# Mon General 1200 J.D. Anderson Drive Morganrown, WV 26505 phonc 304-598-1200 mnv.mongcncrd.com

US. Nuclear regulatory Commission Materials Licensing Branch Region I 475 Allendale Road King of Prussia, PA 19406

RE: Amendment to Radioactive Material License Nos. 47-1 6259-01 Monongalia General Hospital

Gentlemen:

Please add the following physicians as authoriied users:

Andrew J. McDonnell. M.D. for 35.100 and 200Dr. McDonnell's training and experience can be referenced from NY license 421 ComingHospital: Coming NY. License is attached.

Maw Jean Wall. M.D. for 35100,200 and 300Dr. Wall's training and experience can be referenced from OH license 02120180084 Kaiser Permanente Medical Center; Parma, OH. License is attached.

Also, please delete Mark Hackney, MD and Peter Caruso, MD. as they no longer provide services at Monongalia General.

If you have any 9259

questions,

Sincerely,

%F Darryl L. Duncan, FACHE Chief Operating Officer

please contact RSO Mark Perna, M.S. at (412) 551 -

,? % Aug-08-07 04:OBP n o r t h c e n t r a l rad*lmg*9nc 419 483 0142 P.02

I). t:ahrll -27

.04-05-08:12:06 :MGh # 4/ 1 4 '"",,"",A> -,._11 *. m.rlr." L"C. - L.1,n.E. .; I n w , , 9 0 . l ' Y l 1>YO,,,O

. 3 '* 7' Aug-08-07 04:OBP north central radwlmg-inc 419 483 0102

.04-03-0ti;12:06 ;MGC -..-~.-, ̂ ........ .,,.. -. A,,"... "; ,~"~, ,,o-''ll ',*",,,o

' 'n 1: %'Aug-08-07 04:OaP n o r t h central rad*irng*inc 419 483 0142

# 5 / 1 4

P.04

STATE OF NEW YORK ; DOH-' DEPARTMENT OF HEALTH

i/ Cenlrar Field ORlca 217 South Sellna Street Syracuse. Ne# YarC

AnlMllC. Nquofio, M.D.. U.P.N.. .. Or. P.H. Dennlr P. wr b ? V d S 6 h @ t E l W l V O k

;I

October 24.2005

IAesRadiolo y FC 4~0.~anistco &. I Homell. NY 14843

Atm: Lk. Iddo Nermyahu I

Re:!Inspcction of Rndioactive Maten&LicenscNo. 5140

De& Dr. Nemyahu: mi$ letter refers to the in ction conducted by this writer on-Ocrober 20, 2005, authorized by the New York T tat& Department of Kealrh Radioactive Malerials and to d

' o f findings held with you and other members of your staff at h e conclusion OF the inspec

The inspection was an examination of activities conduced undcr your license us tl radiarion safer and to compliance with the requirements of the Stare Sanitary Code. Ct

examinatiom of procedures and represcntetive records, interviews with personnel and

D$ng the inspection, no'items of noncompliance with rhc requirements o f Put 16 an wcrq noted. It. wns noted. howbver, (hat you had not begun to use radioactive materia license. You are nquerlcd to notify this oficc at the time you commencs u6t so rhat a r inspection may be performed.

16. 'Toniring K : adietlm." and h e condjtions of your liccnse(6). The inspection consister

. byrhiswitcr.

Iwish to thank you for the cooperation and asislance given to me during che inspectior free to contactme u(315)- 477-8448 or by dmail ai ghWlBhcalrh.srate.ny.us.

CC: BERP License

Sincerely. Sincerely, .

' . ' *- Pnnclpd Radiological '

Heelrh Specialist

. .

' . ' *- Pnnclpd Radiological '

Heelrh Specialist

X 6 1 1 4

PAGE 03

>f sciiviiics t discussion ion.

:y relate IO ipter 1, Pan ofselective , ibscrvalions

he license c under this o n decriled

Please feel

,,. - . - ... . I

NEW YORK STATE DEPARTMENT OF HEALTH s w ~ o ~ c r r n MATERIALS LICENSE

License E

Amend

D; Lakes Radiology. PLLC

Ho~$J, New York 14843 450 %anistoo strwt

Anmtion: Iddo N*uryhhu. M.D. RadiationSafety Offiem

Dear Licenscc:

In accordance with the request dntd April 19,2006; sijged by Iddo Netanyal York State Department of Hcnltb Radiobrive Materials Liccnee No. 5 140 is ammda

ChmPt Con& ‘tion No. I to Read

, a

:.

8 1. Name:

Lakes Radiology, PLLC.

- w a d : h

’. 10. A. Radioactive matcriaI listed in Itan 6 shill only be used by the followi f

Andrew McDo~mll, M.D.

* .: Kenneth Nalaboff, M.,D, 4‘.

Iddo Nctanyahu, M.D.

B. RBdionctive material listed in Item 6 shall be usad by Iddo Netanynhu, appqniate 10 fulfill the mponaibiliuec of the Radiation Safety Office

’ . i . . FOR THE m w YORK STATE,DEPARTMEN

Robm E. Danserssu. Chid

PAGE 04

iber 5140

ntNumbcr 1

NO. 06-189

M.D., NeW s follows:

:ndividunle:

.D., as

IF HEALTH

-

ion

, . ,_ ." . _ _ _ -. - .....- ... i%. ~ ' - . ..- NEW YO= STATE DEPARTMENT OF geALTH

RADIOACrrvE MATE& LICENSE

I! Pursuant to chc Public H d r h Law and Pan 16 of the New York Strue Sanjtai arid h~nllmnce on.btat~ncnt0 and npressntatioas hqctofore r.nadt by the licensee da a license is hereby issueil authorizing radioactive mataial(8) for ~ht purpor(s), and desi&tcd below. Thc license is subject IO all appllcable rules, rcgulatioas. and ord h e d c r in effect of all epp.roprince ngukmy agcdcles and to any tonditim specifi : !;

'

$.

2. I

! Address

:450 Canisrco Street '.Hornell, New York 14843

$Attention: Iddo Neranyehu, M.D. 4

Radiation Safety Officer

3.

4.

5 .

Liccnse Number

5140

a. EffcctiveD

JW 18. za

b. Expirarion;

June 30,m

Reference Numbcr OH No. 03445

~

A

6. Radiktive Matcdals 7. Chrmicaland/or 8. Maximu (elcmcnt & mas8 no.) Physical Form. ' liccmee

at one ti

A. Tluonne IS A. Fluorodeoxyglucose A. 300mllI

I ,' I ma

9. iAulhOnzed use (unless ohelwise described, the authorid place of use is h e li :stated in Item 2, above). .

# E / 1 4

PAGE 8 5 '

:ode, l a td w o w , he place(s) now or below.

IC

ries

w e ' s addrss

IS described d dimtly 10

, _.-- -. - . ., . . _._ ..... .... . NEW YORK STATE DEPARTMENT OF HEALTH

UDlOACT WE MATERIALS LICENSE !I

.^ IU.

11. . .

12.

I CONDITIONS

e L

11

:*A. I,

1; Andrew McDonnell, M.D. / ' Iddo Netariyahu, M. D.

Radioactive marcrial,lirtcd in Item 6 shall only be used by the followin,

I1

(B. Radioactive material listed in Im 6 shall be used by Iddo NaanyJlu, i : . appropriate to t\llfill the responsibilities of the Redistion Safety Offica

,:Except fs specifically prpvided otbcrwisc by this ficcnse; tbe 1icmW;c shall ilicensed material dcrcribed in ltcm 6, 7, and 8 of this limse, in sscordancc v ;rqreocnutions, and prbccdura antaked in the dofrrmtab (ineluding any mc tkbclow:

,$. . Application br N e w York State Dcpartmmt of Health Radioactive Mal dated August 12,2003, signed by lddo Nctanyahrq M.D.

S. Letter dated July 22,2003, signed by Iddo Netmyahu, M.D. C. Letter dated Decsmkr 4,2003, s i p d by Iddo Nttsnyahu, M.D.

D. Letter dated Mych 18,2004, signed by Iddo Netanyahu M.D.

E, the New York Statc Department of Hcslth' s regulations shall govern the lice statements in uppficatioas os leners d e o s the statements are more rcsxictive L regulations.

_ . ' Feuimile June 4,2004,'signtd by Iddo Nctmyahy M.D,

5

t# 5 1 1 4

PAGE 86

rrseNo. 5140

ndividuds:

ials License

k S hthc

A.

! :.

' e., where radiosaivc mntMihJs are US& or stored. ,

Radioactive material shalt be stored in a locked facility in the origind shi ing. eonleiner, or a mtaina providing equident tadiation protection. such facacitiy may be a cabin& a safe, or a room. providing the facility i s locked at all tlmea when no. actidtics are in progress relatiq to the w of h e radionaive material. s includes periods, of brief absence of pasomcl from a nuclear medicine dcpmtmw Isboracdj,

Radioactive rna&alg shall not bc stored in the same facilities with materials which might &stantially incicase the f i or explosion hazard of the storage space and i& radioactive contenlp. .

3 B.

I

P i o / 1 4

Prior to disposal BS nom& w m , radioaciivc m t e shall bc surveyed b ih radioactivity cannot be distinguished from background. hll radiation 11 removed or oblitrratd.

The license^ shall not reluue any licensed radioactive mrttrids into the

PAGE 07

dctmm a cthlt bcls'will be

erivirsnmurt

. . . . . . . . ~ - , . . . .

n NEW YORK STATE DEPARTMENT OF HXALTH WXOACTIVJS MATERIALS LICENSE

CONDITIONS . E

censeNo. 5140

13,. " A. Transportation of licensed radioactive &al shall be subject to all US. Department of Trunsporution and other agencies of the United jurisdiction inaofsr N such regulations rclatc to the packaging of marking and labeling of the packages, lo&g and storage

Tmqomtion of low level radioactive waste shall ofthe New York State Dcpa~t~ncnt of

1. rrquizemcnrs, accident reporting, and shipplng papers.

' 8.

I.

I 6 NYCRR Part 381.

I 3 .

15. [ Ltak tern o f sealed s6urccs shsll be pfomed in accordance with Section 16. New York State Sonitary,Codc (IO NYCRR 16). OB-site analyrisof leek test

"performed by p m ~ n s specifically authorkl by the US. Nuclcar Reguld!ory 'Agrsement SUte to perform such ssrviccs. On-site analysis of leak test ~accordnnce with proccduyca approved by the Dcpamnnrt.

16. ' The licensee is authorized to hold.radioactive material witha physical half-lifc days for decay-in-storage before disposal in ordrnary trash, providad.

I'A.

93,

" 17. 'A '4

.04-03-0€:12:06 ;MGH .............................. .; ,,".,, ,,~."", Y 1 9 B L 3 1 6

07/86/2886 08:25 18775253701 LAKES RADIDLCGV

. . . . . . . . . . . - NEW YORKSTATE DEPARTMENT OF HEALTH

RADIOACTIYE MATERlALS LICENSE

coNDxnoNs L

f h e licensee sball maintain the Icner or valid pnmit required in paragtal condition on file for h e duration of the liccme and d e such lcttn or p for inspection by the Departmart upon nqucst.

17. '. C. i

18. 1. Tbr'liceasct sMI submit complete deconrsmiPation procedures to the Qepartm j: ninety (90) ,days prior to the termination of m t i o n s involving radiodve ma1 i rcsiaicttdena.

19. Plans of facilities which the licensee intends to dcdicalc to OperatiorrJ involving ( &oactive mterial Ml be submitted to chc Depamnent for rcvinv and npprov

8uch use.

. I

20. ': The licensee shall mainrain records of idonnation imporrant to safe and cffcctii I( dacommissioniag at Lalres Radiology, P.C., 450 Canistea Street, Hornell. New '

other locations as the Liccnxe chooses. The records shell be maintained until th : (crmiadted by rhe Department md MI include:

I

.: A.

!I B.

Records of spills or other ,musual OCtWencts involving the spread of cc and around the fadiw, equipment, or site;

&-built drawings and modificetions of stmchmg and quipment in resh whm radioactive mt&s arc used W o r stored, and localioac of pors contamination such buried pipis which mq bc subject to contnmiuati

Records of the cost catimnte performed for the decommissioning frmdini amount cmified for decommissioning, and rccotb of the funding metho e ~ s u r i n g funda'if either a funding plan or cellification is uscd.

?

4 ..\

? C. i

21. .Radiation &cy&& may be delegated to qualified tnntics, however rcrmn.si& ' that these tnsks have been completed r tsw with the licensee nunod in Condition ! appropriate m r d s must be mnintained at the addrcss shown in Condition No, 2

n

22. Radioactive materials may be used in the Medical Consultants lmaging Compan ,: of Alliancc Imaging, Inc., coach Located outside of thc W e s Radiology, P.C., oi

described in Ihc Application for New York stat^ Deparrmcnt of Health Radioad Licmpc dated Augrut 12,2003, sign4 by Iddo Netanyahu, M.D. ,

# 1 1 / :4

PPGE €48

em? No. 5140

B of this nit available

t for approval ids in my

c wc of pior to any

amination in

:cd aTcas IC inaccessible

im or the m d for

[ for seeing 0. 1,md

a subsidiary

E Miteriiils- :e3 69

m/wzmfi m:25 18775253781 LAKES RADIOLOGY

- .

. . .,. - - - . - .

NEW YORK STATE DEPARTMZNT OF EIEALTII RADIOACTIVE MATElUAY-3 LICENSE

i CONDITIONS

1

23. The licensee shall maintain doses io rnsmbcrs o f the public from licensed actin ’ total cffetuve done equivalent to an individual shall not exceed 100 millimn in

total effective dose Oquivdent to an individual member of the public ahall inclu resulting from c x p o m to patimta administered radiovtive materials while thc

.’ m a i n on the liCE3IScC’S premises.

‘24. Nuclear Medicine Technologids who meet (he Criccria of 10 NYCRR 16.123(a: perform pnrcnrclal injections of radioactivc maieridr for diagnostic purposes ui supemision of a physicim on the premisee. Rior to rllowing pamDtcral admini nuclear medicine technolo& the Radiation Safety OfIiccr h 1 1 h e that the competent in thc performance of parenteral adminismtim. Records of rhis app

.. relaincd as long aC !he Nuclear Mcdicine,T&nologi:st is working under the liix

25. ’ The licensee shall follow the camp manufactum’s rccommmdations for radia 1: qulity~suraast.

i

26. ’ sealed SOurCC6 containing radioactive matcrial shall not be openod or moved respective s o w c holders by the licensee.

P

1; FOR THE NEW YORK STATE DEPARTMEH

Robert E. Dame Radioactive Materials Section Burcpu of Envkonmmtal Radialia

it 12/ 1 4 __

P A E e9

mse No. 5146

E such chat rbc cyeiu. The doses patiCIllS

i(i) may II the h n by a hologint in id mu1 be L

n safety and

n their

OF HEALTH

toted ion

06/13/2eEs 28: 21 6079628228 M a r 1 1 03 01!OEp

. I

Corning Horpital

2,

! I

3. RcCucncNumbcrn bH No. W3@ DH NO. 01-16

# 13/ 1 4

PAGE elIE2 P . 2

NEW YORK STATE DEPAUTMENT OF HEALTH RADIOACTIVE MATRRlALS LlCENSE

CONDlTIONS Lica

' Amcndn

6.

C.

D.

, E. 7 .

F.

9.

. .

10.

' RadiOilCllVC mcerislc 7. (element Ut mu3 M.) .

Joilinc 125 C:

Molybdenum 991 F. Technetium 99m

Chemical andlor Physid Form

Sealeu 8OUIceS

Scsled sourccs

Dierhylcncmamine. purraaceric add (DTPA)

Oenerator

8. Maximumquai licensee may p atone time '

C. 1 curie

D. i curie

E. 160 millicuries

P. 2curis

AUlllnrized use.(unlefs othenvix described, the authorized pbce of UPC L rhe limn81 sddrus stateU in Item 2; above): '

A. 8rd F. Any dlagnoaic pmccdurc involvin8 mcaiurment of uprake, dilution, excretion, w descrlbed in 10 NYCRR 16.123 (b) (I).

Any diagnostic pmcedure involving imaging arul ~~~A~izatlOll sbdies, described in 10 NYCRR 16.123 @) (2).

For intqstiiial i i e n ~ ~ ~ c n ~ of cancer.

8: and F.

C. nnd D. . E: &lurtian of pulmoarry ventilation.

.4.. .I .

Radioactive material lisled in bcm 6 shall be Used by, or u n d h h Nklaw 01 following individuals. with the spccfibd limltbtiofis:

. . ' krcr &vasa, M.D. Siibitcnu C and D

D. Eugcnc Mnrtin,'M.D.

Andrew J. McDonnell. M.D. ,

Patel 1. Nicholson. MJ.

Subiiems A, B, B, and F

Sabltcms A, 8. E. a d P

ablterns A. R. E. id F . .

x 14 / 1 4

p . 3

---.-.....

This is to acknowledge the receipt of your letterlapplication rc-Sd*~** ( R*.=e; vcd d3/-9 , and to inform you that the initial processing which includes an administrative review has been performed.

& ~ C M U - t ? - / 6 ~ T ? - a f There were no admi istrative omissions. Your application was assigned to a technical reviewer. Please note that the technical review may identify additional omissions or require additional information.

0 Please provide to this office within 30 days of your receipt of this card

A copy of your action has been forwarded to our License Fee & Accounts Receivable Branch, who will contact you separately if there is a fee issue involved.

Your action has been assigned Mail Control Number When calling lo inquire about this action, please refer to this control number. You may call us on (610) 337-5398, or 337-5260.

/FZ7-P3

NRC FORM 532 (R I )

(6~96)

Sincerely, Licensing Assistance Team Leadei