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A Healthy Community Starts Here
P.O. Box 1231 •Havre, Montana 59501 • www.NMHcare.org
ijlErGlE~WlE~ [U JUN 2 0 2016 ~
DNMS June 11, 2016 RE: Change of Radiation Safety Officer for License #25-17441-01
Carol L. Hill, Licensing Assistant US Nuclear Regulatory Commission Region IV Nuclear Materials Licensing Branch 1600 E. Lamar Blvd, Arlington, Texas 76011-4511 817-200-1J40, 800-952-9677, [email protected]
Dear Carol Hill: This letter serves as notification to the Nuclear Regulatory Commission, according to 35.14, that Walter E. Smith, D.O. is the Radiation Safety Officer for License #25-17441-01.
Dr. Smith was previously listed on NRC License #25-16906-01 as Radiation Safety Officer.
Please amend our license to add him as Radiation Safety Officer and remove Steven E. Liston, M.D.asRSO.
Sincerely,
$'~ VP of Professional Sen1ices Northern Montana Hospital 406-262-1417 [email protected]
Northern Montana Hospital
30- 13th Street (406)265-2211
Northern Montana Care Center
24 • Uth Street { 406)265-2238
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NOH-PUBLIC Q u Senaltlva.Securlty Relal9d .Q A.i Slnlltlve Internal .
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Northern Montana Specialty Medical Center
20 • 13th Strec: West (40ti)265-?831
Quality, · CarinQ, Service
Northern Montana Family Medical Center
1410 l<>t Avenue {406)265·5408
Northern Montana Sletten cancer center
40 ·13th Street West (406)262-6000
lh591142
NRCFORM374 PAGE _-1._ OF _L..P,,:·>;ES·
U.S. NUCLEAR REGULATORY COMMISSION Amendment No. 22
MATERIALS LICENSE Purauant to the Atomic Energy Act of 1954, as amended, the Energy Reorganization Ad of 1974 (Public Law 93-438), and Tdle 10, Code of Federal Regulations, Chapter I, Parts so, 31, 32, 33, 34, 35, 36, 39, 40, and 7(1, and In reHance on statements and representations heretofore made by the licensee, a license is hereby Issued authorizing the licensee to receive, acquire, possess, and transfer byproduct, aource, and special nuclear materfal designated below; to use such material for the purpose(s) and at the plece(a) designated below; to dallver or transfer such material to persona authorized to receive It In accordance with the regulaUona of lh8 applicable Part(s). This license shall be deemed to contain the conditions apeclfled In Section 183 of the Atomic Energy Act of 1954, as amended, and Is subject to all applicable rules, regulations, and ordera of the Nuclear Regulatory Commission now or hereafter In effect and to any conditions specified below.
Ucenaee In accordance with application dated June 13, 2013
1. Frances Mahon Deaconess Hospital 3. License number 25-16906-01 is renewed in its entirety to read as follows:
2. 621 Third Street South Glasgow, Montana 59230
iratlon date December 31, 2023 030-11841
6. Byproduct, source, and/or special .""\..W. - 7. Chemical and/or phyalcal fonn material · ~
T I'. 8. Maximum amount that licensee 0 may possess at any one time ;-p ~nder this license
~ Asneeded
0 e As needed
9.
. /) CONDITIONS ~ 10 L. d . . * -,A. ~~-... ~,;1' 1f'. . . 1cense material may be used or stored oi'df at"• llcehsee's faciUties located at 621 Third Street
South, Glasgow, Montana.
11. The Radiation Safety Officer for this license is Walter E. Smith, D.O.
12. Licensed material is only ~uthorized for use by, or under the supervision of:
A. Individuals pennltted to work as an authorized user in accordance with 1 o CFR 35.13 and 35.14.
B. The following individuals are authorized users for the material and medical uses indicated:
Aµthorlzed Users
Martin A. Kurland, M.D. Walter E. Smith, D.O.
Material and Use
35.100; 35.200 35.100; 35.200
"15 9114 2
NRC FORM 374A U.S. NUCLEAR REGULATORY COMMISSION PAGE 2 of 2 PAG.\'S
MATERIALS LICENSE SUPPLEMENTARY SHEET
Date .December 5. 2013
Ucanse Number 25.;16906-01 Docket or Raf'eranaa Number 030-11841 Amendment No. 22
FOR THE U.S. NUCLEAR REGULATORY COMMISSION
By-.1..~~;..-..~~~~~:--:-:0:-::--: Mich lie M. Hammon . .Sc., Health Physicist Nuclear Materials Safety Branch B Region IV Arlington, Texas 760'11-4511
Hill, Carol
From: Sent: To: Subject: Attachments:
Carol,
Williams, Brian G <[email protected]> Monday, June 20, 2016 6:31 PM Hill, Carol [External_Sender] Northern Montana Hospital Change in Radiation Safety Officer 2016_06_20_17 _28_54.pdf
Attached are the forms to change our Radiation Safety Officer here at Northern Montana Hospital.
Thank you,
Brian G. Williams VP of Professional Services Northern Montana Hospital 406-262-1417 Office 406-262-3609 Cell [email protected]
1 ~·581142
NRC FORM532 U.S. NUCLEAR REGULATORY COMMISSION (05-2016) ~<>""'~~
1~' • ' II ACKNOWLEDGEMENT • RECEIPT OF CORRESPONDENCE .. . \;,, <,i.> :-1 ..........
Name and Address of Applicant and/or Licensee Date
I 06/21/2016 I Walter E. Smith, D.O.
License Number{s)
Radiation Safety Officer I 25-17441-01 I Northern Montana Hospital Mail Control Number~s) P.O. Box 1231 I Havre, MT 59501
I 591142
Licensing and/or Technical Reviewer or Branch
CLH
This is to acknowledge receipt of your: 0 Letter and/or D Application Dated: 06/11/2016
The initial processing, which included an administrative review, has been performed.
0 Amendment D Termination D New License D Renewal
0 There were no administrative omissions identified during our initial review.
D This Is to acknowledge receipt of your application for renewal of the material(s) license identified above. Your application is deemed timely filed, and accordingly, the license will not expire until final action has been taken by this office.
D Your application for a new NRC license did not Include your taxpayer identification number. Please complete and submit NRC Form 531, Request for Taxpayer Identification Number, located at the following link: bttp://www,nrc,govlreading-rm/doc-collectioos/forms/nrc53j .pdf
Follow the instructions on the form for submission.
D The following administrative omissions have been identified:
Your application has been assigned the above listed MAIL CONTROL NUMBER. When calling to inquire about this action, please refer to this control number. Your application has been forwarded to a technical reviewer. Please note that the technical review, which is normally completed within 180 days for a renewal application (90 days for all other requests), may identify additional omissions or require additional information. If you have any questions concerning the processing of your application, our contact information is listed below:
Region IV U. S. Nuclear Regulatory Commission DNMS/NMSB - B 1600 E. Lamar Boulevard Arlington, TX 76011-4611 (817) 200-1140
BETWEEN:
Accounts Receivable/Payable and
Regional Licensing Branches
[ FOR ARPS USE ] INFORMATION FROM WBL
Program Code: 02120 Status Code: Pending Amendment Fee Category:7C Exp. Date: 01/31/2015 Fee Comments: Decom Fin Assur Reqd: N
License Fee Worksheet - License Fee Transmittal A.REGION
1. APPLICATION ATTACHED Applicant/Licensee: Northern Montana Hospital
Received Date: 06/20/2016 Docket Number: 3012758 Mail Control Number: 591142 License Number: 25-17441-01
Action Type: Amendment
2. FEE ATTACHED
Amount:
Check No.:
3. COMMENTS
Signed:
Date:
B. LICENSE FEE MANAGEMENT BRANCH (Check when milestone 03 is entered I I
1. Fee Category and Amount: ~~~~~~~~~~~~~~~~~
2. Correct Fee Paid. Application may be processed for:
Amendment:
Renewal:
License:
Signed:
Date:
1
