Powell Valley Health Care - License Termination Request. · 777Avenue H 1/1 Powell, WY 82435 1/1...

PAGE 01POWELL HOSPITAL08/05/2008 13:12 3077541593

R~C~lJIEo ~ AUG Powell Valley 777 A~enue H - Powell, WY 1J2435 06 J008 £l~,~!~<:a~~ Phone (307) 754-1267 - Far (307) 754-3176 - www.pvhc.org , -,\1 ..",,'"'''' I"," DNA!

FACSIMILE TRANSMITTAL SHEET S

TO:

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NAME

COMPANY

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NUMBER OF PAGES INCLUDING THIS ONE

ntiS TRANSMISSION IS INTENDED ONLY FOR THE USl; OF THE INDIVIDUAl.. OR ENTITY TO WHICH IT IS ADDRESSED, AND MAY CONTAIN INFORMATION THAT IS PRIVILEGED. CONFIDHNTIAL, AND EXEMPT FROM DISCLOSURE UND!iR APPLlCABL': LAW. IF THE! READER OF THIS MUsAGE IS HOT THE IN'tENDED RECIPIENT, YOU ARE HEREBY NOTIFIED THAT ANY DISI5EM\NATION, DlSlJUBUTION OR COPYINQ OF tHIS COMMUNICATION 15 5TRICTLY PROHIBITED. IF YOU HAVE RECEIVED THIS COMMUNICAT10N IN ER.ROR, PLEASE NOTIFY U5 IMMEDlA'tELY

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PAGE 02POWELL HOSPITAL PPlGE. \'l3/el33077541593 U;:)I'",,1y I'(~II08/05/2008 13:12 "'-' -' .................. _..... ~

U.Ii. NUCLEAIit ~'GULATQ"'Y COMMlNION AP~ BY~; "0. 3UDoMII EXlI"l1t1!8' ,1/1,,.1. Ei~"'11iid b<rlII~ pOr r1I>POn.. Q llQ""lr WlI~ IhlllT11r\4l101Y t:lIIftIlb~..-t: 30 ,...,... "'I~ tlJlltMllu II ~18Cl ~ N~ '1 ll.t olllllllllilS IlIr III ~'*' INI ~ Idl\'l It ••Nd lor vmsl'd:(l~$lJ· SnI (1).......... IIUIlIIltM1l_ tr ....... _ FOW"ttllq 1.M:8t a-1I.eII ~.S '~l, US. "-r 1Il"~ CGnIIi_n. ~ OC 205':>00')1. or by I~III""IO-ma'ilc 1n~I\lP, IlllI t~ h Dnk orna.. ~ fII InI~I'II'l.IKJ" ."d IIltO~!O~ Malr.;. NIOll·10202, (3150.00tSl, ~ 3' wn'lllllrni lAd 8QdgBl. WN/l.,.llln. DC :MOI.• <l /M8Il&.. " Il1li* IIIlltbnlo\1on Dlll:tbn lIIlIl$l!Cl lIIS1lIllY_ t\ll~~ 'IaKGIOIllll ClOIltlallllmMf. II'- NRO llIIIV l'16I ~ CII' !pcIlll'Il. 11111

CERTIFICATE OF DISPOSITION OF MATERIALS

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r'-I c All r-.diGlietiV' mlteria. hive bel!ln ...moved sLl(;tl1n8t.-ny remllning relldu_ rlKiiollctMty Is wlttltn the lirrlit5 gf 10 CFR PI\1 20, SIAlrMt E. and IS ALARA.

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DATE: "7 - 1'7 -0 g' RECEIVED TO: Nuclear Regulatory Commission

Nuclear Materials Licensing Branch Region IV 611 Ryan Plaza Drive Arlington, TX 76011

JUL 2 1 2008

DNMS

FROM: Powell Hospital District dba Powell Hospital & Nursing Home 777 Ave. H Powell, WY 82435

RE: License No. 49-23163-01, Docket No. 030-20328

Attachments: Proposal, Leak tests

We are in the process of closing our Nuclear Medicine Program at Powell Hospital. We have returned all ofour generators. We would like to transfer ownership of our calibration sources to West Park Hospital- License No. 49-18230-01, Docket No.030-14695 and have attached a proposal to do this.

The sources in the proposal are: Serial No. 27915C (BA-133) Serial No. 2060385A-05 (CO-57) Serial No. S8023004-9 (CS-137) Serial No. 11816-40 (CS-137) See attached leak tests.

Please let us know if the transfer is acceptable. CC: File

777 Avenue H .. Powell. WY 82435 .. Phone (307) 754-2267 or 1-800-428-1398 .. Fax (307) 754-3176 .. www.uvhc.or~

Powell Valley Hospital Powell Valley Care Center Powell Valley Hospice Powell Valley Home Care

The Heartland Mountain View Medical Center Practice Management Associates

th 471 881

7/16/08

Proposal to transfer ownership and transport calibration sources from Powell Hospital License No. 4923163-01 to West Park Hospital license No.49-18230-01.

1. We have acquired a United States Military Ammo can, this ammo can has a rubber sealed latching lid (This is printed on the side-800 cartridge 5.56MM Ball M855 M27 Link LC-94E1 04-069). We plan to place Radioactive stickers on all sides of the can. We plan to line the inside with foam creating a snug fit for the sources. The Can will be scanned empty with a Geiger counter and the reading recorded, also a wipe test of the interior and exterior will be carried out and recorded.

2. We plan to place 4 calibration sources (which were leak tested on 05/08/2008 see attached) into the can. The can will then be latched and taped with caution tape that will be signed by the Powell Hospital RSO and the assisting technologist, then scanned with a Geiger counter and the readings recorded.

3. The RSO of Powell Hospital will have the vehicle that he will use to transport the ammo can scanned by Geiger counter and the area where the ammo can will sit during transport wipe tested before placing ammo can into vehicle, these reading will be recorded. The RSO will then take the ammo can and transport by this vehicle to West Park Hospital 24 miles by paved highway.

4. Upon arriving at West Park Hospital the RSO will remove the Ammo can and carry it into West Park Hospital Nuclear Medicine department. The West Park Hospital RSO and assisting technologist will confirm seal, scan the ammo can with a Geiger counter and wipe test the container, the results will be recorded.

5. The ammo can seal will be cut and the container opened. The interior of the ammo can will be scanned with a Geiger counter and wipe tested, the results will be recorded. The calibration sources will be removed and taken possession of and signed for by the West Park Hospital RSO.

6. The RSO vehicle will be scanned with a Geiger counter and the area where the ammo can sat during transport will be wipe tested upon his return to Powell Hospital and the readings recorded.

7. Transfer of ownership of the calibration sources will be complete.

8. All of the readings and signatures will be recorded on form and sent to the NRC with our release request. (see form attached)

777 Avenue H .. Powell. WY 82435 .. Phone (307) 754-2267 or 1-800-428-1398 .. Fax (307) 754-3176 .. www.pvhc.or:



Form for transport of calibration sources

1. Date: Time:

Location: _

Geiger counter Serial No: Wipe test counter _

Ammo can reading 3ft empty: _

Ammo can surface reading empty: _

Ammo can outside wipe test reading empty: _

Ammo can inside wipe test reading empty: _

Name of person taking readings: Signature of person taking readings:. _

RSO name: RSO signature: _

777 Avenue H "* Powell. WY 82435 "* Phone (307) 754-2267 or 1-800-428-1398 "* Fax (307) 754-3176 "* www.J!vhc.org




2. Date: Time:

Location: _


Ammo can reading at 3ft with sources: _

Ammo can surface reading with sources: _

Ammo can outside wipe test reading with sources: _

Ammo can inside wipe test reading with sources: _

Ammo can sealed with caution tape and signed.

Name of person taking readings: Signature of person taking readings: _


777Avenue H .. Powell. WY 82435 .. Phone (307) 754-2267 or 1-800-428-1398 .. Fax (307) 754-3176 .. www.pvhc.org



-if- tl7/o3j


3. Date: Time:

Location: _

Geiger counter Serial No: Wipe test counter: _

RSO vehicle reading before placing ammo can with sources into car: _

Wipe test of area where ammo can to sit in car: _

RSO vehicle reading after placing ammo can with sources into car: _



777Avenue H 1/1 Powell, WY 82435 1/1 Phone (307) 754-2267 or 1-800-428-1398 1/1 Fax (307) 754-3176 1/1 www,pvhc,ore



c.Ol'np.'lc,c,ion;lt p C(u;~lity C~~fi.:>

Form for transfer of ownership and transport of calibration sources

4. Date: Time:

Location: -----------Geiger counter Serial No: Wipe test counter: _

Ammo can reading 3ft with sources: _


Ammo can outside wipe test reading with sources: _

Verification of signed tape seal.


Powell Hospital RSO name: R,SO signature: _

West Park Hospital RSO name: RSO signature: _

777 Avenue H ., Powell, WY 82435 ., Phone (307) 754-2267 or 1-800-428-1398 ., Fax (307) 754-3176 ., www,pvhc,orr



Form for transfer of ownership and transport of calibration sources

5. Date: Time:

Location: _


Signed seal broken and ammo can opened.

Ammo can reading at 3ft with sources: _


Ammo can inside wipe test reading with sources: _

Sources taken possession of and ownership by West Park Hospital


Powell Hospital RSO name: RSO signature: _

West Park Hospital RSO name: RSO signature: _

777 Avenue H • Powell, WY 82435 • Phone (307) 754-2267 or 1-800-428-1398 • Fax (307) 754-3176 • www,pvhc,orr




6. Date: Time:

Location: _

Geiger counter Serial No: Wipe test counter: _

RSO vehicle used for transporting sources: _

Vehicle inside Geiger counter reading: _

Vehicle area where ammo can set wipe test reading: _

Ammo can reading 3ft empty: _

Ammo can surface reading empty: _

Ammo can outside wipe test reading empty: _

Ammo can inside wipe test reading empty: _



777 Avenue H • Powell, WY 82435 • Phone (307) 754-2267 or 1-800-428-1398 • Fax (307) 754-3176 • www,pvhc,orr



7.

West Park Hospital License No. 49-18230-01, Docket No. 030-14695 takes possession and ownership of the following sources from Powell Hospital License No. 49-23163-01, Docket no.030-20328:

BA-133 Serial No. 27915C CO-57 Serial No. 2060385A-05 CS-137 Serial No. S8023004-9 CS-137 - Serial No. 11816-40

Name of representative of West Park hospital

Date: _ Signature of representative of West Park hospital

Name of RSO of West Park Hospital

Date: _ Signature of RSO of West Park hospital

777 Avenue H ., Powell. WY 82435 ., Phone (307) 754-2267 or 1-800-428-1398 ., Fax (307) 754-3176 ., WWW.Dvhc.org



·

'-.'

1;!\L Monitoring Services P.O. BOX 266677 . HOUSTON, TEXAS 77207-6677 . AREA CODE 713-47~20. FAX 281·532.0929

SEALED SOURCE LEAK TEST CERTIFICATE

TOMASAY PoWELL HOSPITAL & NURSING HOME 777 AVENUE H

POWELL WY 82435

CUSTOMER #:=24-'-4"'- ~_

SOURCE #: 9=--=°:-0.1=-9 _

ACOUNT #: =86=9:.:..P _

RADIONULCIDE: ---=B"-AO--1""'3-=-3 _

ACTIVITY:,_--=0=.OO~O=2~2~6_C=I,-_ SERIAL NO: 27915C

WIPE DATE ----=-4=12=6/=20=0=8 _

EFFICENCY: -=0.=99=5:....-... ----'-__

GROSS CPM:=27=- _ BKG CPM:...:..16~ _ NET CPM:...:..1-,-1 _

EFF X 2.22x10"6 DPMlu CI =MICROCURIE NETCPM

THE ABOVE SOURCE WIPE TEST HAS BEEN ASSAYED IN ACCORDANCE WITH OUR RADIOACTIVE MATERIAL LICENSE AND THE APPROPRIATE REGULATORY REQUIREMENTS. THE REGULATIONS DEFINE A LEAKING SOURCE AS ONE FROM WHICH AN APPROPRIATE WIPE TEST HAS REMOVED 0.005 (5.0X10E-3) MICROCURIE OR MORE OF ACTIVITY.

THF REMOVABLE ACTIVITY WAS: -:4:..:.::.9::.=8=E-D-==-=6 MICROCURIE

ASSAYED BY:

ASSAY NO.: 5/8/200826 DATE: .=51-=-9/=2=-00=--=8'- _

{;-~ · -:;s:;; ~~y

~. .

Monitoring Services P.O. BOX 266671 . HOUSTON, TEXAS 77207-«'71 ,AREA CODE 713-478-6820. FAX 281-532.0929 1\;JiL


TOMASAY POWEU HOSPITAL & NURSING HOME

CUSTOMER #:-=2--'-44"--__~_i77 AVENUEH SOURCE #: 1.:...::8:..:-7.=...9 _

POWELL WY 82435

ACOUNT #:=86=9:..:-P _

RADIONULCIDE: ----=C:...;:O:--5=7'----- _

ACTIVITY:,_-----::;0=.00-=2=0=8.=...9_C=.;I=-----_ SERIAL NO: 2060385A-05

WIPE DATE -------04=12=612=00=8 _

EFFICENCY: --=..:0.=65=2:....- _

GROSS CPM:=31.;..- BKG CPM:--'-16=-- _ NET CPM:--'-15=-- _

NETCPM EFF X 2.22x10"6 DPMlu CI = MICROCURIE


THE REMOVABLE ACTIVITY WAS: ----'1:...:..:.04::.....:.:Ec..::-Q:..:=.5 MICROCURIE. ASSAY NO.: 5/8/2008 25 DATE: =51=9/=2:.::-00::...::8=----- _

ASSAYED BY: ~~ , ~

~~11

Monitoring Services P.O. BOX 266671. HOUSTOO', TEXAS 712JJ7.fi677 . AREA CODE 713-47~2JJ. FAX 281·532-00291\;!iL


TOMASAY POJyELL HOSPITAL &NURSING HOME CUSTOMER #: 244

-~~~~-777 AVENUE H

SOURCE #: 3=0::....:1=9~~_~_ POWELL WY

82435

ACOUNT #:~86=c9,,-,-P _

RADIONULCIDE: Cc:-:;S--=-1.=37=- _

ACTIVITY:._----::O..:..;:.O;...;;.OO=O:...::34-=---_C.:::.;I'--_ SERIAL NO: S8023004-9

WIPE DATE ----:4.:.=12=6/:.=2=00=..::80...-- _

EFFICENCY: _0=.=9S"---__-'- _

GROSS CPM: ~2-=-7 _ BKG CPM:-=-16=-- _ NETCPM:-=-1-=--1 _

NETCPM EFF X2.22x10"6 DPMlu CI =MICROCURIE

THE ABOVE SOURCE WIPE TEST HAS BEEN ASSAYED IN ACCORDANCE WITH OUR RADIOACTIVE MATERIAL LICENSE AND THE APPROPRIATE REGULATORY REQUIREMENTS. THE REGULATIONS DEFINE A LEAKING SOURCE AS ONE FROM WHICH AN APPROPRIATE WIPE TEST HAS REMOVED O.OOS (S.OX10E-3) MICROCURIE OR MORE OF ACTIVITY.

THE ~EMOVABLE ACTIVITY WAS: -:5:.;::.2=2=Ec...:-o:..:::6 MICROCURIE

ASSAY NO.: 5/8/2008 24 DATE: -=:.;Sf'-=9/:.=2~00=--=8'___ ~

~~ASSAYED BY:

~

·'

1;J\L Monitoring Services P.O. BOX 266677 . HOUSTON. TEXAS 77207-6077 . AREA CODE 713-478-6820. FAX 281-532-c!l29


TOMASAY POWELL HOSPITAL &NURSING HOME 717 AVENUE H

POWELL WY 82435

CUSTOMER#:=2~44-,-- _

SOURCE #: 9=6=9=3 .

ACOUNT #: =86=9::..:...P _

RADIONULCIDE: -----"C=S'---'-1:=3.:....7 _

ACTIVITY:_----"'O C=I=---_ SERIAL NO: 11816-40

WIPE DATE -----'.4=12=6/=200=8 _

EFFICENCY: _0=.=.;95=- _

GROSS CPM:--,-,40~ BKG CPM:--,-,16~ _ NET CPM:=24-'- _

EFF X 2.22x10"6 DPMlu CI =MICROCURIE NETCPM


T~E REMOVABLE ACTIVITY WAS: -=1..:....:.1c...:.4=E-D-=..5= MICROCURIE

ASSAYED BY:

~SSAY NO.: 5/8/200823 "DATE: 5/9/2008-==="'-=-----

~~

tn· 4 7 1 8 8 1

ACCEPTANCE REVIEW MEMO (ARM) Licensee: Powell Hospital District, dba License No.: 49-23163-01

Powell Hospital & Nursing Home

Docket No.: 030-20328 Mail Control No.: 471881

Type of Action: Termination Date of Requested Action: 07-17-08

Reviewer Colleen M. ARM reviewer(s): J. Cook Assigned:

Response Deficiencies Noted During Acceptance Review

[ ] Open ended possession limits. Submit inventory. Limit possession. [ ] Submit copies of latest leak test results. [ ] Add IC L.C.lFingerprint LC, add SUNSI markings to license. [ ] Confirm with licensee if they have NARM material.

?f; ~ LA: Call Licensee and ask them to complete NRC 314 and return to NRC.

Reviewer's Initials: Date:

DYes DNo Request for unrestricted release Group 2 or >. Consult with Bravo Branch.

DYes DNo Termination request < 90 days from date of expiration

DYes DNo Expedite (medical emergency, no RSO, location of use/storage not on license, RAM in possession not on license, other)

DYes ONo TAR needed to complete action.

Branch Chief's and/or HP's Initials: Date:

SUNSI Screening according to RIS 2005-31

DYes rr/No Sensitive and Non-Publicly Available if any item below is checked General guidance:

__,RAM = or> than Category 3 (Table 1, RIS 2005-31), use Unity Rule __Exact location of RAM [suite #, bldg. #, location different from mailing address]

(whether = or > than Category 3 or not) __,Design of structure and/or equipment (site specific) __Information on nearby facilities __Detailed design drawings and/or performance information __Emergency planning and/or fire protection systems

Specific guidance for medical, industrial and academic (above Category 3): __RAM quantities and inventory __Manufacturer's name and model number of sealed sources & devices __Site drawings with exact location of RAM, description of facility __RAM security program information (locks, alarms, etc.) __Emergency Plan specifics (routes to/from RAM, response to security events) __Vulnerability/security assessment/accident-safety analysis/risk assess

Mailing lists related to securi~response

Branch Chiefs and/or HP's Initials: l ~U Date: AIJG - 5 2008

'1(',lnvJ:tJ(~ - 8 "\IU

This is to acknowledge the receipt of your letler/application dated DATE

7 -/7 -c2 r .and to inform you that the initial processing, which includes an administrative review, has been performed.

There were no administrative omissions. Your application will be assigned to a technical reviewer. Please noIe that the technical review may identify additional omissions or require additional information. ~

o Please provide to this ollice within 30 days of your receipt of this card:

The action you requested is nor~ally processed within 90 days.

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

Your action has been assiqned Mail Control Number r,t 7/['£/When calling to inquire about this action, please refer to this mail control number. You may call me at 817-860-8103.

Sincerely,

(!~t-~~t- ~~J~ NRC FORM 532 (RIV) Licensing Assistant (10-2006)

(FOR LFMS USE)INFORMATION FROM LTS

BETWEEN:

License Fee Management Branch, ARM Program Code: 02121 and Status Code: 0

Regional Licensing Sections Fee Category: 7C Exp. Date: 20110731 Fee Comments: CODE 23 Decom Fin Assur Reqd: N ....................................................................................................................... ..

LICENSE FEE TRANSMITTAL

A. REGION

1. APPLICATION ATTACHED Applicant/Licensee: POWELL HOSPITAL DISTRICT Received bate: 20080721 Docket No: 3020328 Control No. 471881 License No. 49-23163-01 Action Type Termination

2. FEE ATTACHED=J=Amount: Check No.:

3. COMMENTS

Si9",d~Date _.

B. LICENSE FEE MANAGEMENT BRANCH (Check when milestone 03 is entered / __/)

1. Fee Category and Amount:

2. Correct Fee Paid. Application may be processed for: Amendment Renewal License

3. OTHER

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