllume In the calendar your.

d. I understand that I may be inspected biy NM~ at the above 11Itad work aft& locations and at the LUcensee home office addresn bor acomtes pertormad Innort.Airramwltlt awets or offshore vateS

I underStarid trat conructu of any scilthrtles niot described above, Indkurdng conduct of malyttle on dates or loadjorne dtirroerd fromi thwoe doerthbed

above or without NRt aulimorbtiztonl may subjsct tne ta entaremoaint ction, Including civIl or crlminalnnlnaltles.

cERT$YINE ow=ICR - n2O or miniow en ttoph"Muow 5 hoPnd 7XW I X0AURE

WARJ'fNO:- Falco ttunrt In this Cewlfficate tirra be subject to c I nxDlr criminal pwit ~m NRC rogulatiofSruie ans MtoMUZ I

~the NRC be cornplate aridac teirt Iin all mi~tflial rosSpects. 13 U.S. ectl~on ¶00.1 mtakes ta crk-Anal oftrise! tDi makte s U 'iuuly taise

Lataternent or Tepreserttactlin to anY depanienet or agency Of the Ulnftbd States Uston any rratter within ft slrlsdidition.I AnIOAT rIM~AL UaS.E -DAYP T DTE

I

FOR NRC I ~;L- (JPafl~ . I\ j1Fntm1VFfJ) __\ na t \ b B--- IfUSE ONLY I .L~ Fly N SPAiRC FO~iM 241 [7-'DW ... ::.. - 0 A ( to..

Sent By: K; 41 06652074; 6May-15-03 14:02; Page 8/10

NRc FORM 241 U.S. NUCLEAR REGULATORY COMMISSION A=PO" B nsB: to 5 rp0-C013 is : 01120

7rsreMust: 15 mias. onotItctn Is reored so iht NRC may

n~iiedul' lrmpM1lo of the sotaff A to ensure tla toy srs oonducted in

necordantm with requirements for proteotion of the publig heesit mud

REPORT OF PROPOSED ACTIVITIES IN aaty. Stand mrrtasnhrdtin burdsn estimate to thne RrcrtiaMane ment runchNucloor Regunlotoy Commissioin,

STATES, AREAS OFDEXC0US -OO0 o r byItrntsmll tola~rim~ov.

NON-AGREEMENT STATES, AREeAS OF EXaCLUSIVE fhd VDk i cOft lfOInfortmon fld Requ ary. Affairs.

FEDERAL JURISDICTION, OR OFFSHORE WATERS Wash (r1SODC263. ifOm omeans ued inmont nfrd

.oOloctlton doe not ditpiay a ourrefftiy valid OMB cantral nubet, the

(PleasB resd the Jr"sructifons before comp/lIng this form) NRCe mynot conduct or paonaor, und a purson IR not required tore-p-nd to the InfoPnratio c. IedtoT.

ia N.A-M F U (Pwwm w km io cwneducf U1w scOM, davoihad bmfaw) 2. TYPE OF REPOJT

Krueaer-Gilbert Health Physics, Inc - INmAL REVISION CLARIFICATION

3. ACO=M Or LICENSEF fMs/inG addr aortIA'oei whrs ficamseya. octdJ A. UC04SM CONTACT AND lTILE

'-7L L4t17 ./Health Physicist3601 E. Joppa RoadBaltimdre, Maryland 21234 T FME NiiM9FR

41 0-665-5447 14065277. ACTIVmES TO BE CONDUCTED UNDER THE GENERAL LICENSE GIVEN IN 10 CFR 160.20

3 WELL LOGGING 5 LEAK TESTING AND/OR CALIBRATIONS T.TELETHERAPYARRADIATOR SERVICE

D PORTABLE GAUGES D OTHER (SpeSciy) _

D RECLSTERSD AS USER OF PACKAGWIG (CMRnFCATES OF COMPUANCE NUMERS)

LRADJOGRAPHY '

8. CUEN9T NAME, ADRZESS. CryiCOUNT, STATE ZIP COO L. ACTUCL PtrficAA ADDREss o~vonK L0cATo0.f~l *d ve r rro- b Os o r dcpt~b an a' ) r w-dan S

American .Medical Laboratories, Inc a

14225 Newbrook DriveP.O. Box 10841Chantilly, VA 201 53-0841 la. =T8NCENUMQR 11. WORK LOCAlNTWHONR NUMBER

AP (usdCo*w Aictws Am o)

703- 02-7120 70 -80 -7

12. DATIs SCHEDULED 13. NUMBER OF 14. t 4 16. LOCATION2.ATSSEDLDWORK Ds~ ADD EEMRZFWRECE MJMBERt

EROM TO.. .. NUMSERTO LE

LISr'AOMQNAL WORKISITES ON SEARATE S HEET(S) TO INCLUDE A INFORMATION C NTAINED IN ITEMS 8-16 ABOVE.

17. LSTr RAMIOACTM NATEtL. WHICH WiLL BE POSSESD. USED. IMSTALLED, sE0VCED, OR TESTDpnud derar/p~on oIW* andqUl 0f, O rt*'MK jamd &,wtIZ ardeo* ro1e used)

Ct-137 ICN MLD-01#309 3 8 9 , 250uCi (11/23/87)

Cs-137 NAS MED 3550 #A7380, 182.5 uCi (11/1/97)

16.' AO EEMMSSTATE C LI 40!A UCC; NUMBER STATE I EXP¶RA7 0S DATE

AC-vs V W11M A Ee, FO L&ArSATMItAn I

ABOVE. (Frrctles00.elCI l~~cmn 1 IINC~21) ID0-0-O MD 1 6 /30 / 20 03

Ili. LrM11rJV^1 4kin livlu�l "_ -", -, __ - . -, ,

I. THE UNDO.SIGNED. HEREBY CERTIFY THAT:

All IrforrnatIon In this report Is true And compItte.

b. I have read and unoerstand the provision of ts. general licens. 10 COF 100.20 reprlned on the Inatructionr of this form'T atnd I understand that lam

required to comply with these proviaions as to I byproduct, Sourre or epecial nuclar material which I poexss and use In nonrAgratmnnt Satesor

oafthrv waters under the general licens ftoer which this report Isl1ed with 1n* U.S. Nucler ReguIatory Cofmmizion.

r I understand that activities, Including storage. conducted In non-Agremnt Stste under genrnif license 1 CF'R 1S.20 are lmined to a total of 180 days

In calendar ynar. With the exception of worlc conducted In off-shora waters. which u; autnortzed for an unlimited perlod of dme In tle calendar year.

d. I undersund thVt I may be Inmpeclad by NRC at the abovre listed worK sTe locnt~ou and at the Lickrnue home office address for activIties performed In

non-Agreement States or otfshore watern

I understand thet conduct of arty activities not described above, Including conduct of activitits or dat or locatlons dMTrent trom thoia descrIbed

above or without NRC authorlzation, may sub act me t enforcernnt action, InclrdJg clvil or cr iriln" pinalllh5

COMT1FYV3 O 3FR ASO or MargaSment R~prafenttRnim OM and I7U* M GDA

WARNING: False tatemrnts in this certifcate ray be sabjtct to c I nd/or criminal pa s.1 NRC regulatlonf require Ut sI SiORS to

the NRC be eomplete anld accurate In all rnuteriul respects. li U.S.t motion 1001 maXes JV9 critinil offer to m-ke u willfuly fale

itnwnarnt or representatton to any deparbilent or agency of the United Slates as to any rnftter within its jurisdiction

FOR NRC < h lG II land i bgNATh | DATE |TTL UsAGE -DAYS T O DATE

USE ONLY 76I- Tte i..- _

NCFORM 41 (7gt9 I.. . Q