Casey Colleen

From Rhonda Lennon [rhondalennonyahoocom] Sent Thursday July 19 2012 tsectaPM To Casey C6l1een Cc William Breeden Subject License 13-26797-01 Attachments NRC FORM 314close out survey pdf

Colleen

Attached is a letter to tenninate our License 13-26797-01 along with NRC Fonn 314

If you have have any questions please feel free to contact myself or William Breeden

Thank you

Rhonda F Lennon Practice Manager Columbus Diagnostic Imaging 790 Creekview Drive Columbus IN 47201 812-373-2111

1

Columbus Diagnostic Imaging

July 29 2012

United States Nuclear Regulatory Commission Region III 2443 Warrenville Road Suite 210 lisle Il 60532-4352

RE Ucense Number 13-26797-01

Dear Colleen Carol Casey

This is a formal request to terminate our license 13-26797-01 Attached is a Certificate of Disposition of Materials along with the Close out survey completed on July 18 2012 by William KBreeden JII MS DABR

Please contact our Administrator Rhonda lennon at 812376-1000 for further clarification if you desire

ma~ Robert A DeWeese MD Radiation Safety Officer Columbus Imaging Associates dba Columbus Diagnostic Imaging

790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200 Fax (812) 376-6665middot wwwcolumbusimagingcom

Columbus Diagnostic Imaging

July 29 2012

United States Nuclear Regulatory Commission Region III 2443 Warrenville Road Suite 210 lisle Il 60532-4352

RE Ucense Number 13-26797-01

Dear Colleen Carol Casey

This is a formal request to terminate our license 13-26797-01 Attached is a Certificate of Disposition of Materials along with the Close out survey completed on July 18 2012 by William KBreeden JII MS DABR

Please contact our Administrator Rhonda lennon at 812376-1000 for further clarification if you desire

ma~ Robert A DeWeese MD Radiation Safety Officer Columbus Imaging Associates dba Columbus Diagnostic Imaging

790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200 Fax (812) 376-6665middot wwwcolumbusimagingcom

--

APPROVED BY OMS NO 3150(1028 EXPIRES 101312013NRC FORM 314 US NUCLEAR REGULATORY COMMISSION (1)$2012) ES1imaIed bURIen per Ill$llOII$l 10 IIlIllPIY with lIIis ~ CCIIIecIioII fIIq 30 milUI8$0 CFfUO 380l() 40420)(1) This SIIbmittai is used by NRC as part 01 lilt basis to its deIemIimIIIIoII 111M lilt Iidy is70 38lilt) _72 5ltltk)15)lIl)

teIeased lor un~ed use SeIld _IllS mgllldrtg lIURIen esImIIIe 10 lilt IlIIonneIIon Servres Btanch (15 FS3) US NIICieIII Reg~ COIIIIIWIon WlIIIIIIIgbI DC 2055$-0001 or by inlemel e-mail 10 InIocoIIeclSResouneMgoy IIIICI 10 lilt DesI Ofbr 0IIke 01CERTIFICATE OF D1SPOSITION OF MATERIALS InUmation and RegWllOly AIIaits NEOB-I0202 (3150-0028) 0ftII 01 ManagemenI atIC BOOgeI WashnglCn DC 20503 If ameatI$ used 10 impose an IIIIDImIJIion coIecIIon does flO dl$pIay a ellJel1lly vetil OMS IlOtMlI nll1lbei lilt NRC IN) IlOl COnduct or spDflSQI IIIICI II person is IlOl mqutred 10 respond 1O111e InIormaIIon coIIectlcm

LICENSE NUMBER DOCKET NUMBERLICENSEE NAME AND AOORESS

13-26797-01Columbus Imaging Associates dba Columbus Diagnostic Imaging 790 Creekview Drive LICENSE EXPIRATION DATE Columbus Indiana 47201

A LICENSE STATUS (Check the appropriate box)D This license has expired o This license has not yet expired please terminate it

B DISPOSAL OF RADIOACTIVE MATERIAL (Check _ approprHIte boxes and complete as nee-aI) additional space is needed provide attachments)

The licensee Of any individual executing this certificate on behalf of the licensee certifies that

1 No radioactive materials have ever been procured or possessed by the licensee under this license0 2 All activities authorized by this license have ceased and all radioactive materials procured andor possessed by the licensee0

under this license number cited above have been disposed of in the following manner

0a Transfer of radioactive materials 10 the licensee listed below eckert and Ziegler Isotope Products Inc dba Isotope Products Laboratories California Lic I 509middot19 Cary Renquist RSO

as- ~~2SiQQ0b Disposal of radioactive materials

[] 1 Directty by the licensee

All radioactive waste that was being held for as decay-in storage bas been disposed ofproperly as it has been held for greater than) 0 halfmiddot lives and was indistinguishable from background exposure rate levels See attached log

o 2 By licensed disposal site

o 3 By waste contractor

Dc All radioactive materials have been removed such that any remaining residual radioactivity is within the limits of 10 CFR Part 20 Subpart E and is ALARA

C SURVEYS PERFORMED AND REPORTED o 1 A radiation survey was conducted by the licensee The survey confirms

o a the absence of licensed radioactive materials

Db that any remaining residual radioactivity is within the limits of 10 CFR 20 Subpart E and is ALARA

o 2 A copy of the radiation survey results

[lJ a is attached or b is not attached (ProVIde explanation) or c was towarded to NRC on ~-~ ~

DaleD 3 A radiation survey is not required as only sealed sources were ever possessed under this license and

o Ii The results of the latest leak test are attached andlor [lJ b No leaking sources have ever been identified

The person to be contacted regarding the information provided on this form TELEPHONE 11_l1N COlt1ftl 1EmiddotlIWLADDRaSSNAME

~TlE 812middot376-1000 rhondalcnnonyahoocomRhonda Lennon Practice Manager

Mild all Mute tonIIPcndo_ ~no this license 10

Rhonda lennon at address noted above

C CERTIFYING OFFICIAL I CERTIFY UNDER PENALTY OF PERmiddotIIlRLTUAT THE FOREGOING IS TRUE AND CORRECT

~~- ~~~-~~- IQA~~~middot--WARNING F~se STATEMENTS IN THIS CERTlFlCATE MAY BE SCJBJECT TO CIVIL AflBioR CRIMINAL PENALTIES NRC REGULATIONS REQUIRE TWAT SUBMISSIONS TO THE NRC BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECT 18 USC seCTION 1001 MAKES ITA 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 NRC FORiII314 (05-2012)

Clouse out survey for Columbus Imaging Associates dba Columbus Diagnostic Imaging

6182012 USNRC Materials License 13-26797-01

Location Location Description Exposure Rate (mRhr) Wipe activity(dpm100cmA 2)

1 Dose prep area 2 Dose calibrator 3 Rad waste bins (empty)

4 Seald Source box(empty) 5 patient injection area 6 gamma camera 7 computer console 8 hot lab door and handle

9 imaging room door and handle

10 hot lab floor

11 hot lab floor

12 hot lab floor

13 hot lab floor

14 hot la b floor 15 hot lab floor 16 imaging room floor 17 imaging room floor 18 imaging room floor

19 imaging room floor

20 imaging room floor 21 desk 22 hot lab counter

23 hot lab sink

24 sharps shielding box (empty)

002 002

002 002

002 001 002 002

002

002 002

001

002

002

002 002

002 001

002

002 002 002

002

001

421 421

421 421 403

403 403

18 15

27

29

44

44

32 33

27S 279

32

47

31 20 4

14 9

Wipe tests measured with a Capintec CAPRAC SIN 00658 last calibrated 4612 Exposure rate surveyed with Ludlum 14C SIN 101782 last calibrated 33012

Perfomed by William K Breeden III MS DABR

FA~75tfh~f( JlII (u J 5JJ((i C6gtve t1r1 1tilt t~ -1 vr 6wl rrlv() -b j)7a71 p PCP 0 shy

Medical Physics Survey Sealed Source Inventory

Facility Columbus Diagnostic Imaging Department Nuclear Medicine

Location Columbus Indiana Date July 18 2012

Nuclide

Cs-137

Cs-137

Cs-137

Cs-137

Co-57

1-----shy

Activity Date Model Serial No Type Location

RV-137shyDose Hot Lab

2198uCi 811197 559-162-7 Calibrator200V Vial

~r- shyRod Hot Lab

O1065uCi 811197 IPL 488-31-2

Button Ludlum Survey

10uCi 1295 None 4646 Meter

I I

Imiddot-~ -shy ~~~

Button Ludlum Survey

10 uCi 12195 None 4656 Meter

I ~

Flood Hot Lab 10mCi 9nlO8 BM01-10 BM011008220102

-I_-_0shyI

~~--

I

l-~- I

I

~-

1shy

~~~

- --~~ v_~

~-_

-=1

_ ~ ~~ L__ w_i

M_~ I

Present

No returned to

manufacturer No returned ~I

to manufacturer Yesexempt quantity to

be sold with camera

Yes exempt quantity to

be sold with camera

No returned to

manufacturer

I

I

I Comments Ambient Exposure Rate Survey of Sealed Sources ( Ludlum 14C SN141804 001 mRlhr)

Radiation Safety Officer

Provided by Advanced Medical Physics 16770 Cedar Creek Lane Inoblesville IN 46060middot 3172233022

i1J ( ~ J) 1)1shy

Bathroom0- ) IHot _ah

GJ I Ireg 15 i 7 I

(5)

c

-10

Lr~ Imaging

COLUMBUS DIAGNOSTIC IMAGING DAILY AREA SURVEYS

1 Dose Preparation

2 Dose Calibration J~ 3 Hot Trash cslfJ ) 4 Sealed Snurre Storage(tm ~ 5 Patient Injection Area 6 Gamma Camera 7 Computer Console

~ HJh~lPvl

[) 1m~5 () raquoJt ()o~r O-IS Hiab f$J( I-10 fin Jtj ~

(Zoo~fl~(

u- O~s0 -shy J L ~ltI ~1 C r1

MONTH YEAR

ITriaaer l evels-mRthr 20 20~10 05 10 HandsClothing Initials Comments

~ 1 2 6 7 8 1 ~ II J 1 ( t1- tt~ VIlJ

A

tl2 -w-- (L 0 ( 3 (J Jl 4 f 11 OWl ~ 5 I) r -0 1

6

7 8 9

10 ==t11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

jf =R311

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NUCSl6AMMA ROOM

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7

6

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3

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PRELIMINARY PLANNfNG- ONLY

Wiscontit bull oquipmOllI 110 piiiCtcirti ~ Iiit

THIS LAYOUT WST BE APPROVED BEFORE RNAl llRAWlNGS CAN BE STARTED THANK yOU

PROJECT 1l11E

COLUMBUS DIAGNOSTIC IMAGING CUSTOMER PATNUCLEAR ROOM - MILLENIUM MG GE Project cqulppllat AII n- _ 1M atot laquoyeniIor 1 _ lhltIICOLUMBUS INDIANA Monager td~ ~ 01 -- II CW-rInstalrotion PATE P Iot h ~ rcIII ~ _ t ~SCHEME NO081NAQ80 DRAWH BY TlO DAli 07-22-~

Radioactive Wastl And Disposal Record

Policy and Procedure 1 Seal and slore radioactive waste containers behind adequate shielding 2 Indicate Container 10 andor Conlents (ie Hot Trash Sharps etc) 3 Radioactive waste should be held for at least 10 half-lives of the longest-lived radIoisOtope to be disposed 4 Monitor background and surface with a GM 5uNay Meter on its most sensitive scale without shielding prior to

disposal 5 Waste may be disp~d of if activity Is indistinguIshable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash

Survey Meter Code Brand Model Serial Number

1 1_ tI-~ ILLfVl Lle I L 11Ct- 2 rtrfl IUn ll(r Il ) 7)-)

0Lj 3$YJ

last AsS2V DJte of Waste to La lJisposed Isotope to be

of Dis osed of ~1l~~1~~~ 1 C-

o7h6 I~) o~ ~ j I S-ltC lt1A

~8u~Hit5Sltq~W ) 7 jj-) iiWif( r 9q ~~~IEP1fisect ~84~~ ~dJili(5)i-)Jamp --=T~Y 1Jifll-)~ltilli~~ ~lltY ~~iLl ~ r ))RT=_L 2 ~~LL~~Li2 L ~~ laquo44

-~hO~ - 1iI~l7-~pL-r~-h7 ~2 I-l-h 1~)1] r- I ---shy I~I P - -- v- -shy r-~--- I - ---~~

(Providcd by A~edMedical Physics 16771Hi rak Lanemiddot NoblesviIleIN 46060middot 3172n3022

Radioactive Materials Shipment Ret l and Return Container Survey RecOImiddotd

Instruments Usedor SurllJsAction le~eIs Tile Radiation Safety Of11Cer should be immediately Dotilied when radiatioll or cootamination levels to which personnel DeteclorMeier No Make amp Model Serial No

Efficiencymay be exposed elteed tbe rollowing levels

Area

Restricted

Radiation Survey Conmlnatioll Surveys

50 mRlhr lOOODPMI10Ocm 2 2

BKG Cpm I Initials

Report Date Apri122 2012

Facility Columbus Diagnostic Imaging Columbus IN

State License Number Not Supplied USNRC License Number 13-24706-01

$ogrce Identification

Radionuc6de Cobalt-57 Calibrated Activity Date 090708 Calibrated Activity lOmCi Manufacturer Not Supplied Setia1 Number BM01-10 Model Number BMOl1008220102 Source Description Flood Source

Assay Results Counting Efficiency 0762 cpmdptn 1691543 cpmuCi MDA 102 dpm 78 cpm 000005 uCi Background time ofassay 351 cpm)

Grosscpm PtyWipe 347

Instrument used fot Analysis Ludlum Well Counter MN 2200 SIN 198663

Analysis Results Source is not leaking at this time

Removable contamination is lt0005 uCi

Next Leak Test Due

LeakTest Performed By

Analysis Performed By

IpoundI~ I Radiation Safety Officer (signature)

Report Date

Facility

State License Number USNRC License Number

Source Ideptification

Radionuclide Calibrated Activity Date Cahbrated Activity Manufacturer Serial Number Model Number Source Description

Assay Results Counting Efficiency MDA Background time of assay ~cpm)

April 22 2012

Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01

Cs-137 080197 2198 uCi IPL 559-1627 RV-137-200V Dose CaliJIrator Vial Soutce

02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm 000013 uCi 351

Grosscpm DryWtpe 347

Instrument used for Analysis Ludlum Well Counter MN2200 SIN PR 198663

Analysis Results Source is not leaking at this time Removable contamination is lt0005 uCi

Next Leak Test Due

Leak Test Pedormed By

Analysis Performed By

Officer (signature)

Medical Physics Survey Sealed Source Inventory

Facility Columbus Diagnostic Imaging Department Nuclear Medicine

Location Columbus Indiana Date July 18 2012

Nuclide

Cs-137

Cs-137

Cs-137

Cs-137

Co-57

1-----shy

Activity Date Model Serial No Type Location

RV-137shyDose Hot Lab

2198uCi 811197 559-162-7 Calibrator200V Vial

~r- shyRod Hot Lab

O1065uCi 811197 IPL 488-31-2

Button Ludlum Survey

10uCi 1295 None 4646 Meter

I I

Imiddot-~ -shy ~~~

Button Ludlum Survey

10 uCi 12195 None 4656 Meter

I ~

Flood Hot Lab 10mCi 9nlO8 BM01-10 BM011008220102

-I_-_0shyI

~~--

I

l-~- I

I

~-

1shy

~~~

- --~~ v_~

~-_

-=1

_ ~ ~~ L__ w_i

M_~ I

Present

No returned to

manufacturer No returned ~I

to manufacturer Yesexempt quantity to

be sold with camera

Yes exempt quantity to

be sold with camera

No returned to

manufacturer

I

I

I Comments Ambient Exposure Rate Survey of Sealed Sources ( Ludlum 14C SN141804 001 mRlhr)

Radiation Safety Officer

Provided by Advanced Medical Physics 16770 Cedar Creek Lane Inoblesville IN 46060middot 3172233022

i1J ( ~ J) 1)1shy

Bathroom0- ) IHot _ah

GJ I Ireg 15 i 7 I

(5)

c

-10

Lr~ Imaging

COLUMBUS DIAGNOSTIC IMAGING DAILY AREA SURVEYS

1 Dose Preparation

2 Dose Calibration J~ 3 Hot Trash cslfJ ) 4 Sealed Snurre Storage(tm ~ 5 Patient Injection Area 6 Gamma Camera 7 Computer Console

~ HJh~lPvl

[) 1m~5 () raquoJt ()o~r O-IS Hiab f$J( I-10 fin Jtj ~

(Zoo~fl~(

u- O~s0 -shy J L ~ltI ~1 C r1

MONTH YEAR

ITriaaer l evels-mRthr 20 20~10 05 10 HandsClothing Initials Comments

~ 1 2 6 7 8 1 ~ II J 1 ( t1- tt~ VIlJ

A

tl2 -w-- (L 0 ( 3 (J Jl 4 f 11 OWl ~ 5 I) r -0 1

6

7 8 9

10 ==t11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

jf =R311

__________ __ __

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NUCSl6AMMA ROOM

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bull ____laquo __bullbull___ I ___L

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II ~ ltgtlIe I I EGUIP I IBpoundJI I

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6

(J~Q

existing shelf

10

g

8

7

6

5

4

3

2

l

0-shy

PRELIMINARY PLANNfNG- ONLY

Wiscontit bull oquipmOllI 110 piiiCtcirti ~ Iiit

THIS LAYOUT WST BE APPROVED BEFORE RNAl llRAWlNGS CAN BE STARTED THANK yOU

PROJECT 1l11E

COLUMBUS DIAGNOSTIC IMAGING CUSTOMER PATNUCLEAR ROOM - MILLENIUM MG GE Project cqulppllat AII n- _ 1M atot laquoyeniIor 1 _ lhltIICOLUMBUS INDIANA Monager td~ ~ 01 -- II CW-rInstalrotion PATE P Iot h ~ rcIII ~ _ t ~SCHEME NO081NAQ80 DRAWH BY TlO DAli 07-22-~

Radioactive Wastl And Disposal Record

Policy and Procedure 1 Seal and slore radioactive waste containers behind adequate shielding 2 Indicate Container 10 andor Conlents (ie Hot Trash Sharps etc) 3 Radioactive waste should be held for at least 10 half-lives of the longest-lived radIoisOtope to be disposed 4 Monitor background and surface with a GM 5uNay Meter on its most sensitive scale without shielding prior to

disposal 5 Waste may be disp~d of if activity Is indistinguIshable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash

Survey Meter Code Brand Model Serial Number

1 1_ tI-~ ILLfVl Lle I L 11Ct- 2 rtrfl IUn ll(r Il ) 7)-)

0Lj 3$YJ

last AsS2V DJte of Waste to La lJisposed Isotope to be

of Dis osed of ~1l~~1~~~ 1 C-

o7h6 I~) o~ ~ j I S-ltC lt1A

~8u~Hit5Sltq~W ) 7 jj-) iiWif( r 9q ~~~IEP1fisect ~84~~ ~dJili(5)i-)Jamp --=T~Y 1Jifll-)~ltilli~~ ~lltY ~~iLl ~ r ))RT=_L 2 ~~LL~~Li2 L ~~ laquo44

-~hO~ - 1iI~l7-~pL-r~-h7 ~2 I-l-h 1~)1] r- I ---shy I~I P - -- v- -shy r-~--- I - ---~~

(Providcd by A~edMedical Physics 16771Hi rak Lanemiddot NoblesviIleIN 46060middot 3172n3022

Radioactive Materials Shipment Ret l and Return Container Survey RecOImiddotd

Instruments Usedor SurllJsAction le~eIs Tile Radiation Safety Of11Cer should be immediately Dotilied when radiatioll or cootamination levels to which personnel DeteclorMeier No Make amp Model Serial No

Efficiencymay be exposed elteed tbe rollowing levels

Area

Restricted

Radiation Survey Conmlnatioll Surveys

50 mRlhr lOOODPMI10Ocm 2 2

BKG Cpm I Initials

Report Date Apri122 2012

Facility Columbus Diagnostic Imaging Columbus IN

State License Number Not Supplied USNRC License Number 13-24706-01

$ogrce Identification

Radionuc6de Cobalt-57 Calibrated Activity Date 090708 Calibrated Activity lOmCi Manufacturer Not Supplied Setia1 Number BM01-10 Model Number BMOl1008220102 Source Description Flood Source

Assay Results Counting Efficiency 0762 cpmdptn 1691543 cpmuCi MDA 102 dpm 78 cpm 000005 uCi Background time ofassay 351 cpm)

Grosscpm PtyWipe 347

Instrument used fot Analysis Ludlum Well Counter MN 2200 SIN 198663

Analysis Results Source is not leaking at this time

Removable contamination is lt0005 uCi

Next Leak Test Due

LeakTest Performed By

Analysis Performed By

IpoundI~ I Radiation Safety Officer (signature)

Report Date

Facility

State License Number USNRC License Number

Source Ideptification

Radionuclide Calibrated Activity Date Cahbrated Activity Manufacturer Serial Number Model Number Source Description

Assay Results Counting Efficiency MDA Background time of assay ~cpm)

April 22 2012

Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01

Cs-137 080197 2198 uCi IPL 559-1627 RV-137-200V Dose CaliJIrator Vial Soutce

02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm 000013 uCi 351

Grosscpm DryWtpe 347

Instrument used for Analysis Ludlum Well Counter MN2200 SIN PR 198663

Analysis Results Source is not leaking at this time Removable contamination is lt0005 uCi

Next Leak Test Due

Leak Test Pedormed By

Analysis Performed By

Officer (signature)

i1J ( ~ J) 1)1shy

Bathroom0- ) IHot _ah

GJ I Ireg 15 i 7 I

(5)

c

-10

Lr~ Imaging

COLUMBUS DIAGNOSTIC IMAGING DAILY AREA SURVEYS

1 Dose Preparation

2 Dose Calibration J~ 3 Hot Trash cslfJ ) 4 Sealed Snurre Storage(tm ~ 5 Patient Injection Area 6 Gamma Camera 7 Computer Console

~ HJh~lPvl

[) 1m~5 () raquoJt ()o~r O-IS Hiab f$J( I-10 fin Jtj ~

(Zoo~fl~(

u- O~s0 -shy J L ~ltI ~1 C r1

MONTH YEAR

ITriaaer l evels-mRthr 20 20~10 05 10 HandsClothing Initials Comments

~ 1 2 6 7 8 1 ~ II J 1 ( t1- tt~ VIlJ

A

tl2 -w-- (L 0 ( 3 (J Jl 4 f 11 OWl ~ 5 I) r -0 1

6

7 8 9

10 ==t11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

jf =R311

__________ __ __

I I

I -r----~----------- shy

I I

I

I I

~~~~~6~~~--+----------~-

I I r-u=~-r-=middot-~=JiI-IImiddot----middotmiddot-middotmiddotmiddotmiddotr-middotmiddot-middot-middotmiddot--- --___+-__shy

NUCSl6AMMA ROOM

1--

i

bull ____laquo __bullbull___ I ___L

I I

II ~ ltgtlIe I I EGUIP I IBpoundJI I

i

I _l_____

~ I-Jltl

r

6

(J~Q

existing shelf

10

g

8

7

6

5

4

3

2

l

0-shy

PRELIMINARY PLANNfNG- ONLY

Wiscontit bull oquipmOllI 110 piiiCtcirti ~ Iiit

THIS LAYOUT WST BE APPROVED BEFORE RNAl llRAWlNGS CAN BE STARTED THANK yOU

PROJECT 1l11E

COLUMBUS DIAGNOSTIC IMAGING CUSTOMER PATNUCLEAR ROOM - MILLENIUM MG GE Project cqulppllat AII n- _ 1M atot laquoyeniIor 1 _ lhltIICOLUMBUS INDIANA Monager td~ ~ 01 -- II CW-rInstalrotion PATE P Iot h ~ rcIII ~ _ t ~SCHEME NO081NAQ80 DRAWH BY TlO DAli 07-22-~

Radioactive Wastl And Disposal Record

Policy and Procedure 1 Seal and slore radioactive waste containers behind adequate shielding 2 Indicate Container 10 andor Conlents (ie Hot Trash Sharps etc) 3 Radioactive waste should be held for at least 10 half-lives of the longest-lived radIoisOtope to be disposed 4 Monitor background and surface with a GM 5uNay Meter on its most sensitive scale without shielding prior to

disposal 5 Waste may be disp~d of if activity Is indistinguIshable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash

Survey Meter Code Brand Model Serial Number

1 1_ tI-~ ILLfVl Lle I L 11Ct- 2 rtrfl IUn ll(r Il ) 7)-)

0Lj 3$YJ

last AsS2V DJte of Waste to La lJisposed Isotope to be

of Dis osed of ~1l~~1~~~ 1 C-

o7h6 I~) o~ ~ j I S-ltC lt1A

~8u~Hit5Sltq~W ) 7 jj-) iiWif( r 9q ~~~IEP1fisect ~84~~ ~dJili(5)i-)Jamp --=T~Y 1Jifll-)~ltilli~~ ~lltY ~~iLl ~ r ))RT=_L 2 ~~LL~~Li2 L ~~ laquo44

-~hO~ - 1iI~l7-~pL-r~-h7 ~2 I-l-h 1~)1] r- I ---shy I~I P - -- v- -shy r-~--- I - ---~~

(Providcd by A~edMedical Physics 16771Hi rak Lanemiddot NoblesviIleIN 46060middot 3172n3022

Radioactive Materials Shipment Ret l and Return Container Survey RecOImiddotd

Instruments Usedor SurllJsAction le~eIs Tile Radiation Safety Of11Cer should be immediately Dotilied when radiatioll or cootamination levels to which personnel DeteclorMeier No Make amp Model Serial No

Efficiencymay be exposed elteed tbe rollowing levels

Area

Restricted

Radiation Survey Conmlnatioll Surveys

50 mRlhr lOOODPMI10Ocm 2 2

BKG Cpm I Initials

Report Date Apri122 2012

Facility Columbus Diagnostic Imaging Columbus IN

State License Number Not Supplied USNRC License Number 13-24706-01

$ogrce Identification

Radionuc6de Cobalt-57 Calibrated Activity Date 090708 Calibrated Activity lOmCi Manufacturer Not Supplied Setia1 Number BM01-10 Model Number BMOl1008220102 Source Description Flood Source

Assay Results Counting Efficiency 0762 cpmdptn 1691543 cpmuCi MDA 102 dpm 78 cpm 000005 uCi Background time ofassay 351 cpm)

Grosscpm PtyWipe 347

Instrument used fot Analysis Ludlum Well Counter MN 2200 SIN 198663

Analysis Results Source is not leaking at this time

Removable contamination is lt0005 uCi

Next Leak Test Due

LeakTest Performed By

Analysis Performed By

IpoundI~ I Radiation Safety Officer (signature)

Report Date

Facility

State License Number USNRC License Number

Source Ideptification

Radionuclide Calibrated Activity Date Cahbrated Activity Manufacturer Serial Number Model Number Source Description

Assay Results Counting Efficiency MDA Background time of assay ~cpm)

April 22 2012

Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01

Cs-137 080197 2198 uCi IPL 559-1627 RV-137-200V Dose CaliJIrator Vial Soutce

02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm 000013 uCi 351

Grosscpm DryWtpe 347

Instrument used for Analysis Ludlum Well Counter MN2200 SIN PR 198663

Analysis Results Source is not leaking at this time Removable contamination is lt0005 uCi

Next Leak Test Due

Leak Test Pedormed By

Analysis Performed By

Officer (signature)

__________ __ __

I I

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I I r-u=~-r-=middot-~=JiI-IImiddot----middotmiddot-middotmiddotmiddotmiddotr-middotmiddot-middot-middotmiddot--- --___+-__shy

NUCSl6AMMA ROOM

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bull ____laquo __bullbull___ I ___L

I I

II ~ ltgtlIe I I EGUIP I IBpoundJI I

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6

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existing shelf

10

g

8

7

6

5

4

3

2

l

0-shy

PRELIMINARY PLANNfNG- ONLY

Wiscontit bull oquipmOllI 110 piiiCtcirti ~ Iiit

THIS LAYOUT WST BE APPROVED BEFORE RNAl llRAWlNGS CAN BE STARTED THANK yOU

PROJECT 1l11E

COLUMBUS DIAGNOSTIC IMAGING CUSTOMER PATNUCLEAR ROOM - MILLENIUM MG GE Project cqulppllat AII n- _ 1M atot laquoyeniIor 1 _ lhltIICOLUMBUS INDIANA Monager td~ ~ 01 -- II CW-rInstalrotion PATE P Iot h ~ rcIII ~ _ t ~SCHEME NO081NAQ80 DRAWH BY TlO DAli 07-22-~

Radioactive Wastl And Disposal Record

Policy and Procedure 1 Seal and slore radioactive waste containers behind adequate shielding 2 Indicate Container 10 andor Conlents (ie Hot Trash Sharps etc) 3 Radioactive waste should be held for at least 10 half-lives of the longest-lived radIoisOtope to be disposed 4 Monitor background and surface with a GM 5uNay Meter on its most sensitive scale without shielding prior to

disposal 5 Waste may be disp~d of if activity Is indistinguIshable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash

Survey Meter Code Brand Model Serial Number

1 1_ tI-~ ILLfVl Lle I L 11Ct- 2 rtrfl IUn ll(r Il ) 7)-)

0Lj 3$YJ

last AsS2V DJte of Waste to La lJisposed Isotope to be

of Dis osed of ~1l~~1~~~ 1 C-

o7h6 I~) o~ ~ j I S-ltC lt1A

~8u~Hit5Sltq~W ) 7 jj-) iiWif( r 9q ~~~IEP1fisect ~84~~ ~dJili(5)i-)Jamp --=T~Y 1Jifll-)~ltilli~~ ~lltY ~~iLl ~ r ))RT=_L 2 ~~LL~~Li2 L ~~ laquo44

-~hO~ - 1iI~l7-~pL-r~-h7 ~2 I-l-h 1~)1] r- I ---shy I~I P - -- v- -shy r-~--- I - ---~~

(Providcd by A~edMedical Physics 16771Hi rak Lanemiddot NoblesviIleIN 46060middot 3172n3022

Radioactive Materials Shipment Ret l and Return Container Survey RecOImiddotd

Instruments Usedor SurllJsAction le~eIs Tile Radiation Safety Of11Cer should be immediately Dotilied when radiatioll or cootamination levels to which personnel DeteclorMeier No Make amp Model Serial No

Efficiencymay be exposed elteed tbe rollowing levels

Area

Restricted

Radiation Survey Conmlnatioll Surveys

50 mRlhr lOOODPMI10Ocm 2 2

BKG Cpm I Initials

Report Date Apri122 2012

Facility Columbus Diagnostic Imaging Columbus IN

State License Number Not Supplied USNRC License Number 13-24706-01

$ogrce Identification

Radionuc6de Cobalt-57 Calibrated Activity Date 090708 Calibrated Activity lOmCi Manufacturer Not Supplied Setia1 Number BM01-10 Model Number BMOl1008220102 Source Description Flood Source

Assay Results Counting Efficiency 0762 cpmdptn 1691543 cpmuCi MDA 102 dpm 78 cpm 000005 uCi Background time ofassay 351 cpm)

Grosscpm PtyWipe 347

Instrument used fot Analysis Ludlum Well Counter MN 2200 SIN 198663

Analysis Results Source is not leaking at this time

Removable contamination is lt0005 uCi

Next Leak Test Due

LeakTest Performed By

Analysis Performed By

IpoundI~ I Radiation Safety Officer (signature)

Report Date

Facility

State License Number USNRC License Number

Source Ideptification

Radionuclide Calibrated Activity Date Cahbrated Activity Manufacturer Serial Number Model Number Source Description

Assay Results Counting Efficiency MDA Background time of assay ~cpm)

April 22 2012

Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01

Cs-137 080197 2198 uCi IPL 559-1627 RV-137-200V Dose CaliJIrator Vial Soutce

02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm 000013 uCi 351

Grosscpm DryWtpe 347

Instrument used for Analysis Ludlum Well Counter MN2200 SIN PR 198663

Analysis Results Source is not leaking at this time Removable contamination is lt0005 uCi

Next Leak Test Due

Leak Test Pedormed By

Analysis Performed By

Officer (signature)

~ I-Jltl

r

6

(J~Q

existing shelf

10

g

8

7

6

5

4

3

2

l

0-shy

PRELIMINARY PLANNfNG- ONLY

Wiscontit bull oquipmOllI 110 piiiCtcirti ~ Iiit

THIS LAYOUT WST BE APPROVED BEFORE RNAl llRAWlNGS CAN BE STARTED THANK yOU

PROJECT 1l11E

COLUMBUS DIAGNOSTIC IMAGING CUSTOMER PATNUCLEAR ROOM - MILLENIUM MG GE Project cqulppllat AII n- _ 1M atot laquoyeniIor 1 _ lhltIICOLUMBUS INDIANA Monager td~ ~ 01 -- II CW-rInstalrotion PATE P Iot h ~ rcIII ~ _ t ~SCHEME NO081NAQ80 DRAWH BY TlO DAli 07-22-~

Radioactive Wastl And Disposal Record

Policy and Procedure 1 Seal and slore radioactive waste containers behind adequate shielding 2 Indicate Container 10 andor Conlents (ie Hot Trash Sharps etc) 3 Radioactive waste should be held for at least 10 half-lives of the longest-lived radIoisOtope to be disposed 4 Monitor background and surface with a GM 5uNay Meter on its most sensitive scale without shielding prior to

disposal 5 Waste may be disp~d of if activity Is indistinguIshable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash

Survey Meter Code Brand Model Serial Number

1 1_ tI-~ ILLfVl Lle I L 11Ct- 2 rtrfl IUn ll(r Il ) 7)-)

0Lj 3$YJ

last AsS2V DJte of Waste to La lJisposed Isotope to be

of Dis osed of ~1l~~1~~~ 1 C-

o7h6 I~) o~ ~ j I S-ltC lt1A

~8u~Hit5Sltq~W ) 7 jj-) iiWif( r 9q ~~~IEP1fisect ~84~~ ~dJili(5)i-)Jamp --=T~Y 1Jifll-)~ltilli~~ ~lltY ~~iLl ~ r ))RT=_L 2 ~~LL~~Li2 L ~~ laquo44

-~hO~ - 1iI~l7-~pL-r~-h7 ~2 I-l-h 1~)1] r- I ---shy I~I P - -- v- -shy r-~--- I - ---~~

(Providcd by A~edMedical Physics 16771Hi rak Lanemiddot NoblesviIleIN 46060middot 3172n3022

Radioactive Materials Shipment Ret l and Return Container Survey RecOImiddotd

Instruments Usedor SurllJsAction le~eIs Tile Radiation Safety Of11Cer should be immediately Dotilied when radiatioll or cootamination levels to which personnel DeteclorMeier No Make amp Model Serial No

Efficiencymay be exposed elteed tbe rollowing levels

Area

Restricted

Radiation Survey Conmlnatioll Surveys

50 mRlhr lOOODPMI10Ocm 2 2

BKG Cpm I Initials

Report Date Apri122 2012

Facility Columbus Diagnostic Imaging Columbus IN

State License Number Not Supplied USNRC License Number 13-24706-01

$ogrce Identification

Radionuc6de Cobalt-57 Calibrated Activity Date 090708 Calibrated Activity lOmCi Manufacturer Not Supplied Setia1 Number BM01-10 Model Number BMOl1008220102 Source Description Flood Source

Assay Results Counting Efficiency 0762 cpmdptn 1691543 cpmuCi MDA 102 dpm 78 cpm 000005 uCi Background time ofassay 351 cpm)

Grosscpm PtyWipe 347

Instrument used fot Analysis Ludlum Well Counter MN 2200 SIN 198663

Analysis Results Source is not leaking at this time

Removable contamination is lt0005 uCi

Next Leak Test Due

LeakTest Performed By

Analysis Performed By

IpoundI~ I Radiation Safety Officer (signature)

Report Date

Facility

State License Number USNRC License Number

Source Ideptification

Radionuclide Calibrated Activity Date Cahbrated Activity Manufacturer Serial Number Model Number Source Description

Assay Results Counting Efficiency MDA Background time of assay ~cpm)

April 22 2012

Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01

Cs-137 080197 2198 uCi IPL 559-1627 RV-137-200V Dose CaliJIrator Vial Soutce

02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm 000013 uCi 351

Grosscpm DryWtpe 347

Instrument used for Analysis Ludlum Well Counter MN2200 SIN PR 198663

Analysis Results Source is not leaking at this time Removable contamination is lt0005 uCi

Next Leak Test Due

Leak Test Pedormed By

Analysis Performed By

Officer (signature)

Radioactive Wastl And Disposal Record

Policy and Procedure 1 Seal and slore radioactive waste containers behind adequate shielding 2 Indicate Container 10 andor Conlents (ie Hot Trash Sharps etc) 3 Radioactive waste should be held for at least 10 half-lives of the longest-lived radIoisOtope to be disposed 4 Monitor background and surface with a GM 5uNay Meter on its most sensitive scale without shielding prior to

disposal 5 Waste may be disp~d of if activity Is indistinguIshable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash

Survey Meter Code Brand Model Serial Number

1 1_ tI-~ ILLfVl Lle I L 11Ct- 2 rtrfl IUn ll(r Il ) 7)-)

0Lj 3$YJ

last AsS2V DJte of Waste to La lJisposed Isotope to be

of Dis osed of ~1l~~1~~~ 1 C-

o7h6 I~) o~ ~ j I S-ltC lt1A

~8u~Hit5Sltq~W ) 7 jj-) iiWif( r 9q ~~~IEP1fisect ~84~~ ~dJili(5)i-)Jamp --=T~Y 1Jifll-)~ltilli~~ ~lltY ~~iLl ~ r ))RT=_L 2 ~~LL~~Li2 L ~~ laquo44

-~hO~ - 1iI~l7-~pL-r~-h7 ~2 I-l-h 1~)1] r- I ---shy I~I P - -- v- -shy r-~--- I - ---~~

(Providcd by A~edMedical Physics 16771Hi rak Lanemiddot NoblesviIleIN 46060middot 3172n3022

Radioactive Materials Shipment Ret l and Return Container Survey RecOImiddotd

Instruments Usedor SurllJsAction le~eIs Tile Radiation Safety Of11Cer should be immediately Dotilied when radiatioll or cootamination levels to which personnel DeteclorMeier No Make amp Model Serial No

Efficiencymay be exposed elteed tbe rollowing levels

Area

Restricted

Radiation Survey Conmlnatioll Surveys

50 mRlhr lOOODPMI10Ocm 2 2

BKG Cpm I Initials

Report Date Apri122 2012

Facility Columbus Diagnostic Imaging Columbus IN

State License Number Not Supplied USNRC License Number 13-24706-01

$ogrce Identification

Radionuc6de Cobalt-57 Calibrated Activity Date 090708 Calibrated Activity lOmCi Manufacturer Not Supplied Setia1 Number BM01-10 Model Number BMOl1008220102 Source Description Flood Source

Assay Results Counting Efficiency 0762 cpmdptn 1691543 cpmuCi MDA 102 dpm 78 cpm 000005 uCi Background time ofassay 351 cpm)

Grosscpm PtyWipe 347

Instrument used fot Analysis Ludlum Well Counter MN 2200 SIN 198663

Analysis Results Source is not leaking at this time

Removable contamination is lt0005 uCi

Next Leak Test Due

LeakTest Performed By

Analysis Performed By

IpoundI~ I Radiation Safety Officer (signature)

Report Date

Facility

State License Number USNRC License Number

Source Ideptification

Radionuclide Calibrated Activity Date Cahbrated Activity Manufacturer Serial Number Model Number Source Description

Assay Results Counting Efficiency MDA Background time of assay ~cpm)

April 22 2012

Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01

Cs-137 080197 2198 uCi IPL 559-1627 RV-137-200V Dose CaliJIrator Vial Soutce

02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm 000013 uCi 351

Grosscpm DryWtpe 347

Instrument used for Analysis Ludlum Well Counter MN2200 SIN PR 198663

Analysis Results Source is not leaking at this time Removable contamination is lt0005 uCi

Next Leak Test Due

Leak Test Pedormed By

Analysis Performed By

Officer (signature)

Radioactive Materials Shipment Ret l and Return Container Survey RecOImiddotd

Instruments Usedor SurllJsAction le~eIs Tile Radiation Safety Of11Cer should be immediately Dotilied when radiatioll or cootamination levels to which personnel DeteclorMeier No Make amp Model Serial No

Efficiencymay be exposed elteed tbe rollowing levels

Area

Restricted

Radiation Survey Conmlnatioll Surveys

50 mRlhr lOOODPMI10Ocm 2 2

BKG Cpm I Initials

Report Date Apri122 2012

Facility Columbus Diagnostic Imaging Columbus IN

State License Number Not Supplied USNRC License Number 13-24706-01

$ogrce Identification

Radionuc6de Cobalt-57 Calibrated Activity Date 090708 Calibrated Activity lOmCi Manufacturer Not Supplied Setia1 Number BM01-10 Model Number BMOl1008220102 Source Description Flood Source

Assay Results Counting Efficiency 0762 cpmdptn 1691543 cpmuCi MDA 102 dpm 78 cpm 000005 uCi Background time ofassay 351 cpm)

Grosscpm PtyWipe 347

Instrument used fot Analysis Ludlum Well Counter MN 2200 SIN 198663

Analysis Results Source is not leaking at this time

Removable contamination is lt0005 uCi

Next Leak Test Due

LeakTest Performed By

Analysis Performed By

IpoundI~ I Radiation Safety Officer (signature)

Report Date

Facility

State License Number USNRC License Number

Source Ideptification

Radionuclide Calibrated Activity Date Cahbrated Activity Manufacturer Serial Number Model Number Source Description

Assay Results Counting Efficiency MDA Background time of assay ~cpm)

April 22 2012

Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01

Cs-137 080197 2198 uCi IPL 559-1627 RV-137-200V Dose CaliJIrator Vial Soutce

02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm 000013 uCi 351

Grosscpm DryWtpe 347

Instrument used for Analysis Ludlum Well Counter MN2200 SIN PR 198663

Analysis Results Source is not leaking at this time Removable contamination is lt0005 uCi

Next Leak Test Due

Leak Test Pedormed By

Analysis Performed By

Officer (signature)

Report Date Apri122 2012

Facility Columbus Diagnostic Imaging Columbus IN

State License Number Not Supplied USNRC License Number 13-24706-01

$ogrce Identification

Radionuc6de Cobalt-57 Calibrated Activity Date 090708 Calibrated Activity lOmCi Manufacturer Not Supplied Setia1 Number BM01-10 Model Number BMOl1008220102 Source Description Flood Source

Assay Results Counting Efficiency 0762 cpmdptn 1691543 cpmuCi MDA 102 dpm 78 cpm 000005 uCi Background time ofassay 351 cpm)

Grosscpm PtyWipe 347

Instrument used fot Analysis Ludlum Well Counter MN 2200 SIN 198663

Analysis Results Source is not leaking at this time

Removable contamination is lt0005 uCi

Next Leak Test Due

LeakTest Performed By

Analysis Performed By

IpoundI~ I Radiation Safety Officer (signature)

Report Date

Facility

State License Number USNRC License Number

Source Ideptification

Radionuclide Calibrated Activity Date Cahbrated Activity Manufacturer Serial Number Model Number Source Description

Assay Results Counting Efficiency MDA Background time of assay ~cpm)

April 22 2012

Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01

Cs-137 080197 2198 uCi IPL 559-1627 RV-137-200V Dose CaliJIrator Vial Soutce

02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm 000013 uCi 351

Grosscpm DryWtpe 347

Instrument used for Analysis Ludlum Well Counter MN2200 SIN PR 198663

Analysis Results Source is not leaking at this time Removable contamination is lt0005 uCi

Next Leak Test Due

Leak Test Pedormed By

Analysis Performed By

Officer (signature)

Report Date

Facility

State License Number USNRC License Number

Source Ideptification

Radionuclide Calibrated Activity Date Cahbrated Activity Manufacturer Serial Number Model Number Source Description

Assay Results Counting Efficiency MDA Background time of assay ~cpm)

April 22 2012

Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01

Cs-137 080197 2198 uCi IPL 559-1627 RV-137-200V Dose CaliJIrator Vial Soutce

02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm 000013 uCi 351

Grosscpm DryWtpe 347

Instrument used for Analysis Ludlum Well Counter MN2200 SIN PR 198663

Analysis Results Source is not leaking at this time Removable contamination is lt0005 uCi

Next Leak Test Due

Leak Test Pedormed By

Analysis Performed By

Officer (signature)