Columbus Diagnostic Imaging
August 28 2012
United States Nuclear Regulatory Commission Region III 2443 Warrenville Road Suite 210 Lisle IL 60532-4352
RE Control Number 576969
Dear Colleen Carol Casey
This letter is in response to our request for additional information
Attached is the corrected termination letter in regards to License 13-26797-01 The date was corrected
1 Please see attached Close Out Survey 2 Attached are the sealed sources packing List showing receipt by an authorized entity 3 CFR 3111 materials were never possessed or in use at Columbus Diagnostic Imaging 4 Please see Certificate of Instrument Detection Efficiency
Please contact our Administrator Rhonda Lennon at 812376-1000 for further clarification if you desire
Sincerely
9aJtcJ~ Robert A DeWeese M D Radiation Safety Officer Columbus Imaging Associates dba Columbus Diagnostic Imaging
pound0 SE 10 lUll 790 Creekview Drivemiddot Columbus IN 47201middot (812) 376-1000middot (888) 689-42tttCpoundV
Fax (812) 376-6665middot wwwcolumbusimagingcom
Columbus Diagnostic Imaging
July 19 2012
United States Nuclear Regulatory Commission Region III 2443 Warrenville Road Suite 210 Lisle IL 60532-4352
RE License 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 K Breeden III MS DABR
Please contact our Administrator Rhonda Lennon at 812376-1000 for further clarification if you desire
Robert A DeWeese MD Radiation Safety Officer Columbus Imaging Associates dba Columbus Diagnostic Imaging
790 Creekview Drivemiddot Columbus IN 47201middot (812) 376-1000middot (888) 689-4200 Fax (812) 376-6665middot wwwcolumbusimagingcom
APPROVED BY OMB NO 3150-0028 EXPIRES 1013112013 (02012) NRC FORM 314 US NUCLEAR REGULATORY COMMISSION
Estimated burdampn per responSamp to comply with this mandatory collection request 30 minutes 10 CFR 30360)(1) 40420)(1) This submittal is uSampd by NRC as part 01 the basis lor its determination tIlet the facility is
released for unrestricted use Send comments regardil19 burden estimate to the Information Services Branch (T -5 F53) Us Nuclear Regulatory Commission Washington DC 20555-0001 or by internet amall to InfocollectsResourcenrcgov and to the Desk Officer Office of
70 38U)(1 ) and 7254(k)(5)(1)(1)
CERTIFICATE OF DISPOSITION OF MATERIALS Information and Regulatory Affairs NEOBmiddot10202 (3150-0028) Office of Management and Budget Washington DC 20503 If a means used to Impose an Information colleCtiOn does not display a currently valid OMB control number the NRC may not conduct or sponsor and a person Is not required to respond to the Information collection
LICENSEE NAME AND ADDRESS LICENSE NUMBER DOCKET NUMBER
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)o This license has expired [] This license has not yet expired please terminate it
B DISPOSAL OF RADIOACTIVE MATERIAL (Check the appropriate boxes and complete as necessary additional space is needed provide attachments)
The licensee or 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 license 0 [] 2 All activities authorized by this license have ceased and all radioactive materials procured andor possessed by the licensee
under this license number cited above have been disposed of in the following manner
[] a Transfer of radioactive materials to the licensee listed below
Eckert and Ziegler Isotope Products Inc dba Isotope Products Laboratories California Lic 1509-19 Cary Renquist RSO
CIS- ac~JQ[]b Disposal of radioactive materials
[]1 Directly by the licensee
All radioactive waste that was being held for as decay-in storage has been disposed of properly as it has been held for greater than 10 half-lives and was indistinguishable from background exposure rate levels See attached log
02 By licensed disposal site
3 By waste contractor
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
[] 1 A radiation survey was conducted by the licensee The survey confirms
[] a the absence of licensed radioactive materials
Ob that any remaining residual radioactivity is within the limits of 10 CFR 20 Subpart E and is ALARA
[] 2 A copy of the radiation survey results
[] a is attached or b is not attached (Provide explanation) or c was forwarded to NRC on - _
Date ~-
o 3 A radiation survey is not required as only sealed sources were ever possessed under this license and
[] a The results of the latest leak test are attached andor [] b No leaking sources have ever been identified
The person to be contacted regarding the information provided on this form TELEPHONE (Include Are Code) IE-MAIL ADDRESSNAME I~ITLE
812-376-1000 rhond a [ennonyahoocomRhonda Lennon Practice Manager
Mail all future colTespondence regarding this license to
Rhonda Lennon at address noted above
C CERTIFYING OFFICIAL I CERTIFY UNDER PENALTY OF PER IIIrJV TI-IAT THE FOREGOING IS TRUE AND CORRECT
~~~
I~~ ~~~ ~~~~~~ ~ ID~~~ WARNING F1tSE STATEMENTS IN THIS CERTIFICATE MAY BE SOBJECT TO CIVIL AileOR CRIMINAL PENAL TIES NRC REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRC BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECT 18 USC 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 MATIER WITHIN ITS JURISDICTION
NRC FORM 314 (05middot2012)
Medical Physics Survey Sealed Source Inventory
Facility Columbus Diagnostic Imaging Department Nuclear Medicine
Location Columbus Indiana Date July 18 2012
bull Nuclide
Cs-137 i
Cs-137
Cs-137
Cs-137
Co-57
I
I
i
Activity Date Model Serial No Type
I RV-137shyDose
2198uCi 8197 200V
559-162-7 Calibrator Vial
I
Rod 01065uCi i 8197 IPL 488-31-2
I
Button
10 uCi 1295 None 4646
i shy
Button
10 uCi
I 1295 None 4656
bull
I _shy
Flood 10mCi bull 917108 BM01-10 BM011008220102
Location Present
Hot Lab No returned bull to
manufacturer Hot Lab No returned
to
Ludlum Survey man ufaCturer~1
middot Yes exempt bull Meter quantity to
be sold with
bull camera
I Ludlum Survey bull Yes exempt I Meter
i
quantity to be sold with
camera Hot Lab I No returned
to i manufacturer
Comments Ambient Exposure Rate Survey of Sealed Sources ( Ludlum 14C SN141804 001 mRhr)
Radiation Safety Officer
Provided by Advanced Medical Physics 16770 Cedar Creek Lane Inoblesville IN 46060 3172233022
1m Bathroom l
( -20 imaging
COLUMBUS DIAGNOSTIC IMAGING DAILY AREA SURVEYS
MONTH YEAR -
1 Dose Preparation
2 Dose Calibration l~ 3 Hot Trash Cttl(rhfJ ) 4 Sealed Source Storage(tm
5 Patient Injection Area 6 Gamma Camera 7 Computer Console
~ H~~~ OJIJI
G) Jm~j() 1raquo Door lO-IS ~~ lab t1Olt l-w ~t5~~
flt901f1 flDO (
Ll-- ~s~ J 1 H (~ (t1firl
Trigger Levels-mRhr Bkgd
Day mRhr 1 2 3 4 5 6 7 I
8 9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
20 20 20 20 10 10 05 ~ HandsClothinq Initials Comments 1 2 3 4 5 6 7 8 111 (
t-) ft -gtY v r A U lLI_) l
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PRELIMINARY PCANtflNG ONLY PROJECT TITLE
COLUMBUS DIAGNOSTIC IMAGING NUCLEAR ROOM - MILLENIUM MG
COLUMBUS INDIANA SCHEME NO08INA080 DRAWN BY TlD DATE 07-22-0
t)~o
THIS LAYOUT MUST BE APPROVED BEFORE FINAL DRAWINGS CAN 8E STARTED THANK YOU
CUSTOMER DATE
Of ProjectManagerInitalfotion DATE
tlitwoukec bull - -- - - _ - - - WJScollSin
This eq~t loyouIlf(ftCO ue pin and inI_ndlon 0 Ill iMIl_ cqolpmcnt bullbullmporuonb 11gt I bo IlIltIctol 11101 dodor Iocol reqW_ Ihltgtt could Impltlo lite pnt f III ~I It tlllOlns tbo ClIIIom rupbltJly for uriog III oito and flgtOi eqipmnl pIoltomont pIl6gt Milgt 011 appKcble federal otQt ofldor Deal requiremDn15
Radioactive Wastt ~nd Disposal Record
Policy and Procedure 1 Seal and store radioactive waste containers behind adequate shielding 2 Indicate Container ID andor Contents (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 surtace with a GM Survey Meter on its most sensitive scale without shielding prior to
disposal 5 Waste may be disposed of if activity is indistinguishable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash
0L] ~1YJ
Survey Meter Code
1
2
3
Model Serial Number
c_ r
ttIfn Last Assay 08te of
Waste to lie lJisposed of
r~tko~~middot~-middot~~ oh-ihi _gt Dt( -1
Container 10 JContents
r] tJG-~
Survey Meter
141 cl~fshy n1ht hr~~ch ~
frl-) ~~it1sectP1W~G 1--) I ~ r ~g C1Yl -f~~~llS IO~ ~J1j 84fi12sectt~ ~Jriilif~r)ltJamp --Q qCM Ah2 ~~11 ~ts-h shy I~m ~
~ ~-)7J I~71PZ~~jh 510~ - 1D I ~ I7rD-~ tL ~~1I=1 )jj I -gt J-poundiLill-~7iT-)ridil~~~ tC)V
f n ( - I I M--shy P ~- - v- -shy P -4 shy I ~ if I
f
1 Provided by Advanced Medical Physics 16770 c( ~reek Lane Noblesville IN 46060middot 3172233022 (
m
Radioactive Materials Shipment Rei (and Return Container Survey Record
Action Levels The Radiation Safety Omcer should be immediately notified when radiation or contamination level$ to whicb personnel may be exposed exceed tbe (ollowjng levels
Area Radiation Survey Contamination Surveys
Instruments Usedor Surveys
Meter No Make amp Model
Restricted 50 m81hr J 1OOODPMJIOOcm I 2 tr 0-- I I noV 1-----1
Unrestricted 20 m81hr I 1000 DPMllOO em 1] 3
Serial No Detector Efficiency
Note LQ indicates that the ack e does not exceed s ecified limits fur Limited QuantitidiJlhitm_ellts____---__---_--_________-- Receiot Sm-vey
Container ILabel I IT ITranspo-rt-middoty--=---------+---~c----JA-1t-c~-----+-L---------l----D-at-e lContact
No or III Index 3 mRlhr BKG Initials Retumed I mRlhr
--shy
Date
cm
BKG Cpm Initials
I
Report Date
Facility
State License Number USNRC License Number
Source Identification
Radionuclide Calibrated Activity Date Calibrated 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 13-24706-01
Cobalt-57 090708 10mCi Not Supplied BM01-10 BMOll008220102 Flood Source
0762 cpmdp~ 1691543 cpmuCi 102 dp~ 78 cp~ 000005 uCi 351
Activity (uCi)Gross cpm Netcpm DPM Dry Wipe 000000347 0 0
Instrument used for Analysis Ludlum Well Counter MN2200 SIN 198663
Analysis Results Source is not leaking at this time
Removable contamination is lt0005 uCi
Next Leak Test Due
Leak Test Performed By
Analysis Performed By
Radiation Safety Officer (signature)
I
Report Date
Facility
State License Number USNRC License Number
Source Identification
Radionuclide Calibrated Activity Date Calibrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
Apri122 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137
080197 2198uCi IPL 559-1627 RV-137-200V
Dose Calibrator Vial Source
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm OOOQ13 uCi 351
Activity (uCi) Gross cpm Netcpm DPM Dry Wipe 0000000347 0 0
Instrument used for Analysis
Analysis Results
Next Leak Test Due
Leak Test Performed By
Analysis Performed By
Ludlum Well Counter MN2200 SIN PR 198663
Source is not leaking at this time Removable contamination is lt0005 uCi
I October-12 I t IrftL--WillWn K Btteden III MS D~~ April 62012 ~~ fz--v ( t- shy
Edward E WrolewDABSNM
April 22 2012
Officer (signature)
Clouse out survey for Columbus Imaging Associates dba Columbus Diagnostic Imaging
6182012 USNRC Materials License 13-26797-01
IL~ L~~~())~ Location Location Description Exposure Rate (mRhr) Wipe activity(dpml00cmJ2) ~~
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 la b floor
11 hot lab floor
12 hot lab floor
13 hot lab floor
14 hot lab 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
33 275
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-oJ Jl9~( 11 (IQ IJ J(f~ t6JVe
(e-AIl)) P llan Po tVlCft r~
~~~~ ~~ ~ j
-efTIrf 1h1r f~ h~ vr 6~1
~~~~
CERTIFICATE OF CALIBRATION
Customer Advanced Med Phys
Manufacturer BIODEX
Detector Type GM
Detector Model X End Window
D Side Window
X Pancake
High Voltage -y
Date Received March 20 2012
Calibration Date March 30 2012
NEXT Calibration Due March 30 2013
Calibration Data
Scale Distance
(cm)
Instrument MIN 14C
Probe MIN 44-9 Calibration Geometry X Probe II
Cap ON
Window Open Window Closed
Battery Test Acceptable
Reset Check Test Acceptable
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Activity and SIN
Calculated Measured
Reading mRhr
SIN 101782 SIN PR2424100
X Probe Perpendicular
X Cap Off
] NA
Correction Factor
100x 1000 1813 800800
200 100x 1000 1813 200
x 100 4053 160
x 100 4053 40
x 10 4053 16 160 100
x 10 4053 4 40 100
xl xl
I I
4053
4053 I I
16 160
OA OAO 100
100
x 1 12817 016 016 100
x 1 12817 004 004 100
Comments All instrument readings were within +1- 10 at the time of calibration for all scales used
Applicable correction factors are noted above
This instrument must be checke for proper operation with the dedicated check source prior to
use A reading as indicated above denotes proper operation
UNABLE TO CALIBRATE x 100 SCALE Calibration Source Cs-137 Calibration Date January 15 1985 (+- 3 NBS)
Calibrated Activity 0154 Ci Roentgenshr 1m 00493
MN 773 Source ID S-526
SIN 216 Manufacturer Tech-Ops
Calculated Activity 00821 Ci Roentgenshr 1m 002630 March 30 2012
Photon Measurements Plus Calibrated By _________________
1427 West 86th Street Suite 282 Edward E Wroblewski MA DABSNM
Indianapolis IN 46260
tele 317755-9688 USNRC Materials License Numbcr-13-32533-01
RETURN PACKING LIST All information must be provided to ensure proper
SENOTO
Eckert ampZiegler Isotope Products
1800 North Keystone Street Burbank CA 91504
~~nTjjlllhnmiddot661)309-1010 1-~__ILI~tt--L=-=I--_ampjICI~=----E_~ Fax (661) 257-8303
Email emaIl nucmedsalesezagcom
list must be affixed to the Q~12S and
RETURN RA- 2I fI ofthe package Each returned source EZlflmustb dina1)nHOOne exchange basis ~nly
please contact euroZIP customer service considerations
Reference Serial Capsule Source Wipe Nuclide Activity Date Number D~cription TestsSnCi- J amptQoosaao I ~ IRAbQ)~
(l4t OItli lJIH9f ~ lId) 8J2(gtaL cfgt-57 ~tJ--raquo~s DNo I i i
2) DYes 0 No
3) ___ DYeS 0 No
4) ___ DYes 0 No
If source is damaged broken or le~king describe under Capsule ~scription sectiOfl and submit a copy of the last leak test Keep a copy of this form for your recOrd~ It may be requested by your regulatory agency I acknowledge that the above information is true ~o the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Number (Required) -- shy
FOR EZIP USE OfllY
EZIP has received ~he radioactive sources listed above e(cel)t as noted below
Receivers Name
Receipt Date -LO
Sources not received NA
RETURN PACKING LIST All information must be provided to ensure proper handling of your return
FROM SENDTO
Company Name
Address
City
i Eckert amp Ziegler Isotope Products
1800 North Keystone Street Burbank CA 91504 Telephone (661)309-1010 Fax (661)257-8303 Email nucmedsalesezagcom
RETURN RAshy 2( STOP This packing list must be affixed to the OllTSIOE and a copy placed inside of the package Each returned source to EZIP must be on a one-to-one exchange basisnnly For additional returns please contact poundZIP customer service for additional cost considerations
Nuclide Activity
1gtamp5-1312fj$ C
2) Csift t)middotlCfflAC
3) ___
4) ___
Reference Date
Serial Number SS shy ~t-
crt Itt lft6-3-L
Capsule Description
Source Wipe Tests SnCi
IN Gi(tIJ~- )I~) S~ e~ 0 No
amp) St1 rC f ~o DYes 0 No
CJ Yes 0 NCigt
If source is damaged broken or leaking describe under Capsule Description section and submit a copy of the last leak test Keep a copy of this form for your records It may be requested by your regulatory agency I acknowledge that the above information is true to the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Num~er (Required)
FOR EZIP USE ONLY
EZIP has received the radioactive sources listed above except as noted below
Receivers Name~I~~ tgtltl~ ~No~Q1)s _Co -~bullbullbull - bullbullbull~-~~ -----shy ~ -- - -shy
Receipt Date ~ ~)- ) I
Sources not received riNA
1a902of2
Certificate of Instrument Detection Efficiency for
Columbus Diagnostic Imaging Columbus Indiana
April 6 2012
Instrument Capintec Caprac Well Counter
Instrument Net Conversion DetectionSource Activity Calibration Date
Settin CPM Factor Efficienc
Co-57 09967 uCi 4110 Well 302213 112dpmcpm 8929
MDA= 5x10-5
106 dpm
Results These results are within acceptable limits
-qA Radiation Safety Officer
Advanced Medical Physics LLC 9095 Doral CourtD bull Indianapolis IN 462503172233022 3178495058(fax) ~~~~
Certified in Medical Nuclear Physics by the American Board of Radiology
-~ C~lumbus II~USPOSTAGE Diagnostic ~ IUS POSTAGE $ 0 105 $ 0045 RRSTClASS
bull L l1li-shyImaging RRST ClASS
Mailed From 47201 bull 091042012 031A 0002309440
J ~ 031A 0002309440790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200
Fax (812) 376-6665
Columbus Diagnostic Imaging
July 19 2012
United States Nuclear Regulatory Commission Region III 2443 Warrenville Road Suite 210 Lisle IL 60532-4352
RE License 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 K Breeden III MS DABR
Please contact our Administrator Rhonda Lennon at 812376-1000 for further clarification if you desire
Robert A DeWeese MD Radiation Safety Officer Columbus Imaging Associates dba Columbus Diagnostic Imaging
790 Creekview Drivemiddot Columbus IN 47201middot (812) 376-1000middot (888) 689-4200 Fax (812) 376-6665middot wwwcolumbusimagingcom
APPROVED BY OMB NO 3150-0028 EXPIRES 1013112013 (02012) NRC FORM 314 US NUCLEAR REGULATORY COMMISSION
Estimated burdampn per responSamp to comply with this mandatory collection request 30 minutes 10 CFR 30360)(1) 40420)(1) This submittal is uSampd by NRC as part 01 the basis lor its determination tIlet the facility is
released for unrestricted use Send comments regardil19 burden estimate to the Information Services Branch (T -5 F53) Us Nuclear Regulatory Commission Washington DC 20555-0001 or by internet amall to InfocollectsResourcenrcgov and to the Desk Officer Office of
70 38U)(1 ) and 7254(k)(5)(1)(1)
CERTIFICATE OF DISPOSITION OF MATERIALS Information and Regulatory Affairs NEOBmiddot10202 (3150-0028) Office of Management and Budget Washington DC 20503 If a means used to Impose an Information colleCtiOn does not display a currently valid OMB control number the NRC may not conduct or sponsor and a person Is not required to respond to the Information collection
LICENSEE NAME AND ADDRESS LICENSE NUMBER DOCKET NUMBER
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)o This license has expired [] This license has not yet expired please terminate it
B DISPOSAL OF RADIOACTIVE MATERIAL (Check the appropriate boxes and complete as necessary additional space is needed provide attachments)
The licensee or 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 license 0 [] 2 All activities authorized by this license have ceased and all radioactive materials procured andor possessed by the licensee
under this license number cited above have been disposed of in the following manner
[] a Transfer of radioactive materials to the licensee listed below
Eckert and Ziegler Isotope Products Inc dba Isotope Products Laboratories California Lic 1509-19 Cary Renquist RSO
CIS- ac~JQ[]b Disposal of radioactive materials
[]1 Directly by the licensee
All radioactive waste that was being held for as decay-in storage has been disposed of properly as it has been held for greater than 10 half-lives and was indistinguishable from background exposure rate levels See attached log
02 By licensed disposal site
3 By waste contractor
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
[] 1 A radiation survey was conducted by the licensee The survey confirms
[] a the absence of licensed radioactive materials
Ob that any remaining residual radioactivity is within the limits of 10 CFR 20 Subpart E and is ALARA
[] 2 A copy of the radiation survey results
[] a is attached or b is not attached (Provide explanation) or c was forwarded to NRC on - _
Date ~-
o 3 A radiation survey is not required as only sealed sources were ever possessed under this license and
[] a The results of the latest leak test are attached andor [] b No leaking sources have ever been identified
The person to be contacted regarding the information provided on this form TELEPHONE (Include Are Code) IE-MAIL ADDRESSNAME I~ITLE
812-376-1000 rhond a [ennonyahoocomRhonda Lennon Practice Manager
Mail all future colTespondence regarding this license to
Rhonda Lennon at address noted above
C CERTIFYING OFFICIAL I CERTIFY UNDER PENALTY OF PER IIIrJV TI-IAT THE FOREGOING IS TRUE AND CORRECT
~~~
I~~ ~~~ ~~~~~~ ~ ID~~~ WARNING F1tSE STATEMENTS IN THIS CERTIFICATE MAY BE SOBJECT TO CIVIL AileOR CRIMINAL PENAL TIES NRC REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRC BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECT 18 USC 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 MATIER WITHIN ITS JURISDICTION
NRC FORM 314 (05middot2012)
Medical Physics Survey Sealed Source Inventory
Facility Columbus Diagnostic Imaging Department Nuclear Medicine
Location Columbus Indiana Date July 18 2012
bull Nuclide
Cs-137 i
Cs-137
Cs-137
Cs-137
Co-57
I
I
i
Activity Date Model Serial No Type
I RV-137shyDose
2198uCi 8197 200V
559-162-7 Calibrator Vial
I
Rod 01065uCi i 8197 IPL 488-31-2
I
Button
10 uCi 1295 None 4646
i shy
Button
10 uCi
I 1295 None 4656
bull
I _shy
Flood 10mCi bull 917108 BM01-10 BM011008220102
Location Present
Hot Lab No returned bull to
manufacturer Hot Lab No returned
to
Ludlum Survey man ufaCturer~1
middot Yes exempt bull Meter quantity to
be sold with
bull camera
I Ludlum Survey bull Yes exempt I Meter
i
quantity to be sold with
camera Hot Lab I No returned
to i manufacturer
Comments Ambient Exposure Rate Survey of Sealed Sources ( Ludlum 14C SN141804 001 mRhr)
Radiation Safety Officer
Provided by Advanced Medical Physics 16770 Cedar Creek Lane Inoblesville IN 46060 3172233022
1m Bathroom l
( -20 imaging
COLUMBUS DIAGNOSTIC IMAGING DAILY AREA SURVEYS
MONTH YEAR -
1 Dose Preparation
2 Dose Calibration l~ 3 Hot Trash Cttl(rhfJ ) 4 Sealed Source Storage(tm
5 Patient Injection Area 6 Gamma Camera 7 Computer Console
~ H~~~ OJIJI
G) Jm~j() 1raquo Door lO-IS ~~ lab t1Olt l-w ~t5~~
flt901f1 flDO (
Ll-- ~s~ J 1 H (~ (t1firl
Trigger Levels-mRhr Bkgd
Day mRhr 1 2 3 4 5 6 7 I
8 9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
20 20 20 20 10 10 05 ~ HandsClothinq Initials Comments 1 2 3 4 5 6 7 8 111 (
t-) ft -gtY v r A U lLI_) l
J I U JI t I ~l1 OVV ~ I IJ 11 -
I
I
I
I c
i
I
I i
~~~~=~~-------- t----shy -shy----+-I----shyI I I I
I
I i I
I
~~~~~=~~C~~--- -1----------- ---Jshy
NUC-SJGAMMA
cORRIDOR cru
I I
SI 1 ltFe I I EQUIPI 11441
I
I
I I
t1tl~~-middot - middot--~~itmiddotl----~-middot-middot-I---middot-middot-middotmiddot--middot--- -------+-_----shy
6
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~ shy ~fIr- _ _ -gt-- v~~
I existing shelf
10
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8
7
6
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4
3
2
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OI~~__L--k__~~__~~__4-~~~
PRELIMINARY PCANtflNG ONLY PROJECT TITLE
COLUMBUS DIAGNOSTIC IMAGING NUCLEAR ROOM - MILLENIUM MG
COLUMBUS INDIANA SCHEME NO08INA080 DRAWN BY TlD DATE 07-22-0
t)~o
THIS LAYOUT MUST BE APPROVED BEFORE FINAL DRAWINGS CAN 8E STARTED THANK YOU
CUSTOMER DATE
Of ProjectManagerInitalfotion DATE
tlitwoukec bull - -- - - _ - - - WJScollSin
This eq~t loyouIlf(ftCO ue pin and inI_ndlon 0 Ill iMIl_ cqolpmcnt bullbullmporuonb 11gt I bo IlIltIctol 11101 dodor Iocol reqW_ Ihltgtt could Impltlo lite pnt f III ~I It tlllOlns tbo ClIIIom rupbltJly for uriog III oito and flgtOi eqipmnl pIoltomont pIl6gt Milgt 011 appKcble federal otQt ofldor Deal requiremDn15
Radioactive Wastt ~nd Disposal Record
Policy and Procedure 1 Seal and store radioactive waste containers behind adequate shielding 2 Indicate Container ID andor Contents (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 surtace with a GM Survey Meter on its most sensitive scale without shielding prior to
disposal 5 Waste may be disposed of if activity is indistinguishable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash
0L] ~1YJ
Survey Meter Code
1
2
3
Model Serial Number
c_ r
ttIfn Last Assay 08te of
Waste to lie lJisposed of
r~tko~~middot~-middot~~ oh-ihi _gt Dt( -1
Container 10 JContents
r] tJG-~
Survey Meter
141 cl~fshy n1ht hr~~ch ~
frl-) ~~it1sectP1W~G 1--) I ~ r ~g C1Yl -f~~~llS IO~ ~J1j 84fi12sectt~ ~Jriilif~r)ltJamp --Q qCM Ah2 ~~11 ~ts-h shy I~m ~
~ ~-)7J I~71PZ~~jh 510~ - 1D I ~ I7rD-~ tL ~~1I=1 )jj I -gt J-poundiLill-~7iT-)ridil~~~ tC)V
f n ( - I I M--shy P ~- - v- -shy P -4 shy I ~ if I
f
1 Provided by Advanced Medical Physics 16770 c( ~reek Lane Noblesville IN 46060middot 3172233022 (
m
Radioactive Materials Shipment Rei (and Return Container Survey Record
Action Levels The Radiation Safety Omcer should be immediately notified when radiation or contamination level$ to whicb personnel may be exposed exceed tbe (ollowjng levels
Area Radiation Survey Contamination Surveys
Instruments Usedor Surveys
Meter No Make amp Model
Restricted 50 m81hr J 1OOODPMJIOOcm I 2 tr 0-- I I noV 1-----1
Unrestricted 20 m81hr I 1000 DPMllOO em 1] 3
Serial No Detector Efficiency
Note LQ indicates that the ack e does not exceed s ecified limits fur Limited QuantitidiJlhitm_ellts____---__---_--_________-- Receiot Sm-vey
Container ILabel I IT ITranspo-rt-middoty--=---------+---~c----JA-1t-c~-----+-L---------l----D-at-e lContact
No or III Index 3 mRlhr BKG Initials Retumed I mRlhr
--shy
Date
cm
BKG Cpm Initials
I
Report Date
Facility
State License Number USNRC License Number
Source Identification
Radionuclide Calibrated Activity Date Calibrated 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 13-24706-01
Cobalt-57 090708 10mCi Not Supplied BM01-10 BMOll008220102 Flood Source
0762 cpmdp~ 1691543 cpmuCi 102 dp~ 78 cp~ 000005 uCi 351
Activity (uCi)Gross cpm Netcpm DPM Dry Wipe 000000347 0 0
Instrument used for Analysis Ludlum Well Counter MN2200 SIN 198663
Analysis Results Source is not leaking at this time
Removable contamination is lt0005 uCi
Next Leak Test Due
Leak Test Performed By
Analysis Performed By
Radiation Safety Officer (signature)
I
Report Date
Facility
State License Number USNRC License Number
Source Identification
Radionuclide Calibrated Activity Date Calibrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
Apri122 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137
080197 2198uCi IPL 559-1627 RV-137-200V
Dose Calibrator Vial Source
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm OOOQ13 uCi 351
Activity (uCi) Gross cpm Netcpm DPM Dry Wipe 0000000347 0 0
Instrument used for Analysis
Analysis Results
Next Leak Test Due
Leak Test Performed By
Analysis Performed By
Ludlum Well Counter MN2200 SIN PR 198663
Source is not leaking at this time Removable contamination is lt0005 uCi
I October-12 I t IrftL--WillWn K Btteden III MS D~~ April 62012 ~~ fz--v ( t- shy
Edward E WrolewDABSNM
April 22 2012
Officer (signature)
Clouse out survey for Columbus Imaging Associates dba Columbus Diagnostic Imaging
6182012 USNRC Materials License 13-26797-01
IL~ L~~~())~ Location Location Description Exposure Rate (mRhr) Wipe activity(dpml00cmJ2) ~~
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 la b floor
11 hot lab floor
12 hot lab floor
13 hot lab floor
14 hot lab 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
33 275
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-oJ Jl9~( 11 (IQ IJ J(f~ t6JVe
(e-AIl)) P llan Po tVlCft r~
~~~~ ~~ ~ j
-efTIrf 1h1r f~ h~ vr 6~1
~~~~
CERTIFICATE OF CALIBRATION
Customer Advanced Med Phys
Manufacturer BIODEX
Detector Type GM
Detector Model X End Window
D Side Window
X Pancake
High Voltage -y
Date Received March 20 2012
Calibration Date March 30 2012
NEXT Calibration Due March 30 2013
Calibration Data
Scale Distance
(cm)
Instrument MIN 14C
Probe MIN 44-9 Calibration Geometry X Probe II
Cap ON
Window Open Window Closed
Battery Test Acceptable
Reset Check Test Acceptable
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Activity and SIN
Calculated Measured
Reading mRhr
SIN 101782 SIN PR2424100
X Probe Perpendicular
X Cap Off
] NA
Correction Factor
100x 1000 1813 800800
200 100x 1000 1813 200
x 100 4053 160
x 100 4053 40
x 10 4053 16 160 100
x 10 4053 4 40 100
xl xl
I I
4053
4053 I I
16 160
OA OAO 100
100
x 1 12817 016 016 100
x 1 12817 004 004 100
Comments All instrument readings were within +1- 10 at the time of calibration for all scales used
Applicable correction factors are noted above
This instrument must be checke for proper operation with the dedicated check source prior to
use A reading as indicated above denotes proper operation
UNABLE TO CALIBRATE x 100 SCALE Calibration Source Cs-137 Calibration Date January 15 1985 (+- 3 NBS)
Calibrated Activity 0154 Ci Roentgenshr 1m 00493
MN 773 Source ID S-526
SIN 216 Manufacturer Tech-Ops
Calculated Activity 00821 Ci Roentgenshr 1m 002630 March 30 2012
Photon Measurements Plus Calibrated By _________________
1427 West 86th Street Suite 282 Edward E Wroblewski MA DABSNM
Indianapolis IN 46260
tele 317755-9688 USNRC Materials License Numbcr-13-32533-01
RETURN PACKING LIST All information must be provided to ensure proper
SENOTO
Eckert ampZiegler Isotope Products
1800 North Keystone Street Burbank CA 91504
~~nTjjlllhnmiddot661)309-1010 1-~__ILI~tt--L=-=I--_ampjICI~=----E_~ Fax (661) 257-8303
Email emaIl nucmedsalesezagcom
list must be affixed to the Q~12S and
RETURN RA- 2I fI ofthe package Each returned source EZlflmustb dina1)nHOOne exchange basis ~nly
please contact euroZIP customer service considerations
Reference Serial Capsule Source Wipe Nuclide Activity Date Number D~cription TestsSnCi- J amptQoosaao I ~ IRAbQ)~
(l4t OItli lJIH9f ~ lId) 8J2(gtaL cfgt-57 ~tJ--raquo~s DNo I i i
2) DYes 0 No
3) ___ DYeS 0 No
4) ___ DYes 0 No
If source is damaged broken or le~king describe under Capsule ~scription sectiOfl and submit a copy of the last leak test Keep a copy of this form for your recOrd~ It may be requested by your regulatory agency I acknowledge that the above information is true ~o the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Number (Required) -- shy
FOR EZIP USE OfllY
EZIP has received ~he radioactive sources listed above e(cel)t as noted below
Receivers Name
Receipt Date -LO
Sources not received NA
RETURN PACKING LIST All information must be provided to ensure proper handling of your return
FROM SENDTO
Company Name
Address
City
i Eckert amp Ziegler Isotope Products
1800 North Keystone Street Burbank CA 91504 Telephone (661)309-1010 Fax (661)257-8303 Email nucmedsalesezagcom
RETURN RAshy 2( STOP This packing list must be affixed to the OllTSIOE and a copy placed inside of the package Each returned source to EZIP must be on a one-to-one exchange basisnnly For additional returns please contact poundZIP customer service for additional cost considerations
Nuclide Activity
1gtamp5-1312fj$ C
2) Csift t)middotlCfflAC
3) ___
4) ___
Reference Date
Serial Number SS shy ~t-
crt Itt lft6-3-L
Capsule Description
Source Wipe Tests SnCi
IN Gi(tIJ~- )I~) S~ e~ 0 No
amp) St1 rC f ~o DYes 0 No
CJ Yes 0 NCigt
If source is damaged broken or leaking describe under Capsule Description section and submit a copy of the last leak test Keep a copy of this form for your records It may be requested by your regulatory agency I acknowledge that the above information is true to the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Num~er (Required)
FOR EZIP USE ONLY
EZIP has received the radioactive sources listed above except as noted below
Receivers Name~I~~ tgtltl~ ~No~Q1)s _Co -~bullbullbull - bullbullbull~-~~ -----shy ~ -- - -shy
Receipt Date ~ ~)- ) I
Sources not received riNA
1a902of2
Certificate of Instrument Detection Efficiency for
Columbus Diagnostic Imaging Columbus Indiana
April 6 2012
Instrument Capintec Caprac Well Counter
Instrument Net Conversion DetectionSource Activity Calibration Date
Settin CPM Factor Efficienc
Co-57 09967 uCi 4110 Well 302213 112dpmcpm 8929
MDA= 5x10-5
106 dpm
Results These results are within acceptable limits
-qA Radiation Safety Officer
Advanced Medical Physics LLC 9095 Doral CourtD bull Indianapolis IN 462503172233022 3178495058(fax) ~~~~
Certified in Medical Nuclear Physics by the American Board of Radiology
-~ C~lumbus II~USPOSTAGE Diagnostic ~ IUS POSTAGE $ 0 105 $ 0045 RRSTClASS
bull L l1li-shyImaging RRST ClASS
Mailed From 47201 bull 091042012 031A 0002309440
J ~ 031A 0002309440790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200
Fax (812) 376-6665
APPROVED BY OMB NO 3150-0028 EXPIRES 1013112013 (02012) NRC FORM 314 US NUCLEAR REGULATORY COMMISSION
Estimated burdampn per responSamp to comply with this mandatory collection request 30 minutes 10 CFR 30360)(1) 40420)(1) This submittal is uSampd by NRC as part 01 the basis lor its determination tIlet the facility is
released for unrestricted use Send comments regardil19 burden estimate to the Information Services Branch (T -5 F53) Us Nuclear Regulatory Commission Washington DC 20555-0001 or by internet amall to InfocollectsResourcenrcgov and to the Desk Officer Office of
70 38U)(1 ) and 7254(k)(5)(1)(1)
CERTIFICATE OF DISPOSITION OF MATERIALS Information and Regulatory Affairs NEOBmiddot10202 (3150-0028) Office of Management and Budget Washington DC 20503 If a means used to Impose an Information colleCtiOn does not display a currently valid OMB control number the NRC may not conduct or sponsor and a person Is not required to respond to the Information collection
LICENSEE NAME AND ADDRESS LICENSE NUMBER DOCKET NUMBER
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)o This license has expired [] This license has not yet expired please terminate it
B DISPOSAL OF RADIOACTIVE MATERIAL (Check the appropriate boxes and complete as necessary additional space is needed provide attachments)
The licensee or 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 license 0 [] 2 All activities authorized by this license have ceased and all radioactive materials procured andor possessed by the licensee
under this license number cited above have been disposed of in the following manner
[] a Transfer of radioactive materials to the licensee listed below
Eckert and Ziegler Isotope Products Inc dba Isotope Products Laboratories California Lic 1509-19 Cary Renquist RSO
CIS- ac~JQ[]b Disposal of radioactive materials
[]1 Directly by the licensee
All radioactive waste that was being held for as decay-in storage has been disposed of properly as it has been held for greater than 10 half-lives and was indistinguishable from background exposure rate levels See attached log
02 By licensed disposal site
3 By waste contractor
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
[] 1 A radiation survey was conducted by the licensee The survey confirms
[] a the absence of licensed radioactive materials
Ob that any remaining residual radioactivity is within the limits of 10 CFR 20 Subpart E and is ALARA
[] 2 A copy of the radiation survey results
[] a is attached or b is not attached (Provide explanation) or c was forwarded to NRC on - _
Date ~-
o 3 A radiation survey is not required as only sealed sources were ever possessed under this license and
[] a The results of the latest leak test are attached andor [] b No leaking sources have ever been identified
The person to be contacted regarding the information provided on this form TELEPHONE (Include Are Code) IE-MAIL ADDRESSNAME I~ITLE
812-376-1000 rhond a [ennonyahoocomRhonda Lennon Practice Manager
Mail all future colTespondence regarding this license to
Rhonda Lennon at address noted above
C CERTIFYING OFFICIAL I CERTIFY UNDER PENALTY OF PER IIIrJV TI-IAT THE FOREGOING IS TRUE AND CORRECT
~~~
I~~ ~~~ ~~~~~~ ~ ID~~~ WARNING F1tSE STATEMENTS IN THIS CERTIFICATE MAY BE SOBJECT TO CIVIL AileOR CRIMINAL PENAL TIES NRC REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRC BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECT 18 USC 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 MATIER WITHIN ITS JURISDICTION
NRC FORM 314 (05middot2012)
Medical Physics Survey Sealed Source Inventory
Facility Columbus Diagnostic Imaging Department Nuclear Medicine
Location Columbus Indiana Date July 18 2012
bull Nuclide
Cs-137 i
Cs-137
Cs-137
Cs-137
Co-57
I
I
i
Activity Date Model Serial No Type
I RV-137shyDose
2198uCi 8197 200V
559-162-7 Calibrator Vial
I
Rod 01065uCi i 8197 IPL 488-31-2
I
Button
10 uCi 1295 None 4646
i shy
Button
10 uCi
I 1295 None 4656
bull
I _shy
Flood 10mCi bull 917108 BM01-10 BM011008220102
Location Present
Hot Lab No returned bull to
manufacturer Hot Lab No returned
to
Ludlum Survey man ufaCturer~1
middot Yes exempt bull Meter quantity to
be sold with
bull camera
I Ludlum Survey bull Yes exempt I Meter
i
quantity to be sold with
camera Hot Lab I No returned
to i manufacturer
Comments Ambient Exposure Rate Survey of Sealed Sources ( Ludlum 14C SN141804 001 mRhr)
Radiation Safety Officer
Provided by Advanced Medical Physics 16770 Cedar Creek Lane Inoblesville IN 46060 3172233022
1m Bathroom l
( -20 imaging
COLUMBUS DIAGNOSTIC IMAGING DAILY AREA SURVEYS
MONTH YEAR -
1 Dose Preparation
2 Dose Calibration l~ 3 Hot Trash Cttl(rhfJ ) 4 Sealed Source Storage(tm
5 Patient Injection Area 6 Gamma Camera 7 Computer Console
~ H~~~ OJIJI
G) Jm~j() 1raquo Door lO-IS ~~ lab t1Olt l-w ~t5~~
flt901f1 flDO (
Ll-- ~s~ J 1 H (~ (t1firl
Trigger Levels-mRhr Bkgd
Day mRhr 1 2 3 4 5 6 7 I
8 9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
20 20 20 20 10 10 05 ~ HandsClothinq Initials Comments 1 2 3 4 5 6 7 8 111 (
t-) ft -gtY v r A U lLI_) l
J I U JI t I ~l1 OVV ~ I IJ 11 -
I
I
I
I c
i
I
I i
~~~~=~~-------- t----shy -shy----+-I----shyI I I I
I
I i I
I
~~~~~=~~C~~--- -1----------- ---Jshy
NUC-SJGAMMA
cORRIDOR cru
I I
SI 1 ltFe I I EQUIPI 11441
I
I
I I
t1tl~~-middot - middot--~~itmiddotl----~-middot-middot-I---middot-middot-middotmiddot--middot--- -------+-_----shy
6
~
r middot
~ shy ~fIr- _ _ -gt-- v~~
I existing shelf
10
g
8
7
6
-middot5
4
3
2
r l 2 3 4 5 6 7 8 9 10
OI~~__L--k__~~__~~__4-~~~
PRELIMINARY PCANtflNG ONLY PROJECT TITLE
COLUMBUS DIAGNOSTIC IMAGING NUCLEAR ROOM - MILLENIUM MG
COLUMBUS INDIANA SCHEME NO08INA080 DRAWN BY TlD DATE 07-22-0
t)~o
THIS LAYOUT MUST BE APPROVED BEFORE FINAL DRAWINGS CAN 8E STARTED THANK YOU
CUSTOMER DATE
Of ProjectManagerInitalfotion DATE
tlitwoukec bull - -- - - _ - - - WJScollSin
This eq~t loyouIlf(ftCO ue pin and inI_ndlon 0 Ill iMIl_ cqolpmcnt bullbullmporuonb 11gt I bo IlIltIctol 11101 dodor Iocol reqW_ Ihltgtt could Impltlo lite pnt f III ~I It tlllOlns tbo ClIIIom rupbltJly for uriog III oito and flgtOi eqipmnl pIoltomont pIl6gt Milgt 011 appKcble federal otQt ofldor Deal requiremDn15
Radioactive Wastt ~nd Disposal Record
Policy and Procedure 1 Seal and store radioactive waste containers behind adequate shielding 2 Indicate Container ID andor Contents (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 surtace with a GM Survey Meter on its most sensitive scale without shielding prior to
disposal 5 Waste may be disposed of if activity is indistinguishable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash
0L] ~1YJ
Survey Meter Code
1
2
3
Model Serial Number
c_ r
ttIfn Last Assay 08te of
Waste to lie lJisposed of
r~tko~~middot~-middot~~ oh-ihi _gt Dt( -1
Container 10 JContents
r] tJG-~
Survey Meter
141 cl~fshy n1ht hr~~ch ~
frl-) ~~it1sectP1W~G 1--) I ~ r ~g C1Yl -f~~~llS IO~ ~J1j 84fi12sectt~ ~Jriilif~r)ltJamp --Q qCM Ah2 ~~11 ~ts-h shy I~m ~
~ ~-)7J I~71PZ~~jh 510~ - 1D I ~ I7rD-~ tL ~~1I=1 )jj I -gt J-poundiLill-~7iT-)ridil~~~ tC)V
f n ( - I I M--shy P ~- - v- -shy P -4 shy I ~ if I
f
1 Provided by Advanced Medical Physics 16770 c( ~reek Lane Noblesville IN 46060middot 3172233022 (
m
Radioactive Materials Shipment Rei (and Return Container Survey Record
Action Levels The Radiation Safety Omcer should be immediately notified when radiation or contamination level$ to whicb personnel may be exposed exceed tbe (ollowjng levels
Area Radiation Survey Contamination Surveys
Instruments Usedor Surveys
Meter No Make amp Model
Restricted 50 m81hr J 1OOODPMJIOOcm I 2 tr 0-- I I noV 1-----1
Unrestricted 20 m81hr I 1000 DPMllOO em 1] 3
Serial No Detector Efficiency
Note LQ indicates that the ack e does not exceed s ecified limits fur Limited QuantitidiJlhitm_ellts____---__---_--_________-- Receiot Sm-vey
Container ILabel I IT ITranspo-rt-middoty--=---------+---~c----JA-1t-c~-----+-L---------l----D-at-e lContact
No or III Index 3 mRlhr BKG Initials Retumed I mRlhr
--shy
Date
cm
BKG Cpm Initials
I
Report Date
Facility
State License Number USNRC License Number
Source Identification
Radionuclide Calibrated Activity Date Calibrated 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 13-24706-01
Cobalt-57 090708 10mCi Not Supplied BM01-10 BMOll008220102 Flood Source
0762 cpmdp~ 1691543 cpmuCi 102 dp~ 78 cp~ 000005 uCi 351
Activity (uCi)Gross cpm Netcpm DPM Dry Wipe 000000347 0 0
Instrument used for Analysis Ludlum Well Counter MN2200 SIN 198663
Analysis Results Source is not leaking at this time
Removable contamination is lt0005 uCi
Next Leak Test Due
Leak Test Performed By
Analysis Performed By
Radiation Safety Officer (signature)
I
Report Date
Facility
State License Number USNRC License Number
Source Identification
Radionuclide Calibrated Activity Date Calibrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
Apri122 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137
080197 2198uCi IPL 559-1627 RV-137-200V
Dose Calibrator Vial Source
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm OOOQ13 uCi 351
Activity (uCi) Gross cpm Netcpm DPM Dry Wipe 0000000347 0 0
Instrument used for Analysis
Analysis Results
Next Leak Test Due
Leak Test Performed By
Analysis Performed By
Ludlum Well Counter MN2200 SIN PR 198663
Source is not leaking at this time Removable contamination is lt0005 uCi
I October-12 I t IrftL--WillWn K Btteden III MS D~~ April 62012 ~~ fz--v ( t- shy
Edward E WrolewDABSNM
April 22 2012
Officer (signature)
Clouse out survey for Columbus Imaging Associates dba Columbus Diagnostic Imaging
6182012 USNRC Materials License 13-26797-01
IL~ L~~~())~ Location Location Description Exposure Rate (mRhr) Wipe activity(dpml00cmJ2) ~~
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 la b floor
11 hot lab floor
12 hot lab floor
13 hot lab floor
14 hot lab 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
33 275
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-oJ Jl9~( 11 (IQ IJ J(f~ t6JVe
(e-AIl)) P llan Po tVlCft r~
~~~~ ~~ ~ j
-efTIrf 1h1r f~ h~ vr 6~1
~~~~
CERTIFICATE OF CALIBRATION
Customer Advanced Med Phys
Manufacturer BIODEX
Detector Type GM
Detector Model X End Window
D Side Window
X Pancake
High Voltage -y
Date Received March 20 2012
Calibration Date March 30 2012
NEXT Calibration Due March 30 2013
Calibration Data
Scale Distance
(cm)
Instrument MIN 14C
Probe MIN 44-9 Calibration Geometry X Probe II
Cap ON
Window Open Window Closed
Battery Test Acceptable
Reset Check Test Acceptable
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Activity and SIN
Calculated Measured
Reading mRhr
SIN 101782 SIN PR2424100
X Probe Perpendicular
X Cap Off
] NA
Correction Factor
100x 1000 1813 800800
200 100x 1000 1813 200
x 100 4053 160
x 100 4053 40
x 10 4053 16 160 100
x 10 4053 4 40 100
xl xl
I I
4053
4053 I I
16 160
OA OAO 100
100
x 1 12817 016 016 100
x 1 12817 004 004 100
Comments All instrument readings were within +1- 10 at the time of calibration for all scales used
Applicable correction factors are noted above
This instrument must be checke for proper operation with the dedicated check source prior to
use A reading as indicated above denotes proper operation
UNABLE TO CALIBRATE x 100 SCALE Calibration Source Cs-137 Calibration Date January 15 1985 (+- 3 NBS)
Calibrated Activity 0154 Ci Roentgenshr 1m 00493
MN 773 Source ID S-526
SIN 216 Manufacturer Tech-Ops
Calculated Activity 00821 Ci Roentgenshr 1m 002630 March 30 2012
Photon Measurements Plus Calibrated By _________________
1427 West 86th Street Suite 282 Edward E Wroblewski MA DABSNM
Indianapolis IN 46260
tele 317755-9688 USNRC Materials License Numbcr-13-32533-01
RETURN PACKING LIST All information must be provided to ensure proper
SENOTO
Eckert ampZiegler Isotope Products
1800 North Keystone Street Burbank CA 91504
~~nTjjlllhnmiddot661)309-1010 1-~__ILI~tt--L=-=I--_ampjICI~=----E_~ Fax (661) 257-8303
Email emaIl nucmedsalesezagcom
list must be affixed to the Q~12S and
RETURN RA- 2I fI ofthe package Each returned source EZlflmustb dina1)nHOOne exchange basis ~nly
please contact euroZIP customer service considerations
Reference Serial Capsule Source Wipe Nuclide Activity Date Number D~cription TestsSnCi- J amptQoosaao I ~ IRAbQ)~
(l4t OItli lJIH9f ~ lId) 8J2(gtaL cfgt-57 ~tJ--raquo~s DNo I i i
2) DYes 0 No
3) ___ DYeS 0 No
4) ___ DYes 0 No
If source is damaged broken or le~king describe under Capsule ~scription sectiOfl and submit a copy of the last leak test Keep a copy of this form for your recOrd~ It may be requested by your regulatory agency I acknowledge that the above information is true ~o the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Number (Required) -- shy
FOR EZIP USE OfllY
EZIP has received ~he radioactive sources listed above e(cel)t as noted below
Receivers Name
Receipt Date -LO
Sources not received NA
RETURN PACKING LIST All information must be provided to ensure proper handling of your return
FROM SENDTO
Company Name
Address
City
i Eckert amp Ziegler Isotope Products
1800 North Keystone Street Burbank CA 91504 Telephone (661)309-1010 Fax (661)257-8303 Email nucmedsalesezagcom
RETURN RAshy 2( STOP This packing list must be affixed to the OllTSIOE and a copy placed inside of the package Each returned source to EZIP must be on a one-to-one exchange basisnnly For additional returns please contact poundZIP customer service for additional cost considerations
Nuclide Activity
1gtamp5-1312fj$ C
2) Csift t)middotlCfflAC
3) ___
4) ___
Reference Date
Serial Number SS shy ~t-
crt Itt lft6-3-L
Capsule Description
Source Wipe Tests SnCi
IN Gi(tIJ~- )I~) S~ e~ 0 No
amp) St1 rC f ~o DYes 0 No
CJ Yes 0 NCigt
If source is damaged broken or leaking describe under Capsule Description section and submit a copy of the last leak test Keep a copy of this form for your records It may be requested by your regulatory agency I acknowledge that the above information is true to the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Num~er (Required)
FOR EZIP USE ONLY
EZIP has received the radioactive sources listed above except as noted below
Receivers Name~I~~ tgtltl~ ~No~Q1)s _Co -~bullbullbull - bullbullbull~-~~ -----shy ~ -- - -shy
Receipt Date ~ ~)- ) I
Sources not received riNA
1a902of2
Certificate of Instrument Detection Efficiency for
Columbus Diagnostic Imaging Columbus Indiana
April 6 2012
Instrument Capintec Caprac Well Counter
Instrument Net Conversion DetectionSource Activity Calibration Date
Settin CPM Factor Efficienc
Co-57 09967 uCi 4110 Well 302213 112dpmcpm 8929
MDA= 5x10-5
106 dpm
Results These results are within acceptable limits
-qA Radiation Safety Officer
Advanced Medical Physics LLC 9095 Doral CourtD bull Indianapolis IN 462503172233022 3178495058(fax) ~~~~
Certified in Medical Nuclear Physics by the American Board of Radiology
-~ C~lumbus II~USPOSTAGE Diagnostic ~ IUS POSTAGE $ 0 105 $ 0045 RRSTClASS
bull L l1li-shyImaging RRST ClASS
Mailed From 47201 bull 091042012 031A 0002309440
J ~ 031A 0002309440790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200
Fax (812) 376-6665
Medical Physics Survey Sealed Source Inventory
Facility Columbus Diagnostic Imaging Department Nuclear Medicine
Location Columbus Indiana Date July 18 2012
bull Nuclide
Cs-137 i
Cs-137
Cs-137
Cs-137
Co-57
I
I
i
Activity Date Model Serial No Type
I RV-137shyDose
2198uCi 8197 200V
559-162-7 Calibrator Vial
I
Rod 01065uCi i 8197 IPL 488-31-2
I
Button
10 uCi 1295 None 4646
i shy
Button
10 uCi
I 1295 None 4656
bull
I _shy
Flood 10mCi bull 917108 BM01-10 BM011008220102
Location Present
Hot Lab No returned bull to
manufacturer Hot Lab No returned
to
Ludlum Survey man ufaCturer~1
middot Yes exempt bull Meter quantity to
be sold with
bull camera
I Ludlum Survey bull Yes exempt I Meter
i
quantity to be sold with
camera Hot Lab I No returned
to i manufacturer
Comments Ambient Exposure Rate Survey of Sealed Sources ( Ludlum 14C SN141804 001 mRhr)
Radiation Safety Officer
Provided by Advanced Medical Physics 16770 Cedar Creek Lane Inoblesville IN 46060 3172233022
1m Bathroom l
( -20 imaging
COLUMBUS DIAGNOSTIC IMAGING DAILY AREA SURVEYS
MONTH YEAR -
1 Dose Preparation
2 Dose Calibration l~ 3 Hot Trash Cttl(rhfJ ) 4 Sealed Source Storage(tm
5 Patient Injection Area 6 Gamma Camera 7 Computer Console
~ H~~~ OJIJI
G) Jm~j() 1raquo Door lO-IS ~~ lab t1Olt l-w ~t5~~
flt901f1 flDO (
Ll-- ~s~ J 1 H (~ (t1firl
Trigger Levels-mRhr Bkgd
Day mRhr 1 2 3 4 5 6 7 I
8 9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
20 20 20 20 10 10 05 ~ HandsClothinq Initials Comments 1 2 3 4 5 6 7 8 111 (
t-) ft -gtY v r A U lLI_) l
J I U JI t I ~l1 OVV ~ I IJ 11 -
I
I
I
I c
i
I
I i
~~~~=~~-------- t----shy -shy----+-I----shyI I I I
I
I i I
I
~~~~~=~~C~~--- -1----------- ---Jshy
NUC-SJGAMMA
cORRIDOR cru
I I
SI 1 ltFe I I EQUIPI 11441
I
I
I I
t1tl~~-middot - middot--~~itmiddotl----~-middot-middot-I---middot-middot-middotmiddot--middot--- -------+-_----shy
6
~
r middot
~ shy ~fIr- _ _ -gt-- v~~
I existing shelf
10
g
8
7
6
-middot5
4
3
2
r l 2 3 4 5 6 7 8 9 10
OI~~__L--k__~~__~~__4-~~~
PRELIMINARY PCANtflNG ONLY PROJECT TITLE
COLUMBUS DIAGNOSTIC IMAGING NUCLEAR ROOM - MILLENIUM MG
COLUMBUS INDIANA SCHEME NO08INA080 DRAWN BY TlD DATE 07-22-0
t)~o
THIS LAYOUT MUST BE APPROVED BEFORE FINAL DRAWINGS CAN 8E STARTED THANK YOU
CUSTOMER DATE
Of ProjectManagerInitalfotion DATE
tlitwoukec bull - -- - - _ - - - WJScollSin
This eq~t loyouIlf(ftCO ue pin and inI_ndlon 0 Ill iMIl_ cqolpmcnt bullbullmporuonb 11gt I bo IlIltIctol 11101 dodor Iocol reqW_ Ihltgtt could Impltlo lite pnt f III ~I It tlllOlns tbo ClIIIom rupbltJly for uriog III oito and flgtOi eqipmnl pIoltomont pIl6gt Milgt 011 appKcble federal otQt ofldor Deal requiremDn15
Radioactive Wastt ~nd Disposal Record
Policy and Procedure 1 Seal and store radioactive waste containers behind adequate shielding 2 Indicate Container ID andor Contents (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 surtace with a GM Survey Meter on its most sensitive scale without shielding prior to
disposal 5 Waste may be disposed of if activity is indistinguishable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash
0L] ~1YJ
Survey Meter Code
1
2
3
Model Serial Number
c_ r
ttIfn Last Assay 08te of
Waste to lie lJisposed of
r~tko~~middot~-middot~~ oh-ihi _gt Dt( -1
Container 10 JContents
r] tJG-~
Survey Meter
141 cl~fshy n1ht hr~~ch ~
frl-) ~~it1sectP1W~G 1--) I ~ r ~g C1Yl -f~~~llS IO~ ~J1j 84fi12sectt~ ~Jriilif~r)ltJamp --Q qCM Ah2 ~~11 ~ts-h shy I~m ~
~ ~-)7J I~71PZ~~jh 510~ - 1D I ~ I7rD-~ tL ~~1I=1 )jj I -gt J-poundiLill-~7iT-)ridil~~~ tC)V
f n ( - I I M--shy P ~- - v- -shy P -4 shy I ~ if I
f
1 Provided by Advanced Medical Physics 16770 c( ~reek Lane Noblesville IN 46060middot 3172233022 (
m
Radioactive Materials Shipment Rei (and Return Container Survey Record
Action Levels The Radiation Safety Omcer should be immediately notified when radiation or contamination level$ to whicb personnel may be exposed exceed tbe (ollowjng levels
Area Radiation Survey Contamination Surveys
Instruments Usedor Surveys
Meter No Make amp Model
Restricted 50 m81hr J 1OOODPMJIOOcm I 2 tr 0-- I I noV 1-----1
Unrestricted 20 m81hr I 1000 DPMllOO em 1] 3
Serial No Detector Efficiency
Note LQ indicates that the ack e does not exceed s ecified limits fur Limited QuantitidiJlhitm_ellts____---__---_--_________-- Receiot Sm-vey
Container ILabel I IT ITranspo-rt-middoty--=---------+---~c----JA-1t-c~-----+-L---------l----D-at-e lContact
No or III Index 3 mRlhr BKG Initials Retumed I mRlhr
--shy
Date
cm
BKG Cpm Initials
I
Report Date
Facility
State License Number USNRC License Number
Source Identification
Radionuclide Calibrated Activity Date Calibrated 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 13-24706-01
Cobalt-57 090708 10mCi Not Supplied BM01-10 BMOll008220102 Flood Source
0762 cpmdp~ 1691543 cpmuCi 102 dp~ 78 cp~ 000005 uCi 351
Activity (uCi)Gross cpm Netcpm DPM Dry Wipe 000000347 0 0
Instrument used for Analysis Ludlum Well Counter MN2200 SIN 198663
Analysis Results Source is not leaking at this time
Removable contamination is lt0005 uCi
Next Leak Test Due
Leak Test Performed By
Analysis Performed By
Radiation Safety Officer (signature)
I
Report Date
Facility
State License Number USNRC License Number
Source Identification
Radionuclide Calibrated Activity Date Calibrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
Apri122 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137
080197 2198uCi IPL 559-1627 RV-137-200V
Dose Calibrator Vial Source
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm OOOQ13 uCi 351
Activity (uCi) Gross cpm Netcpm DPM Dry Wipe 0000000347 0 0
Instrument used for Analysis
Analysis Results
Next Leak Test Due
Leak Test Performed By
Analysis Performed By
Ludlum Well Counter MN2200 SIN PR 198663
Source is not leaking at this time Removable contamination is lt0005 uCi
I October-12 I t IrftL--WillWn K Btteden III MS D~~ April 62012 ~~ fz--v ( t- shy
Edward E WrolewDABSNM
April 22 2012
Officer (signature)
Clouse out survey for Columbus Imaging Associates dba Columbus Diagnostic Imaging
6182012 USNRC Materials License 13-26797-01
IL~ L~~~())~ Location Location Description Exposure Rate (mRhr) Wipe activity(dpml00cmJ2) ~~
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 la b floor
11 hot lab floor
12 hot lab floor
13 hot lab floor
14 hot lab 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
33 275
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-oJ Jl9~( 11 (IQ IJ J(f~ t6JVe
(e-AIl)) P llan Po tVlCft r~
~~~~ ~~ ~ j
-efTIrf 1h1r f~ h~ vr 6~1
~~~~
CERTIFICATE OF CALIBRATION
Customer Advanced Med Phys
Manufacturer BIODEX
Detector Type GM
Detector Model X End Window
D Side Window
X Pancake
High Voltage -y
Date Received March 20 2012
Calibration Date March 30 2012
NEXT Calibration Due March 30 2013
Calibration Data
Scale Distance
(cm)
Instrument MIN 14C
Probe MIN 44-9 Calibration Geometry X Probe II
Cap ON
Window Open Window Closed
Battery Test Acceptable
Reset Check Test Acceptable
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Activity and SIN
Calculated Measured
Reading mRhr
SIN 101782 SIN PR2424100
X Probe Perpendicular
X Cap Off
] NA
Correction Factor
100x 1000 1813 800800
200 100x 1000 1813 200
x 100 4053 160
x 100 4053 40
x 10 4053 16 160 100
x 10 4053 4 40 100
xl xl
I I
4053
4053 I I
16 160
OA OAO 100
100
x 1 12817 016 016 100
x 1 12817 004 004 100
Comments All instrument readings were within +1- 10 at the time of calibration for all scales used
Applicable correction factors are noted above
This instrument must be checke for proper operation with the dedicated check source prior to
use A reading as indicated above denotes proper operation
UNABLE TO CALIBRATE x 100 SCALE Calibration Source Cs-137 Calibration Date January 15 1985 (+- 3 NBS)
Calibrated Activity 0154 Ci Roentgenshr 1m 00493
MN 773 Source ID S-526
SIN 216 Manufacturer Tech-Ops
Calculated Activity 00821 Ci Roentgenshr 1m 002630 March 30 2012
Photon Measurements Plus Calibrated By _________________
1427 West 86th Street Suite 282 Edward E Wroblewski MA DABSNM
Indianapolis IN 46260
tele 317755-9688 USNRC Materials License Numbcr-13-32533-01
RETURN PACKING LIST All information must be provided to ensure proper
SENOTO
Eckert ampZiegler Isotope Products
1800 North Keystone Street Burbank CA 91504
~~nTjjlllhnmiddot661)309-1010 1-~__ILI~tt--L=-=I--_ampjICI~=----E_~ Fax (661) 257-8303
Email emaIl nucmedsalesezagcom
list must be affixed to the Q~12S and
RETURN RA- 2I fI ofthe package Each returned source EZlflmustb dina1)nHOOne exchange basis ~nly
please contact euroZIP customer service considerations
Reference Serial Capsule Source Wipe Nuclide Activity Date Number D~cription TestsSnCi- J amptQoosaao I ~ IRAbQ)~
(l4t OItli lJIH9f ~ lId) 8J2(gtaL cfgt-57 ~tJ--raquo~s DNo I i i
2) DYes 0 No
3) ___ DYeS 0 No
4) ___ DYes 0 No
If source is damaged broken or le~king describe under Capsule ~scription sectiOfl and submit a copy of the last leak test Keep a copy of this form for your recOrd~ It may be requested by your regulatory agency I acknowledge that the above information is true ~o the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Number (Required) -- shy
FOR EZIP USE OfllY
EZIP has received ~he radioactive sources listed above e(cel)t as noted below
Receivers Name
Receipt Date -LO
Sources not received NA
RETURN PACKING LIST All information must be provided to ensure proper handling of your return
FROM SENDTO
Company Name
Address
City
i Eckert amp Ziegler Isotope Products
1800 North Keystone Street Burbank CA 91504 Telephone (661)309-1010 Fax (661)257-8303 Email nucmedsalesezagcom
RETURN RAshy 2( STOP This packing list must be affixed to the OllTSIOE and a copy placed inside of the package Each returned source to EZIP must be on a one-to-one exchange basisnnly For additional returns please contact poundZIP customer service for additional cost considerations
Nuclide Activity
1gtamp5-1312fj$ C
2) Csift t)middotlCfflAC
3) ___
4) ___
Reference Date
Serial Number SS shy ~t-
crt Itt lft6-3-L
Capsule Description
Source Wipe Tests SnCi
IN Gi(tIJ~- )I~) S~ e~ 0 No
amp) St1 rC f ~o DYes 0 No
CJ Yes 0 NCigt
If source is damaged broken or leaking describe under Capsule Description section and submit a copy of the last leak test Keep a copy of this form for your records It may be requested by your regulatory agency I acknowledge that the above information is true to the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Num~er (Required)
FOR EZIP USE ONLY
EZIP has received the radioactive sources listed above except as noted below
Receivers Name~I~~ tgtltl~ ~No~Q1)s _Co -~bullbullbull - bullbullbull~-~~ -----shy ~ -- - -shy
Receipt Date ~ ~)- ) I
Sources not received riNA
1a902of2
Certificate of Instrument Detection Efficiency for
Columbus Diagnostic Imaging Columbus Indiana
April 6 2012
Instrument Capintec Caprac Well Counter
Instrument Net Conversion DetectionSource Activity Calibration Date
Settin CPM Factor Efficienc
Co-57 09967 uCi 4110 Well 302213 112dpmcpm 8929
MDA= 5x10-5
106 dpm
Results These results are within acceptable limits
-qA Radiation Safety Officer
Advanced Medical Physics LLC 9095 Doral CourtD bull Indianapolis IN 462503172233022 3178495058(fax) ~~~~
Certified in Medical Nuclear Physics by the American Board of Radiology
-~ C~lumbus II~USPOSTAGE Diagnostic ~ IUS POSTAGE $ 0 105 $ 0045 RRSTClASS
bull L l1li-shyImaging RRST ClASS
Mailed From 47201 bull 091042012 031A 0002309440
J ~ 031A 0002309440790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200
Fax (812) 376-6665
1m Bathroom l
( -20 imaging
COLUMBUS DIAGNOSTIC IMAGING DAILY AREA SURVEYS
MONTH YEAR -
1 Dose Preparation
2 Dose Calibration l~ 3 Hot Trash Cttl(rhfJ ) 4 Sealed Source Storage(tm
5 Patient Injection Area 6 Gamma Camera 7 Computer Console
~ H~~~ OJIJI
G) Jm~j() 1raquo Door lO-IS ~~ lab t1Olt l-w ~t5~~
flt901f1 flDO (
Ll-- ~s~ J 1 H (~ (t1firl
Trigger Levels-mRhr Bkgd
Day mRhr 1 2 3 4 5 6 7 I
8 9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
20 20 20 20 10 10 05 ~ HandsClothinq Initials Comments 1 2 3 4 5 6 7 8 111 (
t-) ft -gtY v r A U lLI_) l
J I U JI t I ~l1 OVV ~ I IJ 11 -
I
I
I
I c
i
I
I i
~~~~=~~-------- t----shy -shy----+-I----shyI I I I
I
I i I
I
~~~~~=~~C~~--- -1----------- ---Jshy
NUC-SJGAMMA
cORRIDOR cru
I I
SI 1 ltFe I I EQUIPI 11441
I
I
I I
t1tl~~-middot - middot--~~itmiddotl----~-middot-middot-I---middot-middot-middotmiddot--middot--- -------+-_----shy
6
~
r middot
~ shy ~fIr- _ _ -gt-- v~~
I existing shelf
10
g
8
7
6
-middot5
4
3
2
r l 2 3 4 5 6 7 8 9 10
OI~~__L--k__~~__~~__4-~~~
PRELIMINARY PCANtflNG ONLY PROJECT TITLE
COLUMBUS DIAGNOSTIC IMAGING NUCLEAR ROOM - MILLENIUM MG
COLUMBUS INDIANA SCHEME NO08INA080 DRAWN BY TlD DATE 07-22-0
t)~o
THIS LAYOUT MUST BE APPROVED BEFORE FINAL DRAWINGS CAN 8E STARTED THANK YOU
CUSTOMER DATE
Of ProjectManagerInitalfotion DATE
tlitwoukec bull - -- - - _ - - - WJScollSin
This eq~t loyouIlf(ftCO ue pin and inI_ndlon 0 Ill iMIl_ cqolpmcnt bullbullmporuonb 11gt I bo IlIltIctol 11101 dodor Iocol reqW_ Ihltgtt could Impltlo lite pnt f III ~I It tlllOlns tbo ClIIIom rupbltJly for uriog III oito and flgtOi eqipmnl pIoltomont pIl6gt Milgt 011 appKcble federal otQt ofldor Deal requiremDn15
Radioactive Wastt ~nd Disposal Record
Policy and Procedure 1 Seal and store radioactive waste containers behind adequate shielding 2 Indicate Container ID andor Contents (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 surtace with a GM Survey Meter on its most sensitive scale without shielding prior to
disposal 5 Waste may be disposed of if activity is indistinguishable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash
0L] ~1YJ
Survey Meter Code
1
2
3
Model Serial Number
c_ r
ttIfn Last Assay 08te of
Waste to lie lJisposed of
r~tko~~middot~-middot~~ oh-ihi _gt Dt( -1
Container 10 JContents
r] tJG-~
Survey Meter
141 cl~fshy n1ht hr~~ch ~
frl-) ~~it1sectP1W~G 1--) I ~ r ~g C1Yl -f~~~llS IO~ ~J1j 84fi12sectt~ ~Jriilif~r)ltJamp --Q qCM Ah2 ~~11 ~ts-h shy I~m ~
~ ~-)7J I~71PZ~~jh 510~ - 1D I ~ I7rD-~ tL ~~1I=1 )jj I -gt J-poundiLill-~7iT-)ridil~~~ tC)V
f n ( - I I M--shy P ~- - v- -shy P -4 shy I ~ if I
f
1 Provided by Advanced Medical Physics 16770 c( ~reek Lane Noblesville IN 46060middot 3172233022 (
m
Radioactive Materials Shipment Rei (and Return Container Survey Record
Action Levels The Radiation Safety Omcer should be immediately notified when radiation or contamination level$ to whicb personnel may be exposed exceed tbe (ollowjng levels
Area Radiation Survey Contamination Surveys
Instruments Usedor Surveys
Meter No Make amp Model
Restricted 50 m81hr J 1OOODPMJIOOcm I 2 tr 0-- I I noV 1-----1
Unrestricted 20 m81hr I 1000 DPMllOO em 1] 3
Serial No Detector Efficiency
Note LQ indicates that the ack e does not exceed s ecified limits fur Limited QuantitidiJlhitm_ellts____---__---_--_________-- Receiot Sm-vey
Container ILabel I IT ITranspo-rt-middoty--=---------+---~c----JA-1t-c~-----+-L---------l----D-at-e lContact
No or III Index 3 mRlhr BKG Initials Retumed I mRlhr
--shy
Date
cm
BKG Cpm Initials
I
Report Date
Facility
State License Number USNRC License Number
Source Identification
Radionuclide Calibrated Activity Date Calibrated 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 13-24706-01
Cobalt-57 090708 10mCi Not Supplied BM01-10 BMOll008220102 Flood Source
0762 cpmdp~ 1691543 cpmuCi 102 dp~ 78 cp~ 000005 uCi 351
Activity (uCi)Gross cpm Netcpm DPM Dry Wipe 000000347 0 0
Instrument used for Analysis Ludlum Well Counter MN2200 SIN 198663
Analysis Results Source is not leaking at this time
Removable contamination is lt0005 uCi
Next Leak Test Due
Leak Test Performed By
Analysis Performed By
Radiation Safety Officer (signature)
I
Report Date
Facility
State License Number USNRC License Number
Source Identification
Radionuclide Calibrated Activity Date Calibrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
Apri122 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137
080197 2198uCi IPL 559-1627 RV-137-200V
Dose Calibrator Vial Source
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm OOOQ13 uCi 351
Activity (uCi) Gross cpm Netcpm DPM Dry Wipe 0000000347 0 0
Instrument used for Analysis
Analysis Results
Next Leak Test Due
Leak Test Performed By
Analysis Performed By
Ludlum Well Counter MN2200 SIN PR 198663
Source is not leaking at this time Removable contamination is lt0005 uCi
I October-12 I t IrftL--WillWn K Btteden III MS D~~ April 62012 ~~ fz--v ( t- shy
Edward E WrolewDABSNM
April 22 2012
Officer (signature)
Clouse out survey for Columbus Imaging Associates dba Columbus Diagnostic Imaging
6182012 USNRC Materials License 13-26797-01
IL~ L~~~())~ Location Location Description Exposure Rate (mRhr) Wipe activity(dpml00cmJ2) ~~
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 la b floor
11 hot lab floor
12 hot lab floor
13 hot lab floor
14 hot lab 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
33 275
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-oJ Jl9~( 11 (IQ IJ J(f~ t6JVe
(e-AIl)) P llan Po tVlCft r~
~~~~ ~~ ~ j
-efTIrf 1h1r f~ h~ vr 6~1
~~~~
CERTIFICATE OF CALIBRATION
Customer Advanced Med Phys
Manufacturer BIODEX
Detector Type GM
Detector Model X End Window
D Side Window
X Pancake
High Voltage -y
Date Received March 20 2012
Calibration Date March 30 2012
NEXT Calibration Due March 30 2013
Calibration Data
Scale Distance
(cm)
Instrument MIN 14C
Probe MIN 44-9 Calibration Geometry X Probe II
Cap ON
Window Open Window Closed
Battery Test Acceptable
Reset Check Test Acceptable
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Activity and SIN
Calculated Measured
Reading mRhr
SIN 101782 SIN PR2424100
X Probe Perpendicular
X Cap Off
] NA
Correction Factor
100x 1000 1813 800800
200 100x 1000 1813 200
x 100 4053 160
x 100 4053 40
x 10 4053 16 160 100
x 10 4053 4 40 100
xl xl
I I
4053
4053 I I
16 160
OA OAO 100
100
x 1 12817 016 016 100
x 1 12817 004 004 100
Comments All instrument readings were within +1- 10 at the time of calibration for all scales used
Applicable correction factors are noted above
This instrument must be checke for proper operation with the dedicated check source prior to
use A reading as indicated above denotes proper operation
UNABLE TO CALIBRATE x 100 SCALE Calibration Source Cs-137 Calibration Date January 15 1985 (+- 3 NBS)
Calibrated Activity 0154 Ci Roentgenshr 1m 00493
MN 773 Source ID S-526
SIN 216 Manufacturer Tech-Ops
Calculated Activity 00821 Ci Roentgenshr 1m 002630 March 30 2012
Photon Measurements Plus Calibrated By _________________
1427 West 86th Street Suite 282 Edward E Wroblewski MA DABSNM
Indianapolis IN 46260
tele 317755-9688 USNRC Materials License Numbcr-13-32533-01
RETURN PACKING LIST All information must be provided to ensure proper
SENOTO
Eckert ampZiegler Isotope Products
1800 North Keystone Street Burbank CA 91504
~~nTjjlllhnmiddot661)309-1010 1-~__ILI~tt--L=-=I--_ampjICI~=----E_~ Fax (661) 257-8303
Email emaIl nucmedsalesezagcom
list must be affixed to the Q~12S and
RETURN RA- 2I fI ofthe package Each returned source EZlflmustb dina1)nHOOne exchange basis ~nly
please contact euroZIP customer service considerations
Reference Serial Capsule Source Wipe Nuclide Activity Date Number D~cription TestsSnCi- J amptQoosaao I ~ IRAbQ)~
(l4t OItli lJIH9f ~ lId) 8J2(gtaL cfgt-57 ~tJ--raquo~s DNo I i i
2) DYes 0 No
3) ___ DYeS 0 No
4) ___ DYes 0 No
If source is damaged broken or le~king describe under Capsule ~scription sectiOfl and submit a copy of the last leak test Keep a copy of this form for your recOrd~ It may be requested by your regulatory agency I acknowledge that the above information is true ~o the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Number (Required) -- shy
FOR EZIP USE OfllY
EZIP has received ~he radioactive sources listed above e(cel)t as noted below
Receivers Name
Receipt Date -LO
Sources not received NA
RETURN PACKING LIST All information must be provided to ensure proper handling of your return
FROM SENDTO
Company Name
Address
City
i Eckert amp Ziegler Isotope Products
1800 North Keystone Street Burbank CA 91504 Telephone (661)309-1010 Fax (661)257-8303 Email nucmedsalesezagcom
RETURN RAshy 2( STOP This packing list must be affixed to the OllTSIOE and a copy placed inside of the package Each returned source to EZIP must be on a one-to-one exchange basisnnly For additional returns please contact poundZIP customer service for additional cost considerations
Nuclide Activity
1gtamp5-1312fj$ C
2) Csift t)middotlCfflAC
3) ___
4) ___
Reference Date
Serial Number SS shy ~t-
crt Itt lft6-3-L
Capsule Description
Source Wipe Tests SnCi
IN Gi(tIJ~- )I~) S~ e~ 0 No
amp) St1 rC f ~o DYes 0 No
CJ Yes 0 NCigt
If source is damaged broken or leaking describe under Capsule Description section and submit a copy of the last leak test Keep a copy of this form for your records It may be requested by your regulatory agency I acknowledge that the above information is true to the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Num~er (Required)
FOR EZIP USE ONLY
EZIP has received the radioactive sources listed above except as noted below
Receivers Name~I~~ tgtltl~ ~No~Q1)s _Co -~bullbullbull - bullbullbull~-~~ -----shy ~ -- - -shy
Receipt Date ~ ~)- ) I
Sources not received riNA
1a902of2
Certificate of Instrument Detection Efficiency for
Columbus Diagnostic Imaging Columbus Indiana
April 6 2012
Instrument Capintec Caprac Well Counter
Instrument Net Conversion DetectionSource Activity Calibration Date
Settin CPM Factor Efficienc
Co-57 09967 uCi 4110 Well 302213 112dpmcpm 8929
MDA= 5x10-5
106 dpm
Results These results are within acceptable limits
-qA Radiation Safety Officer
Advanced Medical Physics LLC 9095 Doral CourtD bull Indianapolis IN 462503172233022 3178495058(fax) ~~~~
Certified in Medical Nuclear Physics by the American Board of Radiology
-~ C~lumbus II~USPOSTAGE Diagnostic ~ IUS POSTAGE $ 0 105 $ 0045 RRSTClASS
bull L l1li-shyImaging RRST ClASS
Mailed From 47201 bull 091042012 031A 0002309440
J ~ 031A 0002309440790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200
Fax (812) 376-6665
I i
~~~~=~~-------- t----shy -shy----+-I----shyI I I I
I
I i I
I
~~~~~=~~C~~--- -1----------- ---Jshy
NUC-SJGAMMA
cORRIDOR cru
I I
SI 1 ltFe I I EQUIPI 11441
I
I
I I
t1tl~~-middot - middot--~~itmiddotl----~-middot-middot-I---middot-middot-middotmiddot--middot--- -------+-_----shy
6
~
r middot
~ shy ~fIr- _ _ -gt-- v~~
I existing shelf
10
g
8
7
6
-middot5
4
3
2
r l 2 3 4 5 6 7 8 9 10
OI~~__L--k__~~__~~__4-~~~
PRELIMINARY PCANtflNG ONLY PROJECT TITLE
COLUMBUS DIAGNOSTIC IMAGING NUCLEAR ROOM - MILLENIUM MG
COLUMBUS INDIANA SCHEME NO08INA080 DRAWN BY TlD DATE 07-22-0
t)~o
THIS LAYOUT MUST BE APPROVED BEFORE FINAL DRAWINGS CAN 8E STARTED THANK YOU
CUSTOMER DATE
Of ProjectManagerInitalfotion DATE
tlitwoukec bull - -- - - _ - - - WJScollSin
This eq~t loyouIlf(ftCO ue pin and inI_ndlon 0 Ill iMIl_ cqolpmcnt bullbullmporuonb 11gt I bo IlIltIctol 11101 dodor Iocol reqW_ Ihltgtt could Impltlo lite pnt f III ~I It tlllOlns tbo ClIIIom rupbltJly for uriog III oito and flgtOi eqipmnl pIoltomont pIl6gt Milgt 011 appKcble federal otQt ofldor Deal requiremDn15
Radioactive Wastt ~nd Disposal Record
Policy and Procedure 1 Seal and store radioactive waste containers behind adequate shielding 2 Indicate Container ID andor Contents (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 surtace with a GM Survey Meter on its most sensitive scale without shielding prior to
disposal 5 Waste may be disposed of if activity is indistinguishable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash
0L] ~1YJ
Survey Meter Code
1
2
3
Model Serial Number
c_ r
ttIfn Last Assay 08te of
Waste to lie lJisposed of
r~tko~~middot~-middot~~ oh-ihi _gt Dt( -1
Container 10 JContents
r] tJG-~
Survey Meter
141 cl~fshy n1ht hr~~ch ~
frl-) ~~it1sectP1W~G 1--) I ~ r ~g C1Yl -f~~~llS IO~ ~J1j 84fi12sectt~ ~Jriilif~r)ltJamp --Q qCM Ah2 ~~11 ~ts-h shy I~m ~
~ ~-)7J I~71PZ~~jh 510~ - 1D I ~ I7rD-~ tL ~~1I=1 )jj I -gt J-poundiLill-~7iT-)ridil~~~ tC)V
f n ( - I I M--shy P ~- - v- -shy P -4 shy I ~ if I
f
1 Provided by Advanced Medical Physics 16770 c( ~reek Lane Noblesville IN 46060middot 3172233022 (
m
Radioactive Materials Shipment Rei (and Return Container Survey Record
Action Levels The Radiation Safety Omcer should be immediately notified when radiation or contamination level$ to whicb personnel may be exposed exceed tbe (ollowjng levels
Area Radiation Survey Contamination Surveys
Instruments Usedor Surveys
Meter No Make amp Model
Restricted 50 m81hr J 1OOODPMJIOOcm I 2 tr 0-- I I noV 1-----1
Unrestricted 20 m81hr I 1000 DPMllOO em 1] 3
Serial No Detector Efficiency
Note LQ indicates that the ack e does not exceed s ecified limits fur Limited QuantitidiJlhitm_ellts____---__---_--_________-- Receiot Sm-vey
Container ILabel I IT ITranspo-rt-middoty--=---------+---~c----JA-1t-c~-----+-L---------l----D-at-e lContact
No or III Index 3 mRlhr BKG Initials Retumed I mRlhr
--shy
Date
cm
BKG Cpm Initials
I
Report Date
Facility
State License Number USNRC License Number
Source Identification
Radionuclide Calibrated Activity Date Calibrated 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 13-24706-01
Cobalt-57 090708 10mCi Not Supplied BM01-10 BMOll008220102 Flood Source
0762 cpmdp~ 1691543 cpmuCi 102 dp~ 78 cp~ 000005 uCi 351
Activity (uCi)Gross cpm Netcpm DPM Dry Wipe 000000347 0 0
Instrument used for Analysis Ludlum Well Counter MN2200 SIN 198663
Analysis Results Source is not leaking at this time
Removable contamination is lt0005 uCi
Next Leak Test Due
Leak Test Performed By
Analysis Performed By
Radiation Safety Officer (signature)
I
Report Date
Facility
State License Number USNRC License Number
Source Identification
Radionuclide Calibrated Activity Date Calibrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
Apri122 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137
080197 2198uCi IPL 559-1627 RV-137-200V
Dose Calibrator Vial Source
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm OOOQ13 uCi 351
Activity (uCi) Gross cpm Netcpm DPM Dry Wipe 0000000347 0 0
Instrument used for Analysis
Analysis Results
Next Leak Test Due
Leak Test Performed By
Analysis Performed By
Ludlum Well Counter MN2200 SIN PR 198663
Source is not leaking at this time Removable contamination is lt0005 uCi
I October-12 I t IrftL--WillWn K Btteden III MS D~~ April 62012 ~~ fz--v ( t- shy
Edward E WrolewDABSNM
April 22 2012
Officer (signature)
Clouse out survey for Columbus Imaging Associates dba Columbus Diagnostic Imaging
6182012 USNRC Materials License 13-26797-01
IL~ L~~~())~ Location Location Description Exposure Rate (mRhr) Wipe activity(dpml00cmJ2) ~~
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 la b floor
11 hot lab floor
12 hot lab floor
13 hot lab floor
14 hot lab 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
33 275
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-oJ Jl9~( 11 (IQ IJ J(f~ t6JVe
(e-AIl)) P llan Po tVlCft r~
~~~~ ~~ ~ j
-efTIrf 1h1r f~ h~ vr 6~1
~~~~
CERTIFICATE OF CALIBRATION
Customer Advanced Med Phys
Manufacturer BIODEX
Detector Type GM
Detector Model X End Window
D Side Window
X Pancake
High Voltage -y
Date Received March 20 2012
Calibration Date March 30 2012
NEXT Calibration Due March 30 2013
Calibration Data
Scale Distance
(cm)
Instrument MIN 14C
Probe MIN 44-9 Calibration Geometry X Probe II
Cap ON
Window Open Window Closed
Battery Test Acceptable
Reset Check Test Acceptable
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Activity and SIN
Calculated Measured
Reading mRhr
SIN 101782 SIN PR2424100
X Probe Perpendicular
X Cap Off
] NA
Correction Factor
100x 1000 1813 800800
200 100x 1000 1813 200
x 100 4053 160
x 100 4053 40
x 10 4053 16 160 100
x 10 4053 4 40 100
xl xl
I I
4053
4053 I I
16 160
OA OAO 100
100
x 1 12817 016 016 100
x 1 12817 004 004 100
Comments All instrument readings were within +1- 10 at the time of calibration for all scales used
Applicable correction factors are noted above
This instrument must be checke for proper operation with the dedicated check source prior to
use A reading as indicated above denotes proper operation
UNABLE TO CALIBRATE x 100 SCALE Calibration Source Cs-137 Calibration Date January 15 1985 (+- 3 NBS)
Calibrated Activity 0154 Ci Roentgenshr 1m 00493
MN 773 Source ID S-526
SIN 216 Manufacturer Tech-Ops
Calculated Activity 00821 Ci Roentgenshr 1m 002630 March 30 2012
Photon Measurements Plus Calibrated By _________________
1427 West 86th Street Suite 282 Edward E Wroblewski MA DABSNM
Indianapolis IN 46260
tele 317755-9688 USNRC Materials License Numbcr-13-32533-01
RETURN PACKING LIST All information must be provided to ensure proper
SENOTO
Eckert ampZiegler Isotope Products
1800 North Keystone Street Burbank CA 91504
~~nTjjlllhnmiddot661)309-1010 1-~__ILI~tt--L=-=I--_ampjICI~=----E_~ Fax (661) 257-8303
Email emaIl nucmedsalesezagcom
list must be affixed to the Q~12S and
RETURN RA- 2I fI ofthe package Each returned source EZlflmustb dina1)nHOOne exchange basis ~nly
please contact euroZIP customer service considerations
Reference Serial Capsule Source Wipe Nuclide Activity Date Number D~cription TestsSnCi- J amptQoosaao I ~ IRAbQ)~
(l4t OItli lJIH9f ~ lId) 8J2(gtaL cfgt-57 ~tJ--raquo~s DNo I i i
2) DYes 0 No
3) ___ DYeS 0 No
4) ___ DYes 0 No
If source is damaged broken or le~king describe under Capsule ~scription sectiOfl and submit a copy of the last leak test Keep a copy of this form for your recOrd~ It may be requested by your regulatory agency I acknowledge that the above information is true ~o the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Number (Required) -- shy
FOR EZIP USE OfllY
EZIP has received ~he radioactive sources listed above e(cel)t as noted below
Receivers Name
Receipt Date -LO
Sources not received NA
RETURN PACKING LIST All information must be provided to ensure proper handling of your return
FROM SENDTO
Company Name
Address
City
i Eckert amp Ziegler Isotope Products
1800 North Keystone Street Burbank CA 91504 Telephone (661)309-1010 Fax (661)257-8303 Email nucmedsalesezagcom
RETURN RAshy 2( STOP This packing list must be affixed to the OllTSIOE and a copy placed inside of the package Each returned source to EZIP must be on a one-to-one exchange basisnnly For additional returns please contact poundZIP customer service for additional cost considerations
Nuclide Activity
1gtamp5-1312fj$ C
2) Csift t)middotlCfflAC
3) ___
4) ___
Reference Date
Serial Number SS shy ~t-
crt Itt lft6-3-L
Capsule Description
Source Wipe Tests SnCi
IN Gi(tIJ~- )I~) S~ e~ 0 No
amp) St1 rC f ~o DYes 0 No
CJ Yes 0 NCigt
If source is damaged broken or leaking describe under Capsule Description section and submit a copy of the last leak test Keep a copy of this form for your records It may be requested by your regulatory agency I acknowledge that the above information is true to the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Num~er (Required)
FOR EZIP USE ONLY
EZIP has received the radioactive sources listed above except as noted below
Receivers Name~I~~ tgtltl~ ~No~Q1)s _Co -~bullbullbull - bullbullbull~-~~ -----shy ~ -- - -shy
Receipt Date ~ ~)- ) I
Sources not received riNA
1a902of2
Certificate of Instrument Detection Efficiency for
Columbus Diagnostic Imaging Columbus Indiana
April 6 2012
Instrument Capintec Caprac Well Counter
Instrument Net Conversion DetectionSource Activity Calibration Date
Settin CPM Factor Efficienc
Co-57 09967 uCi 4110 Well 302213 112dpmcpm 8929
MDA= 5x10-5
106 dpm
Results These results are within acceptable limits
-qA Radiation Safety Officer
Advanced Medical Physics LLC 9095 Doral CourtD bull Indianapolis IN 462503172233022 3178495058(fax) ~~~~
Certified in Medical Nuclear Physics by the American Board of Radiology
-~ C~lumbus II~USPOSTAGE Diagnostic ~ IUS POSTAGE $ 0 105 $ 0045 RRSTClASS
bull L l1li-shyImaging RRST ClASS
Mailed From 47201 bull 091042012 031A 0002309440
J ~ 031A 0002309440790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200
Fax (812) 376-6665
6
~
r middot
~ shy ~fIr- _ _ -gt-- v~~
I existing shelf
10
g
8
7
6
-middot5
4
3
2
r l 2 3 4 5 6 7 8 9 10
OI~~__L--k__~~__~~__4-~~~
PRELIMINARY PCANtflNG ONLY PROJECT TITLE
COLUMBUS DIAGNOSTIC IMAGING NUCLEAR ROOM - MILLENIUM MG
COLUMBUS INDIANA SCHEME NO08INA080 DRAWN BY TlD DATE 07-22-0
t)~o
THIS LAYOUT MUST BE APPROVED BEFORE FINAL DRAWINGS CAN 8E STARTED THANK YOU
CUSTOMER DATE
Of ProjectManagerInitalfotion DATE
tlitwoukec bull - -- - - _ - - - WJScollSin
This eq~t loyouIlf(ftCO ue pin and inI_ndlon 0 Ill iMIl_ cqolpmcnt bullbullmporuonb 11gt I bo IlIltIctol 11101 dodor Iocol reqW_ Ihltgtt could Impltlo lite pnt f III ~I It tlllOlns tbo ClIIIom rupbltJly for uriog III oito and flgtOi eqipmnl pIoltomont pIl6gt Milgt 011 appKcble federal otQt ofldor Deal requiremDn15
Radioactive Wastt ~nd Disposal Record
Policy and Procedure 1 Seal and store radioactive waste containers behind adequate shielding 2 Indicate Container ID andor Contents (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 surtace with a GM Survey Meter on its most sensitive scale without shielding prior to
disposal 5 Waste may be disposed of if activity is indistinguishable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash
0L] ~1YJ
Survey Meter Code
1
2
3
Model Serial Number
c_ r
ttIfn Last Assay 08te of
Waste to lie lJisposed of
r~tko~~middot~-middot~~ oh-ihi _gt Dt( -1
Container 10 JContents
r] tJG-~
Survey Meter
141 cl~fshy n1ht hr~~ch ~
frl-) ~~it1sectP1W~G 1--) I ~ r ~g C1Yl -f~~~llS IO~ ~J1j 84fi12sectt~ ~Jriilif~r)ltJamp --Q qCM Ah2 ~~11 ~ts-h shy I~m ~
~ ~-)7J I~71PZ~~jh 510~ - 1D I ~ I7rD-~ tL ~~1I=1 )jj I -gt J-poundiLill-~7iT-)ridil~~~ tC)V
f n ( - I I M--shy P ~- - v- -shy P -4 shy I ~ if I
f
1 Provided by Advanced Medical Physics 16770 c( ~reek Lane Noblesville IN 46060middot 3172233022 (
m
Radioactive Materials Shipment Rei (and Return Container Survey Record
Action Levels The Radiation Safety Omcer should be immediately notified when radiation or contamination level$ to whicb personnel may be exposed exceed tbe (ollowjng levels
Area Radiation Survey Contamination Surveys
Instruments Usedor Surveys
Meter No Make amp Model
Restricted 50 m81hr J 1OOODPMJIOOcm I 2 tr 0-- I I noV 1-----1
Unrestricted 20 m81hr I 1000 DPMllOO em 1] 3
Serial No Detector Efficiency
Note LQ indicates that the ack e does not exceed s ecified limits fur Limited QuantitidiJlhitm_ellts____---__---_--_________-- Receiot Sm-vey
Container ILabel I IT ITranspo-rt-middoty--=---------+---~c----JA-1t-c~-----+-L---------l----D-at-e lContact
No or III Index 3 mRlhr BKG Initials Retumed I mRlhr
--shy
Date
cm
BKG Cpm Initials
I
Report Date
Facility
State License Number USNRC License Number
Source Identification
Radionuclide Calibrated Activity Date Calibrated 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 13-24706-01
Cobalt-57 090708 10mCi Not Supplied BM01-10 BMOll008220102 Flood Source
0762 cpmdp~ 1691543 cpmuCi 102 dp~ 78 cp~ 000005 uCi 351
Activity (uCi)Gross cpm Netcpm DPM Dry Wipe 000000347 0 0
Instrument used for Analysis Ludlum Well Counter MN2200 SIN 198663
Analysis Results Source is not leaking at this time
Removable contamination is lt0005 uCi
Next Leak Test Due
Leak Test Performed By
Analysis Performed By
Radiation Safety Officer (signature)
I
Report Date
Facility
State License Number USNRC License Number
Source Identification
Radionuclide Calibrated Activity Date Calibrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
Apri122 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137
080197 2198uCi IPL 559-1627 RV-137-200V
Dose Calibrator Vial Source
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm OOOQ13 uCi 351
Activity (uCi) Gross cpm Netcpm DPM Dry Wipe 0000000347 0 0
Instrument used for Analysis
Analysis Results
Next Leak Test Due
Leak Test Performed By
Analysis Performed By
Ludlum Well Counter MN2200 SIN PR 198663
Source is not leaking at this time Removable contamination is lt0005 uCi
I October-12 I t IrftL--WillWn K Btteden III MS D~~ April 62012 ~~ fz--v ( t- shy
Edward E WrolewDABSNM
April 22 2012
Officer (signature)
Clouse out survey for Columbus Imaging Associates dba Columbus Diagnostic Imaging
6182012 USNRC Materials License 13-26797-01
IL~ L~~~())~ Location Location Description Exposure Rate (mRhr) Wipe activity(dpml00cmJ2) ~~
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 la b floor
11 hot lab floor
12 hot lab floor
13 hot lab floor
14 hot lab 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
33 275
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-oJ Jl9~( 11 (IQ IJ J(f~ t6JVe
(e-AIl)) P llan Po tVlCft r~
~~~~ ~~ ~ j
-efTIrf 1h1r f~ h~ vr 6~1
~~~~
CERTIFICATE OF CALIBRATION
Customer Advanced Med Phys
Manufacturer BIODEX
Detector Type GM
Detector Model X End Window
D Side Window
X Pancake
High Voltage -y
Date Received March 20 2012
Calibration Date March 30 2012
NEXT Calibration Due March 30 2013
Calibration Data
Scale Distance
(cm)
Instrument MIN 14C
Probe MIN 44-9 Calibration Geometry X Probe II
Cap ON
Window Open Window Closed
Battery Test Acceptable
Reset Check Test Acceptable
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Activity and SIN
Calculated Measured
Reading mRhr
SIN 101782 SIN PR2424100
X Probe Perpendicular
X Cap Off
] NA
Correction Factor
100x 1000 1813 800800
200 100x 1000 1813 200
x 100 4053 160
x 100 4053 40
x 10 4053 16 160 100
x 10 4053 4 40 100
xl xl
I I
4053
4053 I I
16 160
OA OAO 100
100
x 1 12817 016 016 100
x 1 12817 004 004 100
Comments All instrument readings were within +1- 10 at the time of calibration for all scales used
Applicable correction factors are noted above
This instrument must be checke for proper operation with the dedicated check source prior to
use A reading as indicated above denotes proper operation
UNABLE TO CALIBRATE x 100 SCALE Calibration Source Cs-137 Calibration Date January 15 1985 (+- 3 NBS)
Calibrated Activity 0154 Ci Roentgenshr 1m 00493
MN 773 Source ID S-526
SIN 216 Manufacturer Tech-Ops
Calculated Activity 00821 Ci Roentgenshr 1m 002630 March 30 2012
Photon Measurements Plus Calibrated By _________________
1427 West 86th Street Suite 282 Edward E Wroblewski MA DABSNM
Indianapolis IN 46260
tele 317755-9688 USNRC Materials License Numbcr-13-32533-01
RETURN PACKING LIST All information must be provided to ensure proper
SENOTO
Eckert ampZiegler Isotope Products
1800 North Keystone Street Burbank CA 91504
~~nTjjlllhnmiddot661)309-1010 1-~__ILI~tt--L=-=I--_ampjICI~=----E_~ Fax (661) 257-8303
Email emaIl nucmedsalesezagcom
list must be affixed to the Q~12S and
RETURN RA- 2I fI ofthe package Each returned source EZlflmustb dina1)nHOOne exchange basis ~nly
please contact euroZIP customer service considerations
Reference Serial Capsule Source Wipe Nuclide Activity Date Number D~cription TestsSnCi- J amptQoosaao I ~ IRAbQ)~
(l4t OItli lJIH9f ~ lId) 8J2(gtaL cfgt-57 ~tJ--raquo~s DNo I i i
2) DYes 0 No
3) ___ DYeS 0 No
4) ___ DYes 0 No
If source is damaged broken or le~king describe under Capsule ~scription sectiOfl and submit a copy of the last leak test Keep a copy of this form for your recOrd~ It may be requested by your regulatory agency I acknowledge that the above information is true ~o the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Number (Required) -- shy
FOR EZIP USE OfllY
EZIP has received ~he radioactive sources listed above e(cel)t as noted below
Receivers Name
Receipt Date -LO
Sources not received NA
RETURN PACKING LIST All information must be provided to ensure proper handling of your return
FROM SENDTO
Company Name
Address
City
i Eckert amp Ziegler Isotope Products
1800 North Keystone Street Burbank CA 91504 Telephone (661)309-1010 Fax (661)257-8303 Email nucmedsalesezagcom
RETURN RAshy 2( STOP This packing list must be affixed to the OllTSIOE and a copy placed inside of the package Each returned source to EZIP must be on a one-to-one exchange basisnnly For additional returns please contact poundZIP customer service for additional cost considerations
Nuclide Activity
1gtamp5-1312fj$ C
2) Csift t)middotlCfflAC
3) ___
4) ___
Reference Date
Serial Number SS shy ~t-
crt Itt lft6-3-L
Capsule Description
Source Wipe Tests SnCi
IN Gi(tIJ~- )I~) S~ e~ 0 No
amp) St1 rC f ~o DYes 0 No
CJ Yes 0 NCigt
If source is damaged broken or leaking describe under Capsule Description section and submit a copy of the last leak test Keep a copy of this form for your records It may be requested by your regulatory agency I acknowledge that the above information is true to the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Num~er (Required)
FOR EZIP USE ONLY
EZIP has received the radioactive sources listed above except as noted below
Receivers Name~I~~ tgtltl~ ~No~Q1)s _Co -~bullbullbull - bullbullbull~-~~ -----shy ~ -- - -shy
Receipt Date ~ ~)- ) I
Sources not received riNA
1a902of2
Certificate of Instrument Detection Efficiency for
Columbus Diagnostic Imaging Columbus Indiana
April 6 2012
Instrument Capintec Caprac Well Counter
Instrument Net Conversion DetectionSource Activity Calibration Date
Settin CPM Factor Efficienc
Co-57 09967 uCi 4110 Well 302213 112dpmcpm 8929
MDA= 5x10-5
106 dpm
Results These results are within acceptable limits
-qA Radiation Safety Officer
Advanced Medical Physics LLC 9095 Doral CourtD bull Indianapolis IN 462503172233022 3178495058(fax) ~~~~
Certified in Medical Nuclear Physics by the American Board of Radiology
-~ C~lumbus II~USPOSTAGE Diagnostic ~ IUS POSTAGE $ 0 105 $ 0045 RRSTClASS
bull L l1li-shyImaging RRST ClASS
Mailed From 47201 bull 091042012 031A 0002309440
J ~ 031A 0002309440790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200
Fax (812) 376-6665
Radioactive Wastt ~nd Disposal Record
Policy and Procedure 1 Seal and store radioactive waste containers behind adequate shielding 2 Indicate Container ID andor Contents (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 surtace with a GM Survey Meter on its most sensitive scale without shielding prior to
disposal 5 Waste may be disposed of if activity is indistinguishable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash
0L] ~1YJ
Survey Meter Code
1
2
3
Model Serial Number
c_ r
ttIfn Last Assay 08te of
Waste to lie lJisposed of
r~tko~~middot~-middot~~ oh-ihi _gt Dt( -1
Container 10 JContents
r] tJG-~
Survey Meter
141 cl~fshy n1ht hr~~ch ~
frl-) ~~it1sectP1W~G 1--) I ~ r ~g C1Yl -f~~~llS IO~ ~J1j 84fi12sectt~ ~Jriilif~r)ltJamp --Q qCM Ah2 ~~11 ~ts-h shy I~m ~
~ ~-)7J I~71PZ~~jh 510~ - 1D I ~ I7rD-~ tL ~~1I=1 )jj I -gt J-poundiLill-~7iT-)ridil~~~ tC)V
f n ( - I I M--shy P ~- - v- -shy P -4 shy I ~ if I
f
1 Provided by Advanced Medical Physics 16770 c( ~reek Lane Noblesville IN 46060middot 3172233022 (
m
Radioactive Materials Shipment Rei (and Return Container Survey Record
Action Levels The Radiation Safety Omcer should be immediately notified when radiation or contamination level$ to whicb personnel may be exposed exceed tbe (ollowjng levels
Area Radiation Survey Contamination Surveys
Instruments Usedor Surveys
Meter No Make amp Model
Restricted 50 m81hr J 1OOODPMJIOOcm I 2 tr 0-- I I noV 1-----1
Unrestricted 20 m81hr I 1000 DPMllOO em 1] 3
Serial No Detector Efficiency
Note LQ indicates that the ack e does not exceed s ecified limits fur Limited QuantitidiJlhitm_ellts____---__---_--_________-- Receiot Sm-vey
Container ILabel I IT ITranspo-rt-middoty--=---------+---~c----JA-1t-c~-----+-L---------l----D-at-e lContact
No or III Index 3 mRlhr BKG Initials Retumed I mRlhr
--shy
Date
cm
BKG Cpm Initials
I
Report Date
Facility
State License Number USNRC License Number
Source Identification
Radionuclide Calibrated Activity Date Calibrated 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 13-24706-01
Cobalt-57 090708 10mCi Not Supplied BM01-10 BMOll008220102 Flood Source
0762 cpmdp~ 1691543 cpmuCi 102 dp~ 78 cp~ 000005 uCi 351
Activity (uCi)Gross cpm Netcpm DPM Dry Wipe 000000347 0 0
Instrument used for Analysis Ludlum Well Counter MN2200 SIN 198663
Analysis Results Source is not leaking at this time
Removable contamination is lt0005 uCi
Next Leak Test Due
Leak Test Performed By
Analysis Performed By
Radiation Safety Officer (signature)
I
Report Date
Facility
State License Number USNRC License Number
Source Identification
Radionuclide Calibrated Activity Date Calibrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
Apri122 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137
080197 2198uCi IPL 559-1627 RV-137-200V
Dose Calibrator Vial Source
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm OOOQ13 uCi 351
Activity (uCi) Gross cpm Netcpm DPM Dry Wipe 0000000347 0 0
Instrument used for Analysis
Analysis Results
Next Leak Test Due
Leak Test Performed By
Analysis Performed By
Ludlum Well Counter MN2200 SIN PR 198663
Source is not leaking at this time Removable contamination is lt0005 uCi
I October-12 I t IrftL--WillWn K Btteden III MS D~~ April 62012 ~~ fz--v ( t- shy
Edward E WrolewDABSNM
April 22 2012
Officer (signature)
Clouse out survey for Columbus Imaging Associates dba Columbus Diagnostic Imaging
6182012 USNRC Materials License 13-26797-01
IL~ L~~~())~ Location Location Description Exposure Rate (mRhr) Wipe activity(dpml00cmJ2) ~~
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 la b floor
11 hot lab floor
12 hot lab floor
13 hot lab floor
14 hot lab 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
33 275
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-oJ Jl9~( 11 (IQ IJ J(f~ t6JVe
(e-AIl)) P llan Po tVlCft r~
~~~~ ~~ ~ j
-efTIrf 1h1r f~ h~ vr 6~1
~~~~
CERTIFICATE OF CALIBRATION
Customer Advanced Med Phys
Manufacturer BIODEX
Detector Type GM
Detector Model X End Window
D Side Window
X Pancake
High Voltage -y
Date Received March 20 2012
Calibration Date March 30 2012
NEXT Calibration Due March 30 2013
Calibration Data
Scale Distance
(cm)
Instrument MIN 14C
Probe MIN 44-9 Calibration Geometry X Probe II
Cap ON
Window Open Window Closed
Battery Test Acceptable
Reset Check Test Acceptable
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Activity and SIN
Calculated Measured
Reading mRhr
SIN 101782 SIN PR2424100
X Probe Perpendicular
X Cap Off
] NA
Correction Factor
100x 1000 1813 800800
200 100x 1000 1813 200
x 100 4053 160
x 100 4053 40
x 10 4053 16 160 100
x 10 4053 4 40 100
xl xl
I I
4053
4053 I I
16 160
OA OAO 100
100
x 1 12817 016 016 100
x 1 12817 004 004 100
Comments All instrument readings were within +1- 10 at the time of calibration for all scales used
Applicable correction factors are noted above
This instrument must be checke for proper operation with the dedicated check source prior to
use A reading as indicated above denotes proper operation
UNABLE TO CALIBRATE x 100 SCALE Calibration Source Cs-137 Calibration Date January 15 1985 (+- 3 NBS)
Calibrated Activity 0154 Ci Roentgenshr 1m 00493
MN 773 Source ID S-526
SIN 216 Manufacturer Tech-Ops
Calculated Activity 00821 Ci Roentgenshr 1m 002630 March 30 2012
Photon Measurements Plus Calibrated By _________________
1427 West 86th Street Suite 282 Edward E Wroblewski MA DABSNM
Indianapolis IN 46260
tele 317755-9688 USNRC Materials License Numbcr-13-32533-01
RETURN PACKING LIST All information must be provided to ensure proper
SENOTO
Eckert ampZiegler Isotope Products
1800 North Keystone Street Burbank CA 91504
~~nTjjlllhnmiddot661)309-1010 1-~__ILI~tt--L=-=I--_ampjICI~=----E_~ Fax (661) 257-8303
Email emaIl nucmedsalesezagcom
list must be affixed to the Q~12S and
RETURN RA- 2I fI ofthe package Each returned source EZlflmustb dina1)nHOOne exchange basis ~nly
please contact euroZIP customer service considerations
Reference Serial Capsule Source Wipe Nuclide Activity Date Number D~cription TestsSnCi- J amptQoosaao I ~ IRAbQ)~
(l4t OItli lJIH9f ~ lId) 8J2(gtaL cfgt-57 ~tJ--raquo~s DNo I i i
2) DYes 0 No
3) ___ DYeS 0 No
4) ___ DYes 0 No
If source is damaged broken or le~king describe under Capsule ~scription sectiOfl and submit a copy of the last leak test Keep a copy of this form for your recOrd~ It may be requested by your regulatory agency I acknowledge that the above information is true ~o the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Number (Required) -- shy
FOR EZIP USE OfllY
EZIP has received ~he radioactive sources listed above e(cel)t as noted below
Receivers Name
Receipt Date -LO
Sources not received NA
RETURN PACKING LIST All information must be provided to ensure proper handling of your return
FROM SENDTO
Company Name
Address
City
i Eckert amp Ziegler Isotope Products
1800 North Keystone Street Burbank CA 91504 Telephone (661)309-1010 Fax (661)257-8303 Email nucmedsalesezagcom
RETURN RAshy 2( STOP This packing list must be affixed to the OllTSIOE and a copy placed inside of the package Each returned source to EZIP must be on a one-to-one exchange basisnnly For additional returns please contact poundZIP customer service for additional cost considerations
Nuclide Activity
1gtamp5-1312fj$ C
2) Csift t)middotlCfflAC
3) ___
4) ___
Reference Date
Serial Number SS shy ~t-
crt Itt lft6-3-L
Capsule Description
Source Wipe Tests SnCi
IN Gi(tIJ~- )I~) S~ e~ 0 No
amp) St1 rC f ~o DYes 0 No
CJ Yes 0 NCigt
If source is damaged broken or leaking describe under Capsule Description section and submit a copy of the last leak test Keep a copy of this form for your records It may be requested by your regulatory agency I acknowledge that the above information is true to the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Num~er (Required)
FOR EZIP USE ONLY
EZIP has received the radioactive sources listed above except as noted below
Receivers Name~I~~ tgtltl~ ~No~Q1)s _Co -~bullbullbull - bullbullbull~-~~ -----shy ~ -- - -shy
Receipt Date ~ ~)- ) I
Sources not received riNA
1a902of2
Certificate of Instrument Detection Efficiency for
Columbus Diagnostic Imaging Columbus Indiana
April 6 2012
Instrument Capintec Caprac Well Counter
Instrument Net Conversion DetectionSource Activity Calibration Date
Settin CPM Factor Efficienc
Co-57 09967 uCi 4110 Well 302213 112dpmcpm 8929
MDA= 5x10-5
106 dpm
Results These results are within acceptable limits
-qA Radiation Safety Officer
Advanced Medical Physics LLC 9095 Doral CourtD bull Indianapolis IN 462503172233022 3178495058(fax) ~~~~
Certified in Medical Nuclear Physics by the American Board of Radiology
-~ C~lumbus II~USPOSTAGE Diagnostic ~ IUS POSTAGE $ 0 105 $ 0045 RRSTClASS
bull L l1li-shyImaging RRST ClASS
Mailed From 47201 bull 091042012 031A 0002309440
J ~ 031A 0002309440790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200
Fax (812) 376-6665
Radioactive Materials Shipment Rei (and Return Container Survey Record
Action Levels The Radiation Safety Omcer should be immediately notified when radiation or contamination level$ to whicb personnel may be exposed exceed tbe (ollowjng levels
Area Radiation Survey Contamination Surveys
Instruments Usedor Surveys
Meter No Make amp Model
Restricted 50 m81hr J 1OOODPMJIOOcm I 2 tr 0-- I I noV 1-----1
Unrestricted 20 m81hr I 1000 DPMllOO em 1] 3
Serial No Detector Efficiency
Note LQ indicates that the ack e does not exceed s ecified limits fur Limited QuantitidiJlhitm_ellts____---__---_--_________-- Receiot Sm-vey
Container ILabel I IT ITranspo-rt-middoty--=---------+---~c----JA-1t-c~-----+-L---------l----D-at-e lContact
No or III Index 3 mRlhr BKG Initials Retumed I mRlhr
--shy
Date
cm
BKG Cpm Initials
I
Report Date
Facility
State License Number USNRC License Number
Source Identification
Radionuclide Calibrated Activity Date Calibrated 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 13-24706-01
Cobalt-57 090708 10mCi Not Supplied BM01-10 BMOll008220102 Flood Source
0762 cpmdp~ 1691543 cpmuCi 102 dp~ 78 cp~ 000005 uCi 351
Activity (uCi)Gross cpm Netcpm DPM Dry Wipe 000000347 0 0
Instrument used for Analysis Ludlum Well Counter MN2200 SIN 198663
Analysis Results Source is not leaking at this time
Removable contamination is lt0005 uCi
Next Leak Test Due
Leak Test Performed By
Analysis Performed By
Radiation Safety Officer (signature)
I
Report Date
Facility
State License Number USNRC License Number
Source Identification
Radionuclide Calibrated Activity Date Calibrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
Apri122 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137
080197 2198uCi IPL 559-1627 RV-137-200V
Dose Calibrator Vial Source
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm OOOQ13 uCi 351
Activity (uCi) Gross cpm Netcpm DPM Dry Wipe 0000000347 0 0
Instrument used for Analysis
Analysis Results
Next Leak Test Due
Leak Test Performed By
Analysis Performed By
Ludlum Well Counter MN2200 SIN PR 198663
Source is not leaking at this time Removable contamination is lt0005 uCi
I October-12 I t IrftL--WillWn K Btteden III MS D~~ April 62012 ~~ fz--v ( t- shy
Edward E WrolewDABSNM
April 22 2012
Officer (signature)
Clouse out survey for Columbus Imaging Associates dba Columbus Diagnostic Imaging
6182012 USNRC Materials License 13-26797-01
IL~ L~~~())~ Location Location Description Exposure Rate (mRhr) Wipe activity(dpml00cmJ2) ~~
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 la b floor
11 hot lab floor
12 hot lab floor
13 hot lab floor
14 hot lab 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
33 275
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-oJ Jl9~( 11 (IQ IJ J(f~ t6JVe
(e-AIl)) P llan Po tVlCft r~
~~~~ ~~ ~ j
-efTIrf 1h1r f~ h~ vr 6~1
~~~~
CERTIFICATE OF CALIBRATION
Customer Advanced Med Phys
Manufacturer BIODEX
Detector Type GM
Detector Model X End Window
D Side Window
X Pancake
High Voltage -y
Date Received March 20 2012
Calibration Date March 30 2012
NEXT Calibration Due March 30 2013
Calibration Data
Scale Distance
(cm)
Instrument MIN 14C
Probe MIN 44-9 Calibration Geometry X Probe II
Cap ON
Window Open Window Closed
Battery Test Acceptable
Reset Check Test Acceptable
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Activity and SIN
Calculated Measured
Reading mRhr
SIN 101782 SIN PR2424100
X Probe Perpendicular
X Cap Off
] NA
Correction Factor
100x 1000 1813 800800
200 100x 1000 1813 200
x 100 4053 160
x 100 4053 40
x 10 4053 16 160 100
x 10 4053 4 40 100
xl xl
I I
4053
4053 I I
16 160
OA OAO 100
100
x 1 12817 016 016 100
x 1 12817 004 004 100
Comments All instrument readings were within +1- 10 at the time of calibration for all scales used
Applicable correction factors are noted above
This instrument must be checke for proper operation with the dedicated check source prior to
use A reading as indicated above denotes proper operation
UNABLE TO CALIBRATE x 100 SCALE Calibration Source Cs-137 Calibration Date January 15 1985 (+- 3 NBS)
Calibrated Activity 0154 Ci Roentgenshr 1m 00493
MN 773 Source ID S-526
SIN 216 Manufacturer Tech-Ops
Calculated Activity 00821 Ci Roentgenshr 1m 002630 March 30 2012
Photon Measurements Plus Calibrated By _________________
1427 West 86th Street Suite 282 Edward E Wroblewski MA DABSNM
Indianapolis IN 46260
tele 317755-9688 USNRC Materials License Numbcr-13-32533-01
RETURN PACKING LIST All information must be provided to ensure proper
SENOTO
Eckert ampZiegler Isotope Products
1800 North Keystone Street Burbank CA 91504
~~nTjjlllhnmiddot661)309-1010 1-~__ILI~tt--L=-=I--_ampjICI~=----E_~ Fax (661) 257-8303
Email emaIl nucmedsalesezagcom
list must be affixed to the Q~12S and
RETURN RA- 2I fI ofthe package Each returned source EZlflmustb dina1)nHOOne exchange basis ~nly
please contact euroZIP customer service considerations
Reference Serial Capsule Source Wipe Nuclide Activity Date Number D~cription TestsSnCi- J amptQoosaao I ~ IRAbQ)~
(l4t OItli lJIH9f ~ lId) 8J2(gtaL cfgt-57 ~tJ--raquo~s DNo I i i
2) DYes 0 No
3) ___ DYeS 0 No
4) ___ DYes 0 No
If source is damaged broken or le~king describe under Capsule ~scription sectiOfl and submit a copy of the last leak test Keep a copy of this form for your recOrd~ It may be requested by your regulatory agency I acknowledge that the above information is true ~o the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Number (Required) -- shy
FOR EZIP USE OfllY
EZIP has received ~he radioactive sources listed above e(cel)t as noted below
Receivers Name
Receipt Date -LO
Sources not received NA
RETURN PACKING LIST All information must be provided to ensure proper handling of your return
FROM SENDTO
Company Name
Address
City
i Eckert amp Ziegler Isotope Products
1800 North Keystone Street Burbank CA 91504 Telephone (661)309-1010 Fax (661)257-8303 Email nucmedsalesezagcom
RETURN RAshy 2( STOP This packing list must be affixed to the OllTSIOE and a copy placed inside of the package Each returned source to EZIP must be on a one-to-one exchange basisnnly For additional returns please contact poundZIP customer service for additional cost considerations
Nuclide Activity
1gtamp5-1312fj$ C
2) Csift t)middotlCfflAC
3) ___
4) ___
Reference Date
Serial Number SS shy ~t-
crt Itt lft6-3-L
Capsule Description
Source Wipe Tests SnCi
IN Gi(tIJ~- )I~) S~ e~ 0 No
amp) St1 rC f ~o DYes 0 No
CJ Yes 0 NCigt
If source is damaged broken or leaking describe under Capsule Description section and submit a copy of the last leak test Keep a copy of this form for your records It may be requested by your regulatory agency I acknowledge that the above information is true to the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Num~er (Required)
FOR EZIP USE ONLY
EZIP has received the radioactive sources listed above except as noted below
Receivers Name~I~~ tgtltl~ ~No~Q1)s _Co -~bullbullbull - bullbullbull~-~~ -----shy ~ -- - -shy
Receipt Date ~ ~)- ) I
Sources not received riNA
1a902of2
Certificate of Instrument Detection Efficiency for
Columbus Diagnostic Imaging Columbus Indiana
April 6 2012
Instrument Capintec Caprac Well Counter
Instrument Net Conversion DetectionSource Activity Calibration Date
Settin CPM Factor Efficienc
Co-57 09967 uCi 4110 Well 302213 112dpmcpm 8929
MDA= 5x10-5
106 dpm
Results These results are within acceptable limits
-qA Radiation Safety Officer
Advanced Medical Physics LLC 9095 Doral CourtD bull Indianapolis IN 462503172233022 3178495058(fax) ~~~~
Certified in Medical Nuclear Physics by the American Board of Radiology
-~ C~lumbus II~USPOSTAGE Diagnostic ~ IUS POSTAGE $ 0 105 $ 0045 RRSTClASS
bull L l1li-shyImaging RRST ClASS
Mailed From 47201 bull 091042012 031A 0002309440
J ~ 031A 0002309440790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200
Fax (812) 376-6665
I
Report Date
Facility
State License Number USNRC License Number
Source Identification
Radionuclide Calibrated Activity Date Calibrated 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 13-24706-01
Cobalt-57 090708 10mCi Not Supplied BM01-10 BMOll008220102 Flood Source
0762 cpmdp~ 1691543 cpmuCi 102 dp~ 78 cp~ 000005 uCi 351
Activity (uCi)Gross cpm Netcpm DPM Dry Wipe 000000347 0 0
Instrument used for Analysis Ludlum Well Counter MN2200 SIN 198663
Analysis Results Source is not leaking at this time
Removable contamination is lt0005 uCi
Next Leak Test Due
Leak Test Performed By
Analysis Performed By
Radiation Safety Officer (signature)
I
Report Date
Facility
State License Number USNRC License Number
Source Identification
Radionuclide Calibrated Activity Date Calibrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
Apri122 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137
080197 2198uCi IPL 559-1627 RV-137-200V
Dose Calibrator Vial Source
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm OOOQ13 uCi 351
Activity (uCi) Gross cpm Netcpm DPM Dry Wipe 0000000347 0 0
Instrument used for Analysis
Analysis Results
Next Leak Test Due
Leak Test Performed By
Analysis Performed By
Ludlum Well Counter MN2200 SIN PR 198663
Source is not leaking at this time Removable contamination is lt0005 uCi
I October-12 I t IrftL--WillWn K Btteden III MS D~~ April 62012 ~~ fz--v ( t- shy
Edward E WrolewDABSNM
April 22 2012
Officer (signature)
Clouse out survey for Columbus Imaging Associates dba Columbus Diagnostic Imaging
6182012 USNRC Materials License 13-26797-01
IL~ L~~~())~ Location Location Description Exposure Rate (mRhr) Wipe activity(dpml00cmJ2) ~~
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 la b floor
11 hot lab floor
12 hot lab floor
13 hot lab floor
14 hot lab 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
33 275
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-oJ Jl9~( 11 (IQ IJ J(f~ t6JVe
(e-AIl)) P llan Po tVlCft r~
~~~~ ~~ ~ j
-efTIrf 1h1r f~ h~ vr 6~1
~~~~
CERTIFICATE OF CALIBRATION
Customer Advanced Med Phys
Manufacturer BIODEX
Detector Type GM
Detector Model X End Window
D Side Window
X Pancake
High Voltage -y
Date Received March 20 2012
Calibration Date March 30 2012
NEXT Calibration Due March 30 2013
Calibration Data
Scale Distance
(cm)
Instrument MIN 14C
Probe MIN 44-9 Calibration Geometry X Probe II
Cap ON
Window Open Window Closed
Battery Test Acceptable
Reset Check Test Acceptable
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Activity and SIN
Calculated Measured
Reading mRhr
SIN 101782 SIN PR2424100
X Probe Perpendicular
X Cap Off
] NA
Correction Factor
100x 1000 1813 800800
200 100x 1000 1813 200
x 100 4053 160
x 100 4053 40
x 10 4053 16 160 100
x 10 4053 4 40 100
xl xl
I I
4053
4053 I I
16 160
OA OAO 100
100
x 1 12817 016 016 100
x 1 12817 004 004 100
Comments All instrument readings were within +1- 10 at the time of calibration for all scales used
Applicable correction factors are noted above
This instrument must be checke for proper operation with the dedicated check source prior to
use A reading as indicated above denotes proper operation
UNABLE TO CALIBRATE x 100 SCALE Calibration Source Cs-137 Calibration Date January 15 1985 (+- 3 NBS)
Calibrated Activity 0154 Ci Roentgenshr 1m 00493
MN 773 Source ID S-526
SIN 216 Manufacturer Tech-Ops
Calculated Activity 00821 Ci Roentgenshr 1m 002630 March 30 2012
Photon Measurements Plus Calibrated By _________________
1427 West 86th Street Suite 282 Edward E Wroblewski MA DABSNM
Indianapolis IN 46260
tele 317755-9688 USNRC Materials License Numbcr-13-32533-01
RETURN PACKING LIST All information must be provided to ensure proper
SENOTO
Eckert ampZiegler Isotope Products
1800 North Keystone Street Burbank CA 91504
~~nTjjlllhnmiddot661)309-1010 1-~__ILI~tt--L=-=I--_ampjICI~=----E_~ Fax (661) 257-8303
Email emaIl nucmedsalesezagcom
list must be affixed to the Q~12S and
RETURN RA- 2I fI ofthe package Each returned source EZlflmustb dina1)nHOOne exchange basis ~nly
please contact euroZIP customer service considerations
Reference Serial Capsule Source Wipe Nuclide Activity Date Number D~cription TestsSnCi- J amptQoosaao I ~ IRAbQ)~
(l4t OItli lJIH9f ~ lId) 8J2(gtaL cfgt-57 ~tJ--raquo~s DNo I i i
2) DYes 0 No
3) ___ DYeS 0 No
4) ___ DYes 0 No
If source is damaged broken or le~king describe under Capsule ~scription sectiOfl and submit a copy of the last leak test Keep a copy of this form for your recOrd~ It may be requested by your regulatory agency I acknowledge that the above information is true ~o the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Number (Required) -- shy
FOR EZIP USE OfllY
EZIP has received ~he radioactive sources listed above e(cel)t as noted below
Receivers Name
Receipt Date -LO
Sources not received NA
RETURN PACKING LIST All information must be provided to ensure proper handling of your return
FROM SENDTO
Company Name
Address
City
i Eckert amp Ziegler Isotope Products
1800 North Keystone Street Burbank CA 91504 Telephone (661)309-1010 Fax (661)257-8303 Email nucmedsalesezagcom
RETURN RAshy 2( STOP This packing list must be affixed to the OllTSIOE and a copy placed inside of the package Each returned source to EZIP must be on a one-to-one exchange basisnnly For additional returns please contact poundZIP customer service for additional cost considerations
Nuclide Activity
1gtamp5-1312fj$ C
2) Csift t)middotlCfflAC
3) ___
4) ___
Reference Date
Serial Number SS shy ~t-
crt Itt lft6-3-L
Capsule Description
Source Wipe Tests SnCi
IN Gi(tIJ~- )I~) S~ e~ 0 No
amp) St1 rC f ~o DYes 0 No
CJ Yes 0 NCigt
If source is damaged broken or leaking describe under Capsule Description section and submit a copy of the last leak test Keep a copy of this form for your records It may be requested by your regulatory agency I acknowledge that the above information is true to the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Num~er (Required)
FOR EZIP USE ONLY
EZIP has received the radioactive sources listed above except as noted below
Receivers Name~I~~ tgtltl~ ~No~Q1)s _Co -~bullbullbull - bullbullbull~-~~ -----shy ~ -- - -shy
Receipt Date ~ ~)- ) I
Sources not received riNA
1a902of2
Certificate of Instrument Detection Efficiency for
Columbus Diagnostic Imaging Columbus Indiana
April 6 2012
Instrument Capintec Caprac Well Counter
Instrument Net Conversion DetectionSource Activity Calibration Date
Settin CPM Factor Efficienc
Co-57 09967 uCi 4110 Well 302213 112dpmcpm 8929
MDA= 5x10-5
106 dpm
Results These results are within acceptable limits
-qA Radiation Safety Officer
Advanced Medical Physics LLC 9095 Doral CourtD bull Indianapolis IN 462503172233022 3178495058(fax) ~~~~
Certified in Medical Nuclear Physics by the American Board of Radiology
-~ C~lumbus II~USPOSTAGE Diagnostic ~ IUS POSTAGE $ 0 105 $ 0045 RRSTClASS
bull L l1li-shyImaging RRST ClASS
Mailed From 47201 bull 091042012 031A 0002309440
J ~ 031A 0002309440790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200
Fax (812) 376-6665
I
Report Date
Facility
State License Number USNRC License Number
Source Identification
Radionuclide Calibrated Activity Date Calibrated Activity Manufacturer Serial Number Model Number Source Description
Assay Results Counting Efficiency MDA Background time of assay ~cpm)
Apri122 2012
Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01
Cs-137
080197 2198uCi IPL 559-1627 RV-137-200V
Dose Calibrator Vial Source
02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm OOOQ13 uCi 351
Activity (uCi) Gross cpm Netcpm DPM Dry Wipe 0000000347 0 0
Instrument used for Analysis
Analysis Results
Next Leak Test Due
Leak Test Performed By
Analysis Performed By
Ludlum Well Counter MN2200 SIN PR 198663
Source is not leaking at this time Removable contamination is lt0005 uCi
I October-12 I t IrftL--WillWn K Btteden III MS D~~ April 62012 ~~ fz--v ( t- shy
Edward E WrolewDABSNM
April 22 2012
Officer (signature)
Clouse out survey for Columbus Imaging Associates dba Columbus Diagnostic Imaging
6182012 USNRC Materials License 13-26797-01
IL~ L~~~())~ Location Location Description Exposure Rate (mRhr) Wipe activity(dpml00cmJ2) ~~
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 la b floor
11 hot lab floor
12 hot lab floor
13 hot lab floor
14 hot lab 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
33 275
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-oJ Jl9~( 11 (IQ IJ J(f~ t6JVe
(e-AIl)) P llan Po tVlCft r~
~~~~ ~~ ~ j
-efTIrf 1h1r f~ h~ vr 6~1
~~~~
CERTIFICATE OF CALIBRATION
Customer Advanced Med Phys
Manufacturer BIODEX
Detector Type GM
Detector Model X End Window
D Side Window
X Pancake
High Voltage -y
Date Received March 20 2012
Calibration Date March 30 2012
NEXT Calibration Due March 30 2013
Calibration Data
Scale Distance
(cm)
Instrument MIN 14C
Probe MIN 44-9 Calibration Geometry X Probe II
Cap ON
Window Open Window Closed
Battery Test Acceptable
Reset Check Test Acceptable
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Activity and SIN
Calculated Measured
Reading mRhr
SIN 101782 SIN PR2424100
X Probe Perpendicular
X Cap Off
] NA
Correction Factor
100x 1000 1813 800800
200 100x 1000 1813 200
x 100 4053 160
x 100 4053 40
x 10 4053 16 160 100
x 10 4053 4 40 100
xl xl
I I
4053
4053 I I
16 160
OA OAO 100
100
x 1 12817 016 016 100
x 1 12817 004 004 100
Comments All instrument readings were within +1- 10 at the time of calibration for all scales used
Applicable correction factors are noted above
This instrument must be checke for proper operation with the dedicated check source prior to
use A reading as indicated above denotes proper operation
UNABLE TO CALIBRATE x 100 SCALE Calibration Source Cs-137 Calibration Date January 15 1985 (+- 3 NBS)
Calibrated Activity 0154 Ci Roentgenshr 1m 00493
MN 773 Source ID S-526
SIN 216 Manufacturer Tech-Ops
Calculated Activity 00821 Ci Roentgenshr 1m 002630 March 30 2012
Photon Measurements Plus Calibrated By _________________
1427 West 86th Street Suite 282 Edward E Wroblewski MA DABSNM
Indianapolis IN 46260
tele 317755-9688 USNRC Materials License Numbcr-13-32533-01
RETURN PACKING LIST All information must be provided to ensure proper
SENOTO
Eckert ampZiegler Isotope Products
1800 North Keystone Street Burbank CA 91504
~~nTjjlllhnmiddot661)309-1010 1-~__ILI~tt--L=-=I--_ampjICI~=----E_~ Fax (661) 257-8303
Email emaIl nucmedsalesezagcom
list must be affixed to the Q~12S and
RETURN RA- 2I fI ofthe package Each returned source EZlflmustb dina1)nHOOne exchange basis ~nly
please contact euroZIP customer service considerations
Reference Serial Capsule Source Wipe Nuclide Activity Date Number D~cription TestsSnCi- J amptQoosaao I ~ IRAbQ)~
(l4t OItli lJIH9f ~ lId) 8J2(gtaL cfgt-57 ~tJ--raquo~s DNo I i i
2) DYes 0 No
3) ___ DYeS 0 No
4) ___ DYes 0 No
If source is damaged broken or le~king describe under Capsule ~scription sectiOfl and submit a copy of the last leak test Keep a copy of this form for your recOrd~ It may be requested by your regulatory agency I acknowledge that the above information is true ~o the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Number (Required) -- shy
FOR EZIP USE OfllY
EZIP has received ~he radioactive sources listed above e(cel)t as noted below
Receivers Name
Receipt Date -LO
Sources not received NA
RETURN PACKING LIST All information must be provided to ensure proper handling of your return
FROM SENDTO
Company Name
Address
City
i Eckert amp Ziegler Isotope Products
1800 North Keystone Street Burbank CA 91504 Telephone (661)309-1010 Fax (661)257-8303 Email nucmedsalesezagcom
RETURN RAshy 2( STOP This packing list must be affixed to the OllTSIOE and a copy placed inside of the package Each returned source to EZIP must be on a one-to-one exchange basisnnly For additional returns please contact poundZIP customer service for additional cost considerations
Nuclide Activity
1gtamp5-1312fj$ C
2) Csift t)middotlCfflAC
3) ___
4) ___
Reference Date
Serial Number SS shy ~t-
crt Itt lft6-3-L
Capsule Description
Source Wipe Tests SnCi
IN Gi(tIJ~- )I~) S~ e~ 0 No
amp) St1 rC f ~o DYes 0 No
CJ Yes 0 NCigt
If source is damaged broken or leaking describe under Capsule Description section and submit a copy of the last leak test Keep a copy of this form for your records It may be requested by your regulatory agency I acknowledge that the above information is true to the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Num~er (Required)
FOR EZIP USE ONLY
EZIP has received the radioactive sources listed above except as noted below
Receivers Name~I~~ tgtltl~ ~No~Q1)s _Co -~bullbullbull - bullbullbull~-~~ -----shy ~ -- - -shy
Receipt Date ~ ~)- ) I
Sources not received riNA
1a902of2
Certificate of Instrument Detection Efficiency for
Columbus Diagnostic Imaging Columbus Indiana
April 6 2012
Instrument Capintec Caprac Well Counter
Instrument Net Conversion DetectionSource Activity Calibration Date
Settin CPM Factor Efficienc
Co-57 09967 uCi 4110 Well 302213 112dpmcpm 8929
MDA= 5x10-5
106 dpm
Results These results are within acceptable limits
-qA Radiation Safety Officer
Advanced Medical Physics LLC 9095 Doral CourtD bull Indianapolis IN 462503172233022 3178495058(fax) ~~~~
Certified in Medical Nuclear Physics by the American Board of Radiology
-~ C~lumbus II~USPOSTAGE Diagnostic ~ IUS POSTAGE $ 0 105 $ 0045 RRSTClASS
bull L l1li-shyImaging RRST ClASS
Mailed From 47201 bull 091042012 031A 0002309440
J ~ 031A 0002309440790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200
Fax (812) 376-6665
Clouse out survey for Columbus Imaging Associates dba Columbus Diagnostic Imaging
6182012 USNRC Materials License 13-26797-01
IL~ L~~~())~ Location Location Description Exposure Rate (mRhr) Wipe activity(dpml00cmJ2) ~~
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 la b floor
11 hot lab floor
12 hot lab floor
13 hot lab floor
14 hot lab 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
33 275
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-oJ Jl9~( 11 (IQ IJ J(f~ t6JVe
(e-AIl)) P llan Po tVlCft r~
~~~~ ~~ ~ j
-efTIrf 1h1r f~ h~ vr 6~1
~~~~
CERTIFICATE OF CALIBRATION
Customer Advanced Med Phys
Manufacturer BIODEX
Detector Type GM
Detector Model X End Window
D Side Window
X Pancake
High Voltage -y
Date Received March 20 2012
Calibration Date March 30 2012
NEXT Calibration Due March 30 2013
Calibration Data
Scale Distance
(cm)
Instrument MIN 14C
Probe MIN 44-9 Calibration Geometry X Probe II
Cap ON
Window Open Window Closed
Battery Test Acceptable
Reset Check Test Acceptable
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Activity and SIN
Calculated Measured
Reading mRhr
SIN 101782 SIN PR2424100
X Probe Perpendicular
X Cap Off
] NA
Correction Factor
100x 1000 1813 800800
200 100x 1000 1813 200
x 100 4053 160
x 100 4053 40
x 10 4053 16 160 100
x 10 4053 4 40 100
xl xl
I I
4053
4053 I I
16 160
OA OAO 100
100
x 1 12817 016 016 100
x 1 12817 004 004 100
Comments All instrument readings were within +1- 10 at the time of calibration for all scales used
Applicable correction factors are noted above
This instrument must be checke for proper operation with the dedicated check source prior to
use A reading as indicated above denotes proper operation
UNABLE TO CALIBRATE x 100 SCALE Calibration Source Cs-137 Calibration Date January 15 1985 (+- 3 NBS)
Calibrated Activity 0154 Ci Roentgenshr 1m 00493
MN 773 Source ID S-526
SIN 216 Manufacturer Tech-Ops
Calculated Activity 00821 Ci Roentgenshr 1m 002630 March 30 2012
Photon Measurements Plus Calibrated By _________________
1427 West 86th Street Suite 282 Edward E Wroblewski MA DABSNM
Indianapolis IN 46260
tele 317755-9688 USNRC Materials License Numbcr-13-32533-01
RETURN PACKING LIST All information must be provided to ensure proper
SENOTO
Eckert ampZiegler Isotope Products
1800 North Keystone Street Burbank CA 91504
~~nTjjlllhnmiddot661)309-1010 1-~__ILI~tt--L=-=I--_ampjICI~=----E_~ Fax (661) 257-8303
Email emaIl nucmedsalesezagcom
list must be affixed to the Q~12S and
RETURN RA- 2I fI ofthe package Each returned source EZlflmustb dina1)nHOOne exchange basis ~nly
please contact euroZIP customer service considerations
Reference Serial Capsule Source Wipe Nuclide Activity Date Number D~cription TestsSnCi- J amptQoosaao I ~ IRAbQ)~
(l4t OItli lJIH9f ~ lId) 8J2(gtaL cfgt-57 ~tJ--raquo~s DNo I i i
2) DYes 0 No
3) ___ DYeS 0 No
4) ___ DYes 0 No
If source is damaged broken or le~king describe under Capsule ~scription sectiOfl and submit a copy of the last leak test Keep a copy of this form for your recOrd~ It may be requested by your regulatory agency I acknowledge that the above information is true ~o the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Number (Required) -- shy
FOR EZIP USE OfllY
EZIP has received ~he radioactive sources listed above e(cel)t as noted below
Receivers Name
Receipt Date -LO
Sources not received NA
RETURN PACKING LIST All information must be provided to ensure proper handling of your return
FROM SENDTO
Company Name
Address
City
i Eckert amp Ziegler Isotope Products
1800 North Keystone Street Burbank CA 91504 Telephone (661)309-1010 Fax (661)257-8303 Email nucmedsalesezagcom
RETURN RAshy 2( STOP This packing list must be affixed to the OllTSIOE and a copy placed inside of the package Each returned source to EZIP must be on a one-to-one exchange basisnnly For additional returns please contact poundZIP customer service for additional cost considerations
Nuclide Activity
1gtamp5-1312fj$ C
2) Csift t)middotlCfflAC
3) ___
4) ___
Reference Date
Serial Number SS shy ~t-
crt Itt lft6-3-L
Capsule Description
Source Wipe Tests SnCi
IN Gi(tIJ~- )I~) S~ e~ 0 No
amp) St1 rC f ~o DYes 0 No
CJ Yes 0 NCigt
If source is damaged broken or leaking describe under Capsule Description section and submit a copy of the last leak test Keep a copy of this form for your records It may be requested by your regulatory agency I acknowledge that the above information is true to the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Num~er (Required)
FOR EZIP USE ONLY
EZIP has received the radioactive sources listed above except as noted below
Receivers Name~I~~ tgtltl~ ~No~Q1)s _Co -~bullbullbull - bullbullbull~-~~ -----shy ~ -- - -shy
Receipt Date ~ ~)- ) I
Sources not received riNA
1a902of2
Certificate of Instrument Detection Efficiency for
Columbus Diagnostic Imaging Columbus Indiana
April 6 2012
Instrument Capintec Caprac Well Counter
Instrument Net Conversion DetectionSource Activity Calibration Date
Settin CPM Factor Efficienc
Co-57 09967 uCi 4110 Well 302213 112dpmcpm 8929
MDA= 5x10-5
106 dpm
Results These results are within acceptable limits
-qA Radiation Safety Officer
Advanced Medical Physics LLC 9095 Doral CourtD bull Indianapolis IN 462503172233022 3178495058(fax) ~~~~
Certified in Medical Nuclear Physics by the American Board of Radiology
-~ C~lumbus II~USPOSTAGE Diagnostic ~ IUS POSTAGE $ 0 105 $ 0045 RRSTClASS
bull L l1li-shyImaging RRST ClASS
Mailed From 47201 bull 091042012 031A 0002309440
J ~ 031A 0002309440790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200
Fax (812) 376-6665
CERTIFICATE OF CALIBRATION
Customer Advanced Med Phys
Manufacturer BIODEX
Detector Type GM
Detector Model X End Window
D Side Window
X Pancake
High Voltage -y
Date Received March 20 2012
Calibration Date March 30 2012
NEXT Calibration Due March 30 2013
Calibration Data
Scale Distance
(cm)
Instrument MIN 14C
Probe MIN 44-9 Calibration Geometry X Probe II
Cap ON
Window Open Window Closed
Battery Test Acceptable
Reset Check Test Acceptable
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Reading (mRhr)
Dedicated Check Source Activity and SIN
Calculated Measured
Reading mRhr
SIN 101782 SIN PR2424100
X Probe Perpendicular
X Cap Off
] NA
Correction Factor
100x 1000 1813 800800
200 100x 1000 1813 200
x 100 4053 160
x 100 4053 40
x 10 4053 16 160 100
x 10 4053 4 40 100
xl xl
I I
4053
4053 I I
16 160
OA OAO 100
100
x 1 12817 016 016 100
x 1 12817 004 004 100
Comments All instrument readings were within +1- 10 at the time of calibration for all scales used
Applicable correction factors are noted above
This instrument must be checke for proper operation with the dedicated check source prior to
use A reading as indicated above denotes proper operation
UNABLE TO CALIBRATE x 100 SCALE Calibration Source Cs-137 Calibration Date January 15 1985 (+- 3 NBS)
Calibrated Activity 0154 Ci Roentgenshr 1m 00493
MN 773 Source ID S-526
SIN 216 Manufacturer Tech-Ops
Calculated Activity 00821 Ci Roentgenshr 1m 002630 March 30 2012
Photon Measurements Plus Calibrated By _________________
1427 West 86th Street Suite 282 Edward E Wroblewski MA DABSNM
Indianapolis IN 46260
tele 317755-9688 USNRC Materials License Numbcr-13-32533-01
RETURN PACKING LIST All information must be provided to ensure proper
SENOTO
Eckert ampZiegler Isotope Products
1800 North Keystone Street Burbank CA 91504
~~nTjjlllhnmiddot661)309-1010 1-~__ILI~tt--L=-=I--_ampjICI~=----E_~ Fax (661) 257-8303
Email emaIl nucmedsalesezagcom
list must be affixed to the Q~12S and
RETURN RA- 2I fI ofthe package Each returned source EZlflmustb dina1)nHOOne exchange basis ~nly
please contact euroZIP customer service considerations
Reference Serial Capsule Source Wipe Nuclide Activity Date Number D~cription TestsSnCi- J amptQoosaao I ~ IRAbQ)~
(l4t OItli lJIH9f ~ lId) 8J2(gtaL cfgt-57 ~tJ--raquo~s DNo I i i
2) DYes 0 No
3) ___ DYeS 0 No
4) ___ DYes 0 No
If source is damaged broken or le~king describe under Capsule ~scription sectiOfl and submit a copy of the last leak test Keep a copy of this form for your recOrd~ It may be requested by your regulatory agency I acknowledge that the above information is true ~o the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Number (Required) -- shy
FOR EZIP USE OfllY
EZIP has received ~he radioactive sources listed above e(cel)t as noted below
Receivers Name
Receipt Date -LO
Sources not received NA
RETURN PACKING LIST All information must be provided to ensure proper handling of your return
FROM SENDTO
Company Name
Address
City
i Eckert amp Ziegler Isotope Products
1800 North Keystone Street Burbank CA 91504 Telephone (661)309-1010 Fax (661)257-8303 Email nucmedsalesezagcom
RETURN RAshy 2( STOP This packing list must be affixed to the OllTSIOE and a copy placed inside of the package Each returned source to EZIP must be on a one-to-one exchange basisnnly For additional returns please contact poundZIP customer service for additional cost considerations
Nuclide Activity
1gtamp5-1312fj$ C
2) Csift t)middotlCfflAC
3) ___
4) ___
Reference Date
Serial Number SS shy ~t-
crt Itt lft6-3-L
Capsule Description
Source Wipe Tests SnCi
IN Gi(tIJ~- )I~) S~ e~ 0 No
amp) St1 rC f ~o DYes 0 No
CJ Yes 0 NCigt
If source is damaged broken or leaking describe under Capsule Description section and submit a copy of the last leak test Keep a copy of this form for your records It may be requested by your regulatory agency I acknowledge that the above information is true to the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Num~er (Required)
FOR EZIP USE ONLY
EZIP has received the radioactive sources listed above except as noted below
Receivers Name~I~~ tgtltl~ ~No~Q1)s _Co -~bullbullbull - bullbullbull~-~~ -----shy ~ -- - -shy
Receipt Date ~ ~)- ) I
Sources not received riNA
1a902of2
Certificate of Instrument Detection Efficiency for
Columbus Diagnostic Imaging Columbus Indiana
April 6 2012
Instrument Capintec Caprac Well Counter
Instrument Net Conversion DetectionSource Activity Calibration Date
Settin CPM Factor Efficienc
Co-57 09967 uCi 4110 Well 302213 112dpmcpm 8929
MDA= 5x10-5
106 dpm
Results These results are within acceptable limits
-qA Radiation Safety Officer
Advanced Medical Physics LLC 9095 Doral CourtD bull Indianapolis IN 462503172233022 3178495058(fax) ~~~~
Certified in Medical Nuclear Physics by the American Board of Radiology
-~ C~lumbus II~USPOSTAGE Diagnostic ~ IUS POSTAGE $ 0 105 $ 0045 RRSTClASS
bull L l1li-shyImaging RRST ClASS
Mailed From 47201 bull 091042012 031A 0002309440
J ~ 031A 0002309440790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200
Fax (812) 376-6665
RETURN PACKING LIST All information must be provided to ensure proper
SENOTO
Eckert ampZiegler Isotope Products
1800 North Keystone Street Burbank CA 91504
~~nTjjlllhnmiddot661)309-1010 1-~__ILI~tt--L=-=I--_ampjICI~=----E_~ Fax (661) 257-8303
Email emaIl nucmedsalesezagcom
list must be affixed to the Q~12S and
RETURN RA- 2I fI ofthe package Each returned source EZlflmustb dina1)nHOOne exchange basis ~nly
please contact euroZIP customer service considerations
Reference Serial Capsule Source Wipe Nuclide Activity Date Number D~cription TestsSnCi- J amptQoosaao I ~ IRAbQ)~
(l4t OItli lJIH9f ~ lId) 8J2(gtaL cfgt-57 ~tJ--raquo~s DNo I i i
2) DYes 0 No
3) ___ DYeS 0 No
4) ___ DYes 0 No
If source is damaged broken or le~king describe under Capsule ~scription sectiOfl and submit a copy of the last leak test Keep a copy of this form for your recOrd~ It may be requested by your regulatory agency I acknowledge that the above information is true ~o the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Number (Required) -- shy
FOR EZIP USE OfllY
EZIP has received ~he radioactive sources listed above e(cel)t as noted below
Receivers Name
Receipt Date -LO
Sources not received NA
RETURN PACKING LIST All information must be provided to ensure proper handling of your return
FROM SENDTO
Company Name
Address
City
i Eckert amp Ziegler Isotope Products
1800 North Keystone Street Burbank CA 91504 Telephone (661)309-1010 Fax (661)257-8303 Email nucmedsalesezagcom
RETURN RAshy 2( STOP This packing list must be affixed to the OllTSIOE and a copy placed inside of the package Each returned source to EZIP must be on a one-to-one exchange basisnnly For additional returns please contact poundZIP customer service for additional cost considerations
Nuclide Activity
1gtamp5-1312fj$ C
2) Csift t)middotlCfflAC
3) ___
4) ___
Reference Date
Serial Number SS shy ~t-
crt Itt lft6-3-L
Capsule Description
Source Wipe Tests SnCi
IN Gi(tIJ~- )I~) S~ e~ 0 No
amp) St1 rC f ~o DYes 0 No
CJ Yes 0 NCigt
If source is damaged broken or leaking describe under Capsule Description section and submit a copy of the last leak test Keep a copy of this form for your records It may be requested by your regulatory agency I acknowledge that the above information is true to the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Num~er (Required)
FOR EZIP USE ONLY
EZIP has received the radioactive sources listed above except as noted below
Receivers Name~I~~ tgtltl~ ~No~Q1)s _Co -~bullbullbull - bullbullbull~-~~ -----shy ~ -- - -shy
Receipt Date ~ ~)- ) I
Sources not received riNA
1a902of2
Certificate of Instrument Detection Efficiency for
Columbus Diagnostic Imaging Columbus Indiana
April 6 2012
Instrument Capintec Caprac Well Counter
Instrument Net Conversion DetectionSource Activity Calibration Date
Settin CPM Factor Efficienc
Co-57 09967 uCi 4110 Well 302213 112dpmcpm 8929
MDA= 5x10-5
106 dpm
Results These results are within acceptable limits
-qA Radiation Safety Officer
Advanced Medical Physics LLC 9095 Doral CourtD bull Indianapolis IN 462503172233022 3178495058(fax) ~~~~
Certified in Medical Nuclear Physics by the American Board of Radiology
-~ C~lumbus II~USPOSTAGE Diagnostic ~ IUS POSTAGE $ 0 105 $ 0045 RRSTClASS
bull L l1li-shyImaging RRST ClASS
Mailed From 47201 bull 091042012 031A 0002309440
J ~ 031A 0002309440790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200
Fax (812) 376-6665
RETURN PACKING LIST All information must be provided to ensure proper handling of your return
FROM SENDTO
Company Name
Address
City
i Eckert amp Ziegler Isotope Products
1800 North Keystone Street Burbank CA 91504 Telephone (661)309-1010 Fax (661)257-8303 Email nucmedsalesezagcom
RETURN RAshy 2( STOP This packing list must be affixed to the OllTSIOE and a copy placed inside of the package Each returned source to EZIP must be on a one-to-one exchange basisnnly For additional returns please contact poundZIP customer service for additional cost considerations
Nuclide Activity
1gtamp5-1312fj$ C
2) Csift t)middotlCfflAC
3) ___
4) ___
Reference Date
Serial Number SS shy ~t-
crt Itt lft6-3-L
Capsule Description
Source Wipe Tests SnCi
IN Gi(tIJ~- )I~) S~ e~ 0 No
amp) St1 rC f ~o DYes 0 No
CJ Yes 0 NCigt
If source is damaged broken or leaking describe under Capsule Description section and submit a copy of the last leak test Keep a copy of this form for your records It may be requested by your regulatory agency I acknowledge that the above information is true to the best of my knowledge
Contacts Signature
Shippers 24 Hour Emergency Response Num~er (Required)
FOR EZIP USE ONLY
EZIP has received the radioactive sources listed above except as noted below
Receivers Name~I~~ tgtltl~ ~No~Q1)s _Co -~bullbullbull - bullbullbull~-~~ -----shy ~ -- - -shy
Receipt Date ~ ~)- ) I
Sources not received riNA
1a902of2
Certificate of Instrument Detection Efficiency for
Columbus Diagnostic Imaging Columbus Indiana
April 6 2012
Instrument Capintec Caprac Well Counter
Instrument Net Conversion DetectionSource Activity Calibration Date
Settin CPM Factor Efficienc
Co-57 09967 uCi 4110 Well 302213 112dpmcpm 8929
MDA= 5x10-5
106 dpm
Results These results are within acceptable limits
-qA Radiation Safety Officer
Advanced Medical Physics LLC 9095 Doral CourtD bull Indianapolis IN 462503172233022 3178495058(fax) ~~~~
Certified in Medical Nuclear Physics by the American Board of Radiology
-~ C~lumbus II~USPOSTAGE Diagnostic ~ IUS POSTAGE $ 0 105 $ 0045 RRSTClASS
bull L l1li-shyImaging RRST ClASS
Mailed From 47201 bull 091042012 031A 0002309440
J ~ 031A 0002309440790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200
Fax (812) 376-6665
Certificate of Instrument Detection Efficiency for
Columbus Diagnostic Imaging Columbus Indiana
April 6 2012
Instrument Capintec Caprac Well Counter
Instrument Net Conversion DetectionSource Activity Calibration Date
Settin CPM Factor Efficienc
Co-57 09967 uCi 4110 Well 302213 112dpmcpm 8929
MDA= 5x10-5
106 dpm
Results These results are within acceptable limits
-qA Radiation Safety Officer
Advanced Medical Physics LLC 9095 Doral CourtD bull Indianapolis IN 462503172233022 3178495058(fax) ~~~~
Certified in Medical Nuclear Physics by the American Board of Radiology
-~ C~lumbus II~USPOSTAGE Diagnostic ~ IUS POSTAGE $ 0 105 $ 0045 RRSTClASS
bull L l1li-shyImaging RRST ClASS
Mailed From 47201 bull 091042012 031A 0002309440
J ~ 031A 0002309440790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200
Fax (812) 376-6665
-~ C~lumbus II~USPOSTAGE Diagnostic ~ IUS POSTAGE $ 0 105 $ 0045 RRSTClASS
bull L l1li-shyImaging RRST ClASS
Mailed From 47201 bull 091042012 031A 0002309440
J ~ 031A 0002309440790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200
Fax (812) 376-6665