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NRC FORM 241 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0013 EXPIRES: 0713112002 (7-1999) Estimated burden per response to comply with this mandatory collection
request: 15 minutes. This notification is required so that NRC may schedule inspection of the activities to ensure that they are conducted in accordance with requirements for protection of the public health and REPORT OF PROPOSED ACTIVITIES IN safety. Send comments regarding burden estimate to the Records Management Branch (T-6 E6), U.S. Nuclear Regulatory Commission, NON-AGREEMENT STATES, AREAS OF EXCLUSIVE Washington, DC 205 5-0001, or by internet e-mail to bisl @nrc.gov and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0013), Office of Management and Budget, FEDERAL JURISDICTION, OR OFFSHORE WATERS Washington D 20503. Ifa means used to impose an information collection does not display a currently valid OMB control number, the
(Please read the instructions before completing this form) NRC may not conduct or sponsor, and a person is not required to respond to, the information collection. 1. NAME OF LICENSEE (Person or firm proposing to conduct the activities described below) 2. TYPE OF REPORT
LAW ENGINEERING AND ENVIRONMENTAL SERVICES, INC. [ INITIAL [] REVISION [] CLARIFICATION 3. ADDRESS OF LICENSEE (Mailing address or other location where licensee may be located) 4. LICENSEE CONTACT AND TITLE
4919 WEST LAUREL STREET JOHN R. GREGOS, JR., RSO TAMPA, FLORIDA 33607 5 TELEPHONE NUMBER 6. FACSIMILE NUMBER
(Include Area Code) (Include Area Code)
813-289-0750 813-289-5474 7. ACTIVITIES TO BE CONDUCTED UNDER THE GENERAL LICENSE GIVEN IN 10 CFR 150.20
D WELL LOGGING F- LEAK TESTING AND/OR CALIBRATIONS D TELETHERAPY/IRRADIATOR SERVICE
PORTABLE GAUGES E- OTHER (Specify) -4>
- RADIOGRAPHY 4> REGISTERED AS USER OF PACKAGING (CERTIFICATES OF COMPLIANCE NUMBERS)
8. CLIENT NAME, ADDRESS, CITY/COUNTY, STATE, ZIP CODE 9. ACTUAL PHYSICAL ADDRESS OF WORK LOCATION
SUNSHINE CONSTRUCTION (Street and Number or other location. Give as complete an address or directions as possible.)
620 ATLANTIS ROAD MACDILL AIR FORCE BASE, FLORIDA MELBOURNE, FLORIDA 32904 ENTIRE BASE AREA
INITIALLY-SMALL ARMS TRAINING RANGE
10. CLIENTTELEPHONE NUMBER 11. WORK LOCATION TELEPHONE NUMBER (Include Area Code) (Include Area Code)
12. DATES SCHEDULED 13. NUMBER OF 14. 15. 16. LOCATION WORK DAYS ADD DELETE REFERENCE NUMBER FROM TO NUMBER TO BE
ASSIGNED BY NRC
FEBRUARY 14, 2000 DECEMBER 31, 2000 180
LIST ADDITIONAL WORK SITES ON SEPARATE SHEET(S) TO INCLUDE ALL INFORMATION CONTAINED IN ITEMS 9-16 ABOVE. 17. LIST RADIOACTIVE MATERIAL, WHICH WILL BE POSSESSED, USED, INSTALLED, SERVICED, OR TESTED
(Include description of type and quantity of radioactive material, sealed sources, or devices to be used.)
CESIUM 137, SEALED SOURCE, NOT TO EXCEED 10 MILLICURIES EACH AMERICIUM 241, BERYLLIUM, SEALED SOURCE, NOT TO EXCEED 50 MILLICURIES
18. AGREEMENT STATE SPECIFIC LICENSE WHICH AUTHORIZES THE UNDERSIGNED TO CONDUCT LICENSE NUMBER I STATE I EXPIRATION DATE ACTIVITIES WHICH ARE THE SAME, EXCEPT FOR LOCATION OF USE, AS SPECIFIED IN ITEM 9. ABOVE. (Four copies of the specific license must accompany the initial NRC Fom 241.) 164-13 IFL I 8/31/2004'
19. CERTIFICATION (MUST BE COMPLETED BY APPLICANT) I, THE UNDERSIGNED, HEREBY CERTIFY THAT:
a. All information in this report is true and complete.b. I have read and understand the provision of the general license 10 CFR 150.20 reprinted on the instructions of this form; and I understand that I am
required to comply with these provisions as to all byproduct, source, or special nuclear material which I possess and use in non-Agreement States or offshore waters under the general license for which this report is filed with the U.S. Nuclear Regulatory Commission.
c. I understand that activities, including storage, conducted in non-Agreement States under general license 10 CFR 150.20 are limited to a total of 180 days in calendar year. With the exception of work conducted in off-shore waters, which is authorized for an unlimited period of time in the calendar year.
d. I understand that I may be inspected by NRC at the above listed work site locations and at the Licensee home office address for activities performed in non-Agreement States or offshore waters.
e. I understand that conduct of any activities not described above, including conduct of activities on dates or locations different from those described above or without NRC authorization, may subject me to enforcement action, including civil or criminal penalties.
CERTIFYING OFFICER - RSO or Management Representative (Name and Title) SIGNA /C L/ DATE
JOHN R. GREGOS, JR., RSO I --- W e O WARNING: False statements in this certificate may be subject ivcivil and/or crimipd niealties. NRC regulations require that submissions to the NRC be complete and accurate in all material respects. 18 U.S.C. Section 1001 makes it a criminal offense to make a willfully false statement or representation to any department or agency of the United States as to any matter within its jurisdiction.
FOR NRC REVIEWING OFFICIAL (Typed/Printed Name and Title) T E
USE ONLY INRC FORM 241 V7-1999) PRINTED ON RECYCLED PAPER
Y UU -- r-.RII - . .....
• ... ...... .. • : .1 -- •Wi 11 1 -.. :.• I::17 "?.'•, : :::;E: EE E E ]~ • i• i:ii
............., " ...... IDA::::: : ! i ' . i. - ;;•:: '1 1! •i ]• !!• :iE F • ii• ; ;i•3 iii i•i
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77,,
RADIOACTIVE MATERIIALS LICENSE
Pursuant to Chapter 404, Florida Statutes, and Chapter 54E-5 ,Fl'1da AomInistratiye Code (.A. C.), and In reliance on statements and
representatlons heretofore made by the licensee designated, below, a icehse Is hereby issued authorizing such licensee to receive,
acquire, Oossess and transfer the radioactive material(s), designaied betovw andi to use such radioactive material(s) for the purpose(s)
and at thie place(s) designated below. :This license is subject to• ai. ap li.abie rules, regulations and orders of the state of Florida,
Department of Heatth now or hereafter in effect and to any conditibns apdcified below. I I
Licensee
1. Nbme: LAW ENGINEERING & 4 3 LceseNu". 1.4" •, ,•l, ::• . .b, 3. License Nu brn:. 1 4 1
ENVIRONMENTAL'SE " CEE,, N..,.
2 d~• 49e. L4 ",t. . E"'. ,'" 0 rationDite: 08131/2004
Tampa, FL..S3607 , -:. ' ".. "L'
.. .... .. . ............ .......................
S. . ... . .... ... . :. . ... ..- -...-• , , .,, : , .-.. ...... . . . =. .... ....... .... ..
Cesium 137
Americium 241: beryllium
Cesium 137
Americium 241: beryllium
Americium 241: beryllium
Cesium 1,37
A - .•. : p,, ,v ,, ,
B. rl B.
B ea-lbdi 0l2 , c.
C. d C. Inc. Modei'PN13i1• ,7.,-"
D.
E.
Sealed source.: (CPN4 Int' mational, Inc. Model CPN:-131) i
Sealed source, (Trokxer lectronic Laboratories, Inc. draw h1 Number A-1 02451)
D.
E.
F. Sealed source (Troxler Electronic F. Laboratories, Inc. [,rawihngi Number A-102112) /
T ources; not to exceed 9 millicuries each
7 sources; not to exceed 44 millicuries each
7 sources;. not to exceed 10 millicuries each
7 sources; not to exceed 50 millicuries each
3 sources; not to exceed. 44 millicuries each
I source; not to exceed 9 millicuries
oczn o'1) r,7r4 PiE
A.
B.
E.
F.
''Ii............. ..tt .... ...................
PAGE. 02
S................. ; ............. - ... .. .. .. . .. ... .--L
J
7
I
I ----------..I
I
r L . . .... -, * - ._,
S. ........h ....... ... ........... . . ..... ......... ........ , ....... ... ...........
A. and B. To be used in ",oxier Electronic Lanocat rtes,, In. Model 3400 Series moisture/density gauges to measure properties of corstru ion,, materials or soils.
C. and D. To be used in CPN Internationali, ,nc. Mod:1t MC Series moisture/density gauges to measure properties of construction tats or soils.
E. To be used in Troxler ElectronicrLer,¶ i"i4Mn3216 Seriestdensity gauge to
measure properties of constr6ion or d" Q "'"
F. To be used in Troxler,51,ectr~ , ' I . 0o.del' `B;Series moisture gauge to measure properties, of, co Irist.'-"io -ii:s. '
measure s•t •,eNC r. ... oc............ . .......... . . . . .. . .. ..... .. ... 1 1 . ......
10. A. The authorized placf-. .ýif-aer ~rjb-'Isiei',f, the 'licen see throughout the
iac.,lhsaft.,lempv;ryIeemen state of F.Iorida~,"';Ths.iitInd~ o prl~hli ,qs91'h';'qherý agreemenlt states and stts n ertjuridI 0ca~ea~ Cmission (NRC) under
reciprocityrwh iasbd1 "," prpyotdz, n agrete 4 &teQihe NRC. The auth'ried "aity Ated at the address in
B. Th atoie pl. 091 4 's.ad , i
Item 2. , , : ,, : , ,
11. Failure to comply with th re.p'r•qsini riýy0of thethird degree pursuant to section 404. .. Flor,. _ a'•-'"anft an" dministrative fine of up to stin404.161, Florida Stai•te;.a
$1,000.00 per violatiorpe 'day,404. 6T 6Florida Statutes.
12. A. Licensed materials u the'supervision and in the physical
presence of, indiiduals •W$e iipleted a training program for gauge
users accepted by the departme The. insee shall maintain documentation of
training, to include valid trainingi cer tt ,I of each user for the duration, of employment of the individual or 5 years, whi'cheve is •reater.
B. The radiation safety officer is Eric K Bigham.
13. The licensee shall comply with the provisions of phapter 64E-5, F.A.C., Part IX, "Notices, InstructionPs and Report3 to Workers insOectionsr' and Part I:11, "Standards for Protection
Against Radiation."
......... ... .....-.. .
. ....... . , 85 921 364 PR.E._3
The licensee shall not transfer possession, or ohtrol of radioactive material, or products containing radioactive material as a contaminantI t xcept:
A. By transfer to a specifically ficensed! recioient; or
B. As provided o1herwise by specific povision of this license pursuant to the requirements of Chapter 64E-5, F.A.C.
15. Radioactive, material itransported c shipment and transported in aci Chapter 64E-5, F.A.C.
16. The licensee shall assUre thato'aa follow the appropriafe ktih•.a•s:-re shall be tested at least ,semjianb Subitems C and ,Du" ;;''' shý5!b6 taken by the licensee usig 4,
performed by ldorl iW licensing state tQ ,pod Tesf • containing the r-njrnufaures identity of each searediour rgdc each test sampre e•'pres'sed; imIP safety officer or desigoe ,,1tIieo ; department.
"ýqphfwres shall be packaged, prepared for do of Federal Regulations and
forjleal, age or contamination and ,1303, ý.2A.C. Licensed material Adoipt-listed in Items 6, 7, 8, and, 9, fhote6st sample (smear) shall be M,02ofthe test sample shall be
ht.44RC, a.reement state, or !,q'ir,,ed to retain leak test records b9 e.r'eachýsealed source tested, dactivity, tihe measured activity of dstajnd~ilgnature of the radiation ,for .3years for inspection by the
olk, . , , .1 " . , • .• " . 17. The licenslee shall o dauct a,,h .l, . at least semiannually to
account for all sealed dotee anp.L , this license as required by section 64E-5.1304, F.A.G. ve tdrW...rQ, n aiin~ted for 3 years from the date, of
sectionW 64E-5 1304 FA.cdrr' C.namer~ ~ t~i~ the inventory for inspection by the-,1pam •t di•W•1•ude the manufacturer's name,
model and serial numbers of ea4lQd t0 of each sealed source
radionuclide and its estimated activity lloe-b r10f each sealed source, the date of the
inventory and the signature of the radiation safetV 6fficer or designee.
Except as. specifically providedotherwise.a this license, the licensee shall possess and
use ficensed material described;lnl, toAs 6• 7, 8, and 9 of this license in accordance with
statements, representations and pfoceduresi qontained in the licensee's application
dated July 6, 1999, signed by Stu4rt N. H•1shman; P.E., Managing PrincipalAVP, and
correspondence dated: August 24, 1999, co-,signed by Er~ic K. .B'gbam, C.W.l.. Radiation Safety Officer and
Stuart. N. Heishman, P.E., Managing Principal, Assistant Vice President. I '
I - ....... .. ________________
Pl, 921 G3G4
14.
18. A.
..... ......... ...... .... ............. 5 5 ...........•= •. 5 = 5 •
1~l~~r~s ur~i~i,~ ~ P~Yrdd~r~,.;V __.
.. ~~~~~~ ~ ~ ~ . .... ....... .-......
PAGE. 04
1)Ur-j-F1,>L.1\j I
in ? 91% 2z1ffL11ML1ML=" -
............. ...... ....... ...... ... ..........
......... . ...... ............. ... .... ........... ....... ........... ...... ................... ...... .. ..... :Z: :;ttl .............. .......... ............. I I- i. . . . . . .
18 . B. The licensee shall comply with4.a lappi .ca Administrative Code, and these regulatior applications or correspondence, unfess t " regulations.
,ie requirements of Chiapter 64E-5, Florida .s shall supersede the licensee's statements in e tatements are more restrictive than the
V
.1
For the Bureau of Radiation Control
Li6b, Mitchell Invironmental Specialist II
Bln1# C21 2020 Capital Circle, SE Tallahassee, FL 32399-1741 (960) 4851-437
o07 O-D ý 7G;4
Issuance Date:AUtG 31 19
DB
PAGE. 05 1
I
..DEPARTMNfiT OF fHEALTH BUREAU....AD.. ........................... • • ........... . . .
II
RADIOACTIVE MATERIALS LICENSE SUPPLEMENTAL SHEET
LAW ENGINEERING & ENVIRONMENTAL SERVICES, INC.
4919 W. Laurel Street Tampa, FL 33607
With reference to correspondence dated September 21, 1999, State of Florida Radioactive Materials License Number 164-13 is hereby amended.
TO ADD ITEMS 6, 7, 8 AND 9, SUBITEM G TO READ:
.......................... r ; ............ -'.-- ýý;:_ 6ý6ý11ý . .... .. .......................................................... ... .. .... i.ýn oil ....................... ................................ . ........ ...... ..... v o ............ : ................... ............ ....... ........................ ... .
M P At .. .1. ..... T 1ý' a h*0: I .......... y ............. :gnamaston rn...er- _s; I ..... . ......... .... ...... ...... : " ::W_ ...................... 1 1: ............... .... ................
G. Cobalt 57 G. Sealed source (Amersham Corp. G. 1 source; not to exceed Model CTC.P1, X1 01/2 or 15 millicuries C64444, DuPont Model NER-472, Le316 or C43333, Isotope Products Laboratory Model CUSC0057012M3814N or North American Scientific Model CUS0000CO057015OMN)
9: Authorized Use...........
G. To be used in a Radiation Monitoring Devices, Inc. Model LPA-1 x-ray fluorescence spectrum analyzer to measure lead content in paint.
TO CHANGE CONDITION 12 TO READ:
CONDIViONS77 ]
12. A. Licensed materials shall be used by, or under the supervision and in the physical presence of, individuals who have successfully completed a training program for gauge users accepted by the department. The licensee shall maintain documentation of training, to include valid training certificates, of each user for the duration of employment of the individual or 5 years, whichever is greater.
License Number:� 164-13 Amendment No.: 1 Control Number: .990923-1 228
LICENSEE COPY
Page 1 of 2 .Page(s)
Category:[3l)
Expira ilon Date: 08/31/2004
I.
W299MU7=1
I - I
I
1
STiA-TE OF.F.LQRLDA
DEPARTME NT1 OF HEALTH BUREA OF qA IA O CONT.........OL...
RADIOACTIVE MATERIALS LICENSE SUPPLEMENTAL SHEET
12. B. The radiation safety officer is John Gregos.
Forthe Bur iontro:
Issuance Date: 9CT 2 8 1999CCharl es-(W,'46ifton Environ rental Specialist II Bin #C21 2020 Capital Circle SE Tallahassee, FL 32399-1741 (850) 487-2437
icense Number; 641 AmeqndmeplNo,; Cqontrol ';Number*`;1 9:90923:-1 228
LICENSEE COPYý: Category: 3l)
Page 2 of 2. Page(s) EXWiaton Date;VN O83/O.Q4
i!,E • E • :S E # 0 • .;;....................................... .. ..f• • i....... ..... ....... ... .. ..........
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