• ~s!l\~EfrT!J: 600 MT Highway 91 South · Dillon, MT 59725 · ( 406) 683-3000

25 September 2018

US NRC Region IV Materials Licensing Attention: Carol Hill 1600 East Lamar Blvd. Arlington, TX 76011

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DNMS

RE: Material License 25-29088-01

SUBJECT: Termination of Materials License

This letter is to notify you of our intent to terminate our Materials License effective at the end of the current term- October 31, 2018. Included you will find the required Form NRC-314 which was originally submitted 7/10/16.

I have included my contact information for your convenience.

Resp~~lly,,/ / ,.,

YAii~ ~ Robin Johnson RT(R) MHA 600Hwy 91 So Dillon, MT 59725 406-683-3104 rj ohnson@barretthospital.org

PUBLIC Cl Immediate Release

'jt-Normal Release

NON-PUBLIC Cl A.3 Sensitive-Security Related Cl A.7 Sensitive Internal Cl Other: ·--- - -

Reviewer: //J{1Z: Date:~ '6

Barrett Hospital & HealthCare provides compassionate care, healing and health-improving services to all community members throughout life 'sjoumey. ....

6 1 0 0 7 8

NRC FORM 314 <-,P"Rliiatt,e,.,, U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY 0MB: NO. 3150-0028 EXPIRES: 02/28/2017 (02-2014) ~"" ~ 10CFR30.36(j)(1); • J~· ':, 40.42(i)(1i; 70.380)(1); ; .· .• . ·. . . . ~. and 72.54(k)(5)(1)(1) ·~· ··· · /

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CERTIFICATE OF DISPOSITION OF MATERIALS

Estimated burden per response to comply with this mandatory collection request 30 minutes. This submittal is used by NRC as part of the basis for its detennination that the facility is released for unresbicted use. Send comments regarding burden estimate to the FOIA, Plivacy, and lnfonnation Collections Branch (T-5 F53), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by internet e-mail to lnfocollects. Resource@nrc.gov, and to the Desk Officer, Office of lnfonnation and Regulatory Affairs, NEOB-10202, (3150-0028), Office of Management and Budget Washington, DC 20503. If a means used to impose an infonnation collection does not display a currenUy valid 0MB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the infonnation collection.

LICENSEE NAME AND ADDRESS LICENSE NUMBER DOCKET NUMBER

Barrett Hospital & Healthcare 600 Highway 91 South Dillon, Montana 59725

D This license has expired.

25-29088-01

LICENSE EXPIRATION DATE

A. LICENSE STATUS (Check the appropriate box)

D This license has not yet expired; please terminate it.

B. DISPOSAL OF RADIOACTIVE MATERIAL

September 30, 2021

(Check the appropriate boxes and complete as necessary. If additional space is needed, provide attachments)

The licensee, or any individual executing this certificate on behalf of the licensee, certifies that:

D 1. No radioactive materials have ever been procured or possessed by the licensee under this license.

D 2. All activities authorized by this license have ceased, and all radioactive materials procured and/or possessed by the licensee under this license number cited above have been disposed of in the following manner.

[Z] a. Transfer of radioactive materials to the licensee listed below:

transferred to NRC License #49-27531-01, Front Range Nuclear Services, 5/15/16, Valerie Johnson, RSO 307-637-4199; transferred to CA License #2105-30, Thomas Gray & Associates, 6/13/16, Richard G. Gallego, RSO

D b. Disposal of radioactive materials:

D 1. Directly by the licensee:

D 2. By licensed disposal site:

D 3. By waste contractor:

[Z] c. 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 [Z] 1. A radiation survey was conducted by the licensee. The survey confirms:

[Z] a. the absence of licensed radioactive materials

[Z] b. that any remaining residual radioactivity is within the limits of 10 CFR 20, Subpart E, and is ALARA.

[Z] 2. A copy of the radiation survey results:

[Z] a. is attached; or D b. is not attached (Provide explanation); or D c. was forwarded to NRC on:

D 3. A radiation survey is not required as only sealed sources were ever possessed under this license, and Date

D a. The results of the latest leak test are attached; and/or D b. No leaking sources have ever been identified.

The person to be contacted regarding the information provided on this form:

NAME TITLE TELEPHONE (Include Area Code) E-MAIL ADDRESS

Jefferson Fairbanks Radiation Safety Officer (208) 861-6501 fairbanj@slhs.org

Mail all future correspondence regarding this license to:

Robin Johnson, Director of Medical Imaging, Barrett Hospital & Healthcare, 600 Highway 91 South, Dillon, Montana 59725

C. CERTIFYING OFFICIAL I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT

PRINTED NAME AND TITLE SIGNATURE DATE

Jefferson Fairbanks, Radiation Safety Officer 7/10/16

WARNING: FALSE STATEMENTS IN THIS CERTIFICATE MAY BE SUBJECT TO CIVIL AND/OR CRIMINAL PENALTIES. NRC REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRC BE COMPLETE ANO ACCURATE IN ALL MATERIAL RESPECT.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.

NRC FORM 314 (02-2014) a1oora

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~arrett Hospital & HealthCare Clinic -30 MT Highway 91 South Dillon, MT 59725

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NRC FORM 532 U.S. NUCLEAR REGULATORY COMMISSION (05-2016) r,-t>"'"l"Q(I<.,

l~\ • 0 ACKNOWLEDGEMENT - RECEIPT OF CORRESPONDENCE ; . \ I .,.. ....

Name and Address of Applicant and/or Licensee Date

I 10/02/2018 I

I License Number{s}

Ms. Robin L. Johnson, MHA 25-29088-01 I Barrett Hospital & Healthcare

Mail Control Number{s) 600 Highway 91 South I Dillon, MT 59725 610078 I Licensing and/or Technical Reviewer or Branch

IC.Hill I This is to acknowledge receipt of your: 0 Letter and/or 0 Application Dated: 09/26/2018

The initial processing, which included an administrative review, has been performed.

D Amendment [{] Termination D New License D Renewal

D 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: htt~ ://www.nre.gov/read i n.g-cm/doc-collectionslf ormsla rc53j. gdf

• Follow the instructions on the form for submission.

0 The following administrative omissions have been identified:

NRG Form 314 was not signed. Please send an updated copy with your signature.

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 76011-4511 (817) 200-1103 or (817) 200-1140

NRC FORM 532 (05-2016)

BETWEEN:

Accounts Receivable/Payable and

Regional Licensing Branches

[ FOR ARPS USE ] INFORMATION FROM WBL -·- ·······------ ------------ --- ·

Program Code: 0381 O Status Code: Pending Termination Fee Category:3P Exp. Date: Fee Comments: Decom Fin Assur Reqd: N

License Fee Worksheet - License Fee Transmittal A. REGION

1. APPLICATION ATIACHED Applicant/Licensee: Barrett Hospital & Healthcare

Received Date: 10/01/2018 Docket Number: 3033800 Mail Control Number: 610078 License Number: 25-29088-01

Action Type: Termination

2. FEE ATTACHED

Amount:

Check No.:

I 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