I I. I - . '" . ,·: ...... 'J;:', .... ·. · 111111111111111111111111111111111111111111111111111111111111 I llllllll llll lllll llll lllllll Ill llll llll GL-3849-21 04/05/2017 NRC FORM 664 07- 2015 10 CFR 31.5 APPROVED BY OMB: NO. 3150-0198 SECTION 1 PAGE 1of2 U.S. NUCLEAR REGULATORY COMMISSION GENERAL LICENSEE REGISTRATION EXPIRES: 04/30/2016 Estimated burden per response to comply with this mandatory collection request: 20 minutes. NRC will use this information to track general licensees and their devices to ensure a higher level of device accountability. Send comments regarding burden estimate to the FOIA, Privacy, and Information Collections Branch (T-5 F53), U. S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by internet e-mail to [email protected], and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0198), 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. Complete all six sections of this registration form. If any of the preprinted information is incorrect, provide the changes in the applicable boxes. USE CAPITAL LETTERS. General License Registration Number GL-3849-21 SECTION 1 - GENERAL LICENSEE INFORMATION Enter the company name and the street address/physical location of use for your device(s). For portable devices, specify the primary storage location. Do not use a P.O. Box address. Company Name: BOARD OF MUNICIPAL UTILITIES I I I I I I I I I I I I I Department: SIKESTON POWER STATION I I I I I I I I I I I I I I I Address Line 1: 1551 W WAKEFIELD I I I I I I I I I I Address Line 2: PO BOX 370 I I I I I I I I I I I I I I City: SIKESTON I I I I I I I I I I I I I I I State: MO rn Zip Code: 63801 - I I I -I I I I . I
40
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GL Registration from Board of Municipal Utilities. · I I. I -. '" . ..... ,·: 'J;:', .... ·. · 111111111111111111111111111111111111111111111111111111111111 I llllllll llll lllll
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Estimated burden per response to comply with this mandatory collection request: 20 minutes. NRC will use this information to track general licensees and their devices to ensure a higher level of device accountability. Send comments regarding burden estimate to the FOIA, Privacy, and Information Collections Branch (T-5 F53), U. S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by internet e-mail to [email protected], and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0198), 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.
Complete all six sections of this registration form. If any of the preprinted information is incorrect, provide the changes in the applicable boxes. USE CAPITAL LETTERS.
General License
Registration Number GL-3849-21
SECTION 1 - GENERAL LICENSEE INFORMATION
Enter the company name and the street address/physical location of use for your device(s). For
portable devices, specify the primary storage location. Do not use a P.O. Box address.
Company Name: BOARD OF MUNICIPAL UTILITIES
I I I I I I I I I I I I I Department: SIKESTON POWER STATION
I I I I I I I I I I I I I I I Address Line 1: 1551 W WAKEFIELD
I I I I I I I I I I Address Line 2: PO BOX 370
I I I I I I I I I I I I I I City: SIKESTON
I I I I I I I I I I I I I I I
State: MO rn Zip Code: 63801 - I I I - I I I I . I
SECTION 1 - GENERAL LICENSEE INFORMATION (Continued)
SECTION 1
PAGE 2of2 .
· · Enter the name, telelphone number and title of the person who is the responsible individual for the device(s).
,.,. , ·. ·. Last Name: TURNBOW
I I I I I I I I I I I I I I I I I I I I I I I First Name: STEVE Middle Initial: D
1111111111· I I I D ··. ··.Telephone: (573) 475-3127 Extension:
... 1 I I 11 I I 11 I I I I I I I I I I ·' Title: RADIATION SAFETY OFFICER
I I I I I I I I I I I I I I I I I I I I I I I
' Enter the mailing address where correspondence regarding your device(s) should be sent. '.·.· This address should be specific to the use or storage location of your device(s).
··. Department: SIKESTON POWER STATION
· I I I I I I I I I I I I I I I I I I I I I I I . Address Line 1: 1551 W WAKEFIELD
I,::: I I I I I I I I I I I I I I I I I I 1, . . . .. · Address Line 2: PO BOX 370
;:·;<<·.I I I I I I I I I 1· I I I I I I I I I I I I I City: SIKESTON
···. I I I I I . I I I I I I I I I I I I I I I I I I I . .. state: MO []] Zip Code: 63801 - I I I I I I - I I I I I
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.. · ... · 041os12017 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 ·. · , Our records indicate that you have these devices. Please update the information as necessary. PAGE 1 of 34 .. · · •. '.:·:
. · NRC Device Key 48577 (Internal Control Number)
. . Distributor/Distributed By: TN TECHNOLOGIES, INC.
~; ··-I · I I I I I I I I I I I I I I I I I I I I I I I . Distributor License Number: L01105
_: I . I I I I I I I I I I I I I : ::,, ~-•·•Manufacturer Name: TN TECHNOLOGIES, INC.
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)l I I I I I I I I I I I I I I I I I I I : <Device Serial Number: 8432
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· ...•. ·:: ·NRC Device Key 48578 (Internal Control Number)
. .. Distributor/Distributed By: TN TECHNOLOGIES, INC.
+·1 ··· I I I I I I I I I I I I I I I I I I I I I I . I · . Distributor License Number: L01105
.::1 I I I I I I I I I I I I I . < Manufacturer Name: TN TECHNOLOGIES, INC.
.·\·:1 I I I I I I I I I I I I I I I I I I I I I I I · ' ·,.· Device Model (Not Source Model): 5197
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0410512011 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 .. · ·· .·. Our records indicate that you have these devices. Please update the information as necessary. PAGE 3 of 34 ·
NRC Device Key 48579 · · (Internal Control Number) ·.I
··.;I··· .. I I I I I I I I I I I I I I I I I I I I I ·I I :11
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. : Distributor License Number: L01105
< l I I I I I I I I I I I I I . i
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. .. . . 04/05/2017 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 ' Our records indicate that you have these devices. Please update the information as necessary. PAGE 4 of 34
· , NRC Device Key 48580 (Internal Control Number)
. . Distributor/Distributed By: TN TECHNOLOGIES, INC.
',I · I I I I I I I I I I I I I I I I I I I. I I I I .· · Distributor License Number: L01105
• '. :.1 . I I I I I I I I I I I I I .. :·Manufacturer Name: TN TECHNOLOGIES, INC.
·:/1 I I I I I I · I I I I I I I I I I I I _ I I I I I : : : Device Model (Not Source Model): 5197
'>l I I I I I I I I I I I I I I I ·' Device Serial Number: 8435
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' 04tos12011 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 '· · Our records indicate that you have these devices. Please update the information as necessary. PAGE 5 of 34 . ··
. - ; Distributor/Distributed By: TN TECHNOLOGIES, INC.
·<I . I I I I I I I I I I I I I I I I I I I I I I I .• ·. •· Distributor License Number: LO 1105
<I I I I I I I I I I I I I I • '.Manufacturer Name: TN TECHNOLOGIES, INC .
. -">I I I I I I I I I I I I I I I I I I I I I I I I : ; · Device Model (Not Source Model): 5197
::I I I I I I · I I I I I I I I I I I I I I I I I I • · Device Serial Number: 8437
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· : . 041os12011 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 . · .. · . Our records indicate that you have these devices. Please update the information as necessary. PAGE 7 of 34 ·.
,,,. '
Y NRC Device Key 48583 (Internal Control Number)
. . Distributor/Distributed By: TN TECHNOLOGIES, INC.
·:'_ I · I I I I I I I I I I I I I I I I I I I I I I I · · · · · ... ·. Distributor License Number: L01105
-J ·. I I I I I I I I I I I I · ->'.Manufacturer Name: TN TECHNOLOGIES, INC.
:: .I I I I I I I I I I I I I I I I I I I I I I I I • i /
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:· 1 I · 1 I I I I I I I I I I I I I I I I I I I I I . ·• Device Serial Number: 8438
·::.J · I I I I I I I I I I I I I I I I I I I I I I I I J . :'.Transfer Date (Receipt Date): 08/15/1979
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04/05/2017 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 .. .· • Our records indicate that you have these devices. Please update the information as necessary. PAGE 8 of 34 : ·
''.-
. ·. NRC Device Key 48584 (Internal Control Number)
.. > 04/05/2017 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 . , ". · Our records indicate that you have these devices. Please update the information as necessary. PAGE g of 34
· •·· .· N·Rc Device Key 48585 (Internal Control Number)
.. ,\Distributor/Distributed By: TN TECHNOLOGIES, INC. .
; .. -":l I I I I I I I I I I I I I I I I I I I I I I I :': '· Distributor License Number: L01105
-"·· I I I I I I I I I I I I I I .. Manufacturer Name: TN TECHNOLOGIES, INC.
<ti I I I I I I I I I I I I I I I I I I I I I I ! .: ·. Device Model (Not Source Model): 5197
! 1 · I I I I I I I I I I I I I I I I · I I I I I • ·< Device Serial Number: 8440
... J I I I I I I I I I I I I I I I I I I I I I I I ·.•.•·.Transfer Date (Receipt Date): 08/15/1979
·' ··.:.
·;~\ITJ ITJ I I I I . ·:.;L.:~~ . . •.:/· MM DD YYYY
D Not in possession of device (Also complete Section 4.)
, · · Our records indicate that you have these devices. Please update the information as necessary. PAGE 1 Q of 34
·._ · > NRC Device Key 48586 (Internal Control Number)
<'.Distributor/Distributed By: TN TECHNOLOGIES, INC.
· ! I I I I I I I I I I I I I I I I I I I I I I 1 · I , : : Distributor License Number: L01105
>l I I I I I I I I I I I I I :.Manufacturer Name: TN TECHNOLOGIES, INC.
-<I ·I I I I I I I I I I I I I I I I I I . I I I I I :/ ·Device rylodel (Not Source Model): 5197
·f I I I I I I I I I I I I I I I I I I I I I I I ·. :•·)·Device Serial Number: 8441
I I I I I I I I I I I I I I I I I I I I I I I I I . Transfer Date (Receipt Date): 08/15/1979
:;>•rnrn1 I I I ' MM DD YYYY
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04/05/2017 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 : , : - Our records indicate that you have these devices. Please update the information as necessary. PAGE 11 of 34
: '. NRC Device Key 48587 (Internal Control Number)
<. Distributor/Distributed By: TN TECHNOLOGIES, INC.
'·'1 - I I I I I I I I I I I I I I I I I I I I I I I · ·_ '.-': Distributor License Number: L01105
. '.·:I - I I I I I I I I I I I I I :::;; . M'anufacturer Name: TN TECHNOLOGIES, INC. ,···,_~~~~~~~~~~~~
-_./I I I I I I I I I I I I I I I I I I I I I I I I .. , :Device Model (Not Source Model): 5197
I I I I I I I I I I I I I I I I I I I I I I I I •_ /' Device Serial Number: 8442
\;~l 1 I I I I I I I I I I I I I I I I I I I I I I I ~. Transfer Date (Receipt Date): 08/15/1979
"'ITJOJI I I I D Not in possession of device (Also complete Section 4.) ·
04/05/2017 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 ; : Our records indicate that you have these devices. Please update the information as necessary. PAGE 12 of 34
·.·•··.,Distributor/Distributed By: TN TECHNOLOGIES, INC.
: · 1 I I I I I I I I I I I I I I I I I I I I I . I I · ·•.·Distributor License Number: L01105
: ·1 I I I I I I I I I I I I I . •.·.·:'·Manufacturer Name: TN TECHNOLOGIES, INC.
·.I I I I I I I I I I I I I I I I I I I I I I I ; . · D,evice Model (Not Source Model): 5197
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' ·. .. 04/05/2017 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 · : · Our records indicate that you have these devices. Please update the information as necessary. PAGE 13 of 34 · ..
: ·: NRC Device Key 48589 (Internal Control Number)
. ; : ·Distributor/Distributed By: TN TECHNOLOGIES, INC.
·./I-· I I I I I I I I I I I I I I I I I I I I I I I ··_:·1·-
· •···· Distributor License Number: L01105
:<J · I I I I I I I I I I I I I ..•. Manufacturer Name: TN TECHNOLOGIES, INC.
·:: .. I I I I I I I I I I I I I I I I I I I I I I I I i •.
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1 ·:::,'.I : I I I I I I I I I I I I I I I I I I I I I I I Device Serial Number: 8444
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·::::rnrn1111 . ·.· MM DD YYYY
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04/05/2017 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 .: ·~ Our records indicate that you have these devices. Please update the information as necessary. PAGE 14 of 34
· > NRC Device Key 48590 (Internal Control Number)
< : 0410512011 SECTION 2 - DEVICES SUBJl:CT TO REGISTRATION SECTION 2 : :· Our records indicate that you have these devices. Please update the information as necessary. PAGE 15 of 34 ,' > NRC Device Key 48591 (Internal Control Number) · .... : ..
. : . Distributor/Distributed By: TN TECHNOLOGIES, INC.
:-1 I I I I I I I I I I I I I I I I I I I I I I I ·:···
. :<Distributor License Number: L01105
;.·;l I I I I I I I I I I I I I . . . i
: . ; Manufacturer Name: TN TECHNOLOGIES, INC.
"J . I I I I I I I · 1 I I I I I · I I I I I I I I I I Device Model (Not Source Model): 5197
I I I I I I I I I I I I I I I I 1 · I I I I I I · < Device Serial Number: 8446
~,\J I I I I I I I I I I I I I I I I I I I I I I I I ·>' .. Transfer Date (Receipt Date): 08/15/1979
D Not in possession of device (Also complete Section 4.)
:~ ~. MM DO YYYY
Isotope (e.g. AM241) Activity (e:g. 100) Unit (e.g. mCi)
·:/1 CS137 50~000000000 mCi
I I I I I I I I I I I I I I I I I I I I I I I I I I I I I
.. 1
I I I I I I I I I I I I I I I I I I I I I I I .·:'. 4
:; .. ~I ~I ~I l~l~I I I I I I I I I I I I I I I I I I ·; ! 5 .
. ~I ~I ~I l~l~I . I I I I I I I I I I I I I I I I >·6 .. ,·:., ~I ~I ~I l~I~. I I I I I I I I I I I I I I I I
. ; . .. 041os12011 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 . · · .· > · Our records indicate that you have these devices. Please update the information as necessary. PAGE 16 of 34 : . . :
48592 (Internal Control Number)
: }iDistributor/Distributed By: TN TECHNOLOGIES, INC.
· :·1 I I I I I I I I I I I I I I I I I I I I I I I .•; Distributor License Number: L01105
·.;;,I I I I I I I I I I I I I I . :.r"'Manufacturer Name: TN TECHNOLOGIES, INC.
)'/I I I I I I I I I I I I I I I I I I I I I I I I ' , ' Device Model (Not Source Model): 5197
<:".·1 I I I I I I I I I I I I I I I I I I I I . I I I ···,,:
. : . .Device Serial Number: 8447
;:·:l I I I I I I I I I I I I I I I I I I I I I I I I ";:··Transfer Date (Receipt Date): 08/15/1979
D Not in possession of device (Also complete Section 4.)
Activity (e.g. 100)
50.000000000
I I I I I I I I I I I I I
I I I I I I I I I I I I
I I I I I I I I I I I I I
I I I I I I I I I I I I I I I I I I I I I I I I I
I I I I I I I I I I I I
Unit (e.g. mCi)
mCi
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· · 0410512011 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 . . · > Our records indicate that you have these devices. Please update the information as necessary. PAGE 17 of 34
·:. · NRC Device Key 665377 (Internal Control Number)
. '; , Distributor/Distributed By: TN TECHNOLOGIES, INC.
· .:1 I I I I I I I I I I I I I I I I I I I I I I I • ·Distributor License Number: L01105
·:::<:1 I I I I I I I I I I I I I · Manufacturer Name: TN TECHNOLOGIES, INC.
' ... ·.\ I I I I I I I I I I I I I I I I I I I I I I I · Device Model (Not Source Model): 5190
I I I I I I I I I I I I I I I I I I I I I I -I I , :._ Device Serial Number: 81239
:· .: I . I I I I I I I I I I I I I I I I I I I I I I I I .. ,.·.
·.·, Transfer Date (Receipt Date): 08/15/1979
·'·.rnrn1111 .• MM DD YYYY
Isotope (e.g. AM241)
<. 1 CS137
)'. : I I I I I . 2
I I
\ .. I I I I
D Not in possession of device (Also complete Section 4.)
. · .· · 0410512011 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 \ : Our records indicate that you have these devices. Please update the information as necessary. · PAGE 18 of 34
· · · NRC Device Key 665378 (Internal Control Number)
<~Distributor/Distributed By: TN TECHNOLOGIES, INC.
;'.:rl I I I I I I I I I I I I I I I I I I I I I I I ·;· ..
·· Distributor License Number: LO 1105
: ·::1 I I I I I I I I I I I I I :··<Manufacturer Name: TN TECHNOLOGIES, INC.
>·1 I I I I I I I I I I I I I I I I I I I I I I I :··._:- .
'· ·Device Model (Not Source Model): 5190
/i'.I · I I I I I I I I I I I I I I I I I I I I I ·.·. Device Serial Number: 81240
! • c'. Transfer Date (Receipt Date): 08/15/1979
_::~'·rnrn1 I I I D Not in possession of device (Also complete Section 4.)
MM DD YYYY
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. 1 CS137
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mCi
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> Our records indicate that you have these devices. Please update the information as necessary. PAGE 19 of 34 ·. ·
665379 (Internal Control Number)
. : Distributor/Distributed By: TN TECHNOLOGIES, INC.
<·I· 1 · I I I I I I I I I I I I I I I I I I I I I I ·· •· . Distributor License Number: L01105 ·
. :_,~J I I I I I I I I I I I I I ·Manufacturer Name: TN TECHNOLOGIES, INC.
: ,'.·1 I I I I I I I I I I I I I ·. I I I I I I I I I I I •j'····
! .·, Device Model (Not Source Model): 5219
. >-c:··1 I I I I I I I I I I I I I I I I I I I I I I I ~. ·•·· Device Serial Number: 866 I ... · ..---.-~---r-----r----,.----,--~~~~~---r---r--~~----r----<__,
· :_fl ·.· I I I I I I I I I I I I I I I I I I I I I I I :'·/:Transfer Date (Receipt Date): 08/15/1979 < :·~:
·~\':DJ DJ I I I I .,
, ·' MM DD YYYY :·.·.
D Not in possession of device (Also complete Section 4.)
> Isotope (e.g. AM241) ·:.·.
Activity (e.g. 100) Unit (e.g. mCi)
1 CS137 ' 50.000000000 mCi
'> I I I I I I I I I I I I I I I I I I I I I
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' .·' Our records indicate that you have these devices. Please update the information as necessary. PAGE 20 of 34 . · .··
, ·. NRC Device Key 665380 (Internal Control Number)
.... · .. ·Distributor/Distributed By: TN TECHNOLOGIES, INC.
: ] . I I I I I I I I I I I I I I I I I I I I I I I ·. _:: Distributor License Number: L01105
. : 1.· I I I I I I I I I I I I I ·.·.-. '
. ,.: <Manufacturer Name: TN TECHNOLOGIES, INC .
. :_,,I I I I I I I I I I I I I I I I I I I I I I I I
. · · :. Device Model (Not Source Model): 5219
:· 1 I I I I I I I I. I I I I I I I I I I I I I ·I I . ) Device Serial Number: 867
-· 'I I I I I I I I I I I I I I I I I I I . I I I I I I ·: ....
. Transfer Date (Receipt Date): 08/15/1979
:;.'.:,rnrn1111 .. MM DD YYYY
D Not in possession of device (Also complete Section 4.)
Isotope (e.g. AM241) Activity (e.g. 100) Unit (e.g. mCi)
·. >t CS137 50.000000000 mCi
_ I I I I I I I I I I I I I I I I I I I I I 2
__ · · .---I -.-----r--1 I.----.-- I I I I I I I I I I I I I I I I I ...... -·3
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·, · · 041os12011 SECTION 2. - DEVICES SUBJECT TO REGISTRATION SECTION 2 . · > ·' Our records indicate that you have these devices. Please update the information as necessary. PAGE 21 of 34
'.· ·, ... · ~, ~I l~l~!~I I I I I I I I I I I I I I I I I
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' ' 04/05/2017 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 • .=· Our records indicate that you have these devices. Please update the information as necessary. PAGE 23 of 34
.. <· NRC Device Key 665383 (Internal Control Number)
.,' '. Distributor/Distributed By: TN TECHNOLOGIES, INC.
1.:_ 1 I I I I I I I I . I I I I I I I I I I I I I I I I
i · Distributor License Number: L01105
'<JI I I I I I I I I I I I I -;,:;: Manufacturer Name: TN TECHNOLOGIES, INC.
·J<I I I I I I I I I I I I l l I I )I I l l l I l I \'.' , Device Model (Not Source Model): 5219
:<·! I I I I I I I I I I I I I I I I I I I I I I : ; Device Serial Number: 870
.. :J I I I I I I I I I I I I I I I I I I I I I I I I : i/ ;Transfer Date (Receipt Date): 08/15/1979
;::-:rnrn1 I I I . ,,_. MM DD YYYY
D Not in possession of device (Also complete Section 4.)
,, ; 0410512011 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 · : · Our records indicate that you have these devices. Please update the information as necessary. PAGE 24 of 34 . :
; < . NRC Device Key 665384 (Internal Control Number)
... Distributor/Distributed By: TN TECHNOLOGIES, INC.
: I I I I I I I I I I I I I I I I I I I I I I I I · : Distributor License Number: L01105
:. :~ I I I I I I I I I I I I I I .· Manufacturer Name: TN TECHNOLOGIES, INC. ·
::· J · I I I I I I I I I I I I I I I I I I I I I I I .. · .Device Model (Not Source Model): 5219
. I I I I I I I I I I I I I I I I I I I I I I I I ·. · Device Serial Number: 871
·c1·i ·· I I I I I I I I I I I I I I 11 I I I I I I I I : . Transfer Date (Receipt Date): 08/15/1979 ·
>~:·rn rn I I I ' I
· MM DD YYYY
' ·;," ';~ ·. --
D Not in'possession of device (Also complete Section 4.)
.. , ''. 0410512011 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 ·: • · e •• Our records indicate that you have these devices. Please update the information as necessary. PAGE 25 of 34 : . : ·.·.
. NRC Device Key 665385 (Internal Control Number)
, > Distributor/Distributed By: TN TECHNOLOGIES, INC.
· :- ~ ::J . . I I I I I I I I I . I I I I I I I I I I I I I I .,·
Distributor License Number: L01105 ·
·:.::}·1 I I I . I I I I I . I I I · 1 I , ·.·. Manufacturer Name: TN TECHNOLOGIES, INC.
I I I I I I I I I I I I I I I I I I I I I I I I <·: Device Model (Not Source Model): 5219 .
r:'I I I I I I I I I I I I I I I I I I I I I I I I . :··: Device Serial Number: 872
-'~l 1 I I I I I I I I I I I I I I I I I I I I I I I : ''.~::·'. -- Transfer Date (Receipt Date): 08/15/1979
':;'rm OJ I I I I I :.
''''._; MM DD YYYY
... ,,.,
D Not in possession of device (Also complete Section 4.)
: '. -. -. 04/05/2017 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 . · ·: ·. Our records indicate that you have these devices. Please update the information as necessary. PAGE 26 of 34 . ·
<_; NRC Device Key 665386 (Internal Control Number) ...
\ \ I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I
I I I I I I I I
D Not in possession of device (Also complete Section 4.)
Unit (e.g. mCi)
mCi
I I I I I I I I I I I I I I I I I I I I I I I I ...
I I I I I I I I I I I I I I I I I
: ·, ' I lllllll llllll II llllll lllll lllll lllll llll llllll lllll llll llll I llllllll llll lllll llll llll llll ' ' ' < . , GL-3849-21
:' . . 041os12011 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 '. ) Our records indicate that you have these devices. Please update the information as necessary. PAGE 27 of 34 · ·
; i ,._ I
,: > NRC Device Key 665387 (Internal Control Number) · I
, .. : I lllllll llllll II llllll lllll lllll lllll llll llllll lllll llll llll I llllllll llll lllll llll llll llll ' . ,.··
,: :". GL-3849-21
. . . 0410512011 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 . · < · Our records indicate that you have these devices. Please update the information as necessary. PAGE 28 of 34 . · ··
.. · .· NRC Device Key 665388 (Internal Control Number)
04/05/2017 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 ' · ...•• Our records indicate that you have these devices. Please update the information as necessary. PAGE 29 of 34
. . 04/05/2017 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 . ·,; Our records indicate that you have these devices. Please update the.information as necessary. PAGE 30 of 34 . · ::
.· . NRC Device Key 665390 (Internal Control Number)
i · .. Distributor/Distributed By: THERMO FISCHER SCIENTIFIC
.;;:I I I I I I I I I I I I I I I I I I I I I I I I . '·• Distributor License Number: L03524
. '• .
'..·~~Manufacturer Name: THERMO MEASURETECH
· · ~. ·I I I I I I I I I I I I I I I I I I I I I I 1
• • Device Model (Not Source Model): 7062P
: I I I I I I I I I I I I . I I I I I I I I . I I I I . . : Device Serial Number: 10092
?.:··] I I I I I I I I I I I I I I I I I I I I I I I I 1 •••
. : : Transfer Date (Receipt Date): 08/15/1979
'"ITJITJI I I I .·.,.· ... MM DD YYYY
D Not in possession of device (Also complete Section 4.)
. ;·. -----------=--------· Isotope (e.g. AM241)
· · 1 CS137 .•::· ~I ~I 1,------,1~1~1
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50.000000000
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I I I I I I I I I I I I I I I I I I I I I I I I
Unit (e.g. mCi)
mCi
I I I
I I I I I I I I
I I I I I I I I
I I I
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I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I l l l l l l l l l l I I I I I I I I I I I I I I I I I I I
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- --: - 0410512017 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 .. ·, :: ·our records indicate that you have these devices. Please update the information as necessary. PAGE 32 of 34 . : · : .. ·
-:_ .- NRC Device Key 665393 (Internal Control Number)
·. 04/05/2017 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 . : ' ·. · Our records indicate that you have these devices. Please.,µpdate the information as necessary. PAGE 33 of 34
: I I I I I I . I I I I ·1 I I I I I I I I I I I I I .· : 'Distributor License Number: L03524
. ··I . I I I I I I I I I I I I . I ··. _ Manufacturer Name: THERMO MEASURETECH
-·· ;·1 I I I I I I I I I I I I I I I I I I I I I I I ,·,
· ' . Device Model (Not Source Model): 7062P
<-I I I I I I I I I I I I I I I . I I I I I I I I 1.
· · · Device Serial Number: 10096
-. · I. I I I I I I I I I I I I I I I I I I I I I I I I ·' ···.-Transfer Date (Receipt Date): 08/15/1979
·<.·:.OJ ITJ I I I I MM DD YYYY
D Not in possession of device (Also complete Section. 4.)
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· . 1 CS137
:: I I I I I I .· -_.-.. · ' ':2
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I I I I I I I I I I I I
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: 04/05/2017 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2. · · · Our records indicate that you have these devices. Please update the information as necessary. PAGE 34 of 34 · .
·.. NRC Device Key 665395 (Internal Control Number) .
I I I I 0 Manufacturer/Initial Transferor listed above
How acquired and date (e.g., ' ,· .· from a distributor/manufacturer, 0 Other General Licensee Date Transferred: rn rn I , . other licensee, other source)? . · ··· 0 Other Source (Received) MM DD yyyy
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' ' : 04/05/2017 SECTION 4 - NOT IN POSSESSION OF DEVICE
··. '. : -__ Provide information about devices listed in Section 2 or 6, but no longer in your possession. : ·,:
- " Part 1 Transfer Date:
ITJITJI 111 ·. ~ .
MM DD YYYY . _ . Location of the Device:
SECTION 4 ·.
PAGE 1of1 .
0 Whereabouts Unknown (complete Part 1 only) 0 Transferred to another general licensee (complete Parts 2 and 3) :
0 Never Possessed the Device (complete Part 1 only) 0 Transferred to a Specific Licensee (Not the manufacturer)
•· : __ .;.· 0 Returned to Manufacturer (complete Part 1 only) (complete Part 2)
Part 2 License Number of Recipient (if transferred to a specific licensee):
I I I -1 I I I I I I I I I I Company Name:
,. I I I I I I I I I I I I I I· I I I I I I I I I I I I I : : _ : · Department:
I J I I I I I I I I I I I I I I I I I I I I I I I . · ' Address Line 1: . '-: ~
I I I I I I I I I I I I I I I I I I I I I I I I I I Address Line 2:
:I I I I I I I I I I I I I I I I I I I I I I I I I I -· -.. . City: .. . . . . ... --· r---1 ,----,I lr---r---1 .,.--I .,.--I .,.--I -.---I -.---I -.---I -.---I ~I ~I -.---I -.---I -.---I -.---I ~I ~I -.---I ~I ~I ~I ~I ~I ~l ~l I
State: rn Zip Code: I I · I I I I -I I I I I Part 3 Enter the name of the individual responsible for this device:
· Last Name:
: __ -· 1 I I I I I I I I I I I I I I I I I I I I I I I I I I I First Name: Middle Initial:
>::· -1 I I I I I I I I I I I I I D , _: Telephone Number: I I I I I I I I r---1 ~I l~I Extension: ,----,I ,~,~l~l~I _1'1
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