, 7mm33m----mm----mKm - m m - - - - m,- - - - - - - m ------------m-um NRC FORM 374 w s w 1 2 i # * $ ' 00 89) U.S. NUCLEAR REcuLATORY CQMMIS$lON g Amendment No. 14 | MATERIALS LICENSE Pursuant to the Atomic Energy Act of 1954, as amer.ded, the Energy Reorganization Act of 1974 (Public Law 93-438), and Title 10, h Code of Federal Regulations, Chapter I, Parts 30,31,32,33,34, 35,39,40 and 70, and in reliance on statements and representations heretofore y made by the licensee, a license is hereby issued authorizing the licensee to receive, acquire, possess, and transfer byproduct, source, and special N nuclear material designated below; to use such material for the purpose (s) and at the place (s) designated below; to deliver or transfer such material N to persons authorized to receive it in accordance with the regulations of the applicable Part(s). This license shall be deemed to contain the conditions specified in Section 183 of the Atomic Energy Act of 1954, as amended, and is subject to all applicable rules, regulations and orders of the Nuclear g Regulatory Commission now or hereafter in effect and to any conditions specified below. g - i In accordance with the letter dated ! ucensee September 17, 1993, i 1, Barnert Hospital 3. Ucense number 29-17895-01 is amended in I its entirety to read as follows: | 2. 680 Broadway | Paterson, New Jersey 07514 p b.. i.|Ex;IIration date July 31, 1994 i ,. - . , ,y y - 5. Docket or 7,y 030-13606 i ,(- Reference No. p 6. Byproduct, source, and/or ,\> 7. Chemical and/or physical * r 8. Maximum amount that licensee i special nuclear material M* form V,may possess at any one time I ') hnder this license | , p A.Anybyproductmateria'l ,AxAny radiopharmaceutical? A ras needed I , identified in 10 CFR/ 3 h identified in 10'CFRV I 35.100 /~. k35';100' 1 m /fM b E B. Any byproduct matersial IBh Any' radio' pharmaceutic'al B. A'sj'needed | ~ identified in 10 CFR 4 .fidentified. In 10)CFR?^ LQf , < , $ g - p 235.200 ~ - 35.200 C. Any byproduct mat}erial -- e CRAnysradiopharmaceutical/w' C. As needed I y@$'J: , identified in 10 CFR 'identifi'ed [inkl0?CFR ||&T g l| 4 35.300&)[~{b $ N E @40.6Prspack'agec KitiVK 35.300 D.Anybyproductmaterbl DeAi needed | identifiedin10CFRM iW C[C .ZlyVM;7 W g ' 31.11 { L / 3 $p' D g ia i,k+ - er i 9. Authorized use / v | A. Any uptake, dilution and e'xcretion procedure approved in 10 CFR 35.100. f B. Any imaging and localization pFocedure'ipprov,ed ilf 10 CFR 35.200. ~ p ' C. Any radiopharmaceutical therapy procedufe ap' proved in 10 CFR'35.300. I ' D. h vitro studies. I I CONDITIONS I I 10. Licensed material may be used only at the licensee's facilities located at 'I, - 680 Broadway, Paterson, New Jersey. ( ' ' F | 11. The Radiation Safety Officer for this license is Stuart C. Moses, M.D. N El 12. Authorized Users: Material and Uses: | I 4harles Zimmerman, M.D. 35.100; 35.200; 35.300 t T ' h vitro studies I t4 ' g | Qanfurd Bluestein, M.D. 35.100; 35.200; 35.300 I & h vitro studies | , LEAL HECCli? CCM ML 10 - g @33jM $56 A ========================== C_ PDR
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7mm33m----mm----mKm - m m - - - - m,- - - - - - - m ------------m-um
NRC FORM 374 w s w 1 2 i#* $'
00 89) U.S. NUCLEAR REcuLATORY CQMMIS$lON g
Amendment No. 14|MATERIALS LICENSE
Pursuant to the Atomic Energy Act of 1954, as amer.ded, the Energy Reorganization Act of 1974 (Public Law 93-438), and Title 10, hCode of Federal Regulations, Chapter I, Parts 30,31,32,33,34, 35,39,40 and 70, and in reliance on statements and representations heretofore y
made by the licensee, a license is hereby issued authorizing the licensee to receive, acquire, possess, and transfer byproduct, source, and special N
nuclear material designated below; to use such material for the purpose (s) and at the place (s) designated below; to deliver or transfer such material N
to persons authorized to receive it in accordance with the regulations of the applicable Part(s). This license shall be deemed to contain the conditions
specified in Section 183 of the Atomic Energy Act of 1954, as amended, and is subject to all applicable rules, regulations and orders of the Nuclear gRegulatory Commission now or hereafter in effect and to any conditions specified below. g
-
i
In accordance with the letter dated !ucensee
September 17, 1993, i1, Barnert Hospital 3. Ucense number 29-17895-01 is amended in I
its entirety to read as follows: |2. 680 Broadway |Paterson, New Jersey 07514 p b.. i.|Ex;IIration date July 31, 1994 i,.
- . ,,y y- 5. Docket or7,y 030-13606 i,(- Reference No. p
6. Byproduct, source, and/or ,\> 7. Chemical and/or physical * r 8. Maximum amount that licensee i
special nuclear material M* form V,may possess at any one time I') hnder this license |, p
A.Anybyproductmateria'l ,AxAny radiopharmaceutical? A ras needed I,
identified in 10 CFR/ 3 h identified in 10'CFRV I35.100 /~. k35';100' 1 m /fM b E
B. Any byproduct matersial IBh Any' radio' pharmaceutic'al B. A'sj'needed |~
identified in 10 CFR4 .fidentified. In 10)CFR?^ LQf , < ,$ g
-
p235.200 ~
-35.200
C. Any byproduct mat}erial--
e CRAnysradiopharmaceutical/w' C. As needed I
y@$'J:,
identified in 10 CFR'identifi'ed [inkl0?CFR ||&Tg l|4
35.300&)[~{b $ N E
@40.6Prspack'agecKitiVK35.300
D.Anybyproductmaterbl DeAi needed |identifiedin10CFRMiW C[C
.ZlyVM;7 Wg'
31.11 { L / 3 $p' D g
ia i,k+ - er i9. Authorized use / v
|A. Any uptake, dilution and e'xcretion procedure approved in 10 CFR 35.100. fB. Any imaging and localization pFocedure'ipprov,ed ilf 10 CFR 35.200.
~ p' C. Any radiopharmaceutical therapy procedufe ap' proved in 10 CFR'35.300. I'
D. h vitro studies. II
CONDITIONS II
10. Licensed material may be used only at the licensee's facilities located at 'I,-
680 Broadway, Paterson, New Jersey. ('
'
F
| 11. The Radiation Safety Officer for this license is Stuart C. Moses, M.D. N
El12. Authorized Users: Material and Uses: |
I4harles Zimmerman, M.D. 35.100; 35.200; 35.300 tT'
h vitro studies It4'g
| Qanfurd Bluestein, M.D. 35.100; 35.200; 35.300 I
& h vitro studies |,
LEAL HECCli? CCM ML 10 -
g
@33jM $56 A ==========================
C_ PDR
, , __ _. . . _ ._ _ . ___ ___ - _-
;
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U.S. NUCLEwE!ULATcRY COMMISSION c,' yGg 2 Op, g -
{r.,,. 3;44 --.=, ,AGFS
- +4 Licezne sanber i'
MATERIALS LICENSE - 29-17895-01 I ;' * * " ' " " " ' " " '
SUPPLEMENTARY SHEET030-13606 g
. |-
Amen.iment No.14- 1
I
}(12, continued) CONDITIONS |~
! !Authorized Users: Material and Uses:|
Joel S. Cooperman, M.D. 35.100; 35.200, 35.300 I
.In vitro studies I'
I
IJair E. Leichter, M.D. 35.100; 35.200; 35.300'.In vitro studies i
Alberto C. Dios, M.D. 3,5k1(EE; [35:200 !h " U/ I,\' 35.100; 35.200; 1 5:300 I T
. y{'.Stuart C. Moses, M.D..in vitro studies 3A |
DanielS. Levy,M.D.k 35.100; 35.200 |
K 35.100; 35.200 f h A |Sherry L. Fine, M.D1
MichaelA.Kessleh7M.D. 'h \35!Ni;;35.[00 O I*
<f b / . /' ( \\ l O |,
t
C Q5 A00:35.2 ySteven M. Daly, M.D. i3 [t'"~ 0 t ' vitro stu'diIes- ,/ f l
(f) C '? [g ,fp ; I
Rand Jordan Stack, M.D. g . 00;|qa2200@ yFp*[ |
'
o o 1 0,
s ,PatrickJ.Hines,.M.J. } 0;g5200K Q i
em 8, h licensIn addition to the pbssession likits I shall further restrict' 13 .the possession of lice'ns'sd material s'o' th'at ~at no time pit quantity of radioactive I
material possessed in edess of a quantity which req decommissioning funding in |accordance with 10 CFR 30.35(d), 10 CFR 40.36(b) or 0 CFR 70.25(d). g,
14. Except as specifically provided oth rwi i his license, the licensee shall- conduct !its program in accordance with the statements, representations, and procedures Icontained in the documents, including any enclosures, listed below. The Nuclear i
Regulatory Commission's regulations shall govern unless the statements, |representations, and procedures in the licensee's application and correspondence are g
more restrictive than the regulations. i ;
I
-A. Application dated September 21, 1988 I
B. Letter received March-27, 1989 Ii
C. Letter dated December 3, 1991 | :
D. Letter dated August 7, 1992 i'
I
For the U.S. Nuclear Regulatory Commission I t
i
FEB 111994 0%inal Signed p : j'y
Date By Miche b nr.eim.',
Nuclear Materials Safety Branch p
Region I IKing of Prussia, Pennsylvania 19406 1
N
______________________________________________________j. .
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License No. 29-17895-01Docket No. 030-13606
'
Contml No. 118768
Bamert Hospital_
i
A'ITN: Stuart Moses, M.D.Radiation Safety Officer i
680 Broadway +
Paterson,' New Jersey .07514-1472
!Dear Dr. Moses:'
;
Please review the enclosed document carefully and be sure that you understand all conditions. .
If there are any ermrs or questions, please notify the U.S. Nuclear Regulatory Commission, iRegion I office, the Licensing Assistance Section, (610) 337-5093 or 5239, so that we can iprovide appmpriate corrections and answers. ;
i.
iPlease be advised that your license expires at the end of the day, in the month, and yearstated in the license. Until your license is terminated, you must conduct your pmgram '
involving byproduct materials in accordance with the conditions of your NRC license,representations made in your license application, and NRC regulations. In particular, notethat you'must: j
'1. Operate in accordance with NRC regulations 10 CFR Part 19, " Notices, Instructions
and Reports to Workers; Inspections," 10 CFR Part 20, " Standards for PmtectionAgainst Radiation," and other applicable regulations. '
2. Not possess and use materials authorized in Items 6, 7, and 8, on the license until:
a. you have constmeted the facilities and obtained the equipment described in the llicense application and supporting documentation; and
f
b. you have notified the U.S. N,1 clear Regulatory Commission, Region I,,
ATrN: Chief, Nuclear Materials Safety Branch,'475 Allendale Road,King of Pmssia, Pennsylvania 19406 in writing, that activities authorized by-the license will be initiated.
'.
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OFFICIAL RECORD COPY - G:\WPS\MLTR\L2917895.01 - 02/01/94
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Barnert Hospital -2-
3. Notify NRC, in writing, within 30 days:
a. when an' authorized user or Radiation Safety Officer, permanently discontinuesperformance of duties under the license or has a name change;.or
L 4
L b. when the licensee's mailing address changes (no fee is mquired if the location |of byproduct material remains the same).
'
4. In accordance with 10 CFR 30.36(b) and/or license condition, notify NRC, pmmptly,in writing, and request termination of the license:
!-
a. when you decide to terminate all activities involving materials authorized underthe license; or
b. if you decide not to complete the facility, acquire equipment, or possess and -use authorized material.
5. Request and obtain a license amendment before you:.
.
a. permit anyone to work as an authorized user under the license; .
b. change Radiation Safety Officers;
c. order byproduct material in excess of the amount, or radionuclide, or fonndifferent than authorized on the license;
d. add or change the areas of use, or address or addresses of use identified in thelicense application or on the license; or 4
e. change ownership of your organization.-
6. Submit a complete renewal application with proper fee or termination request at least-30 days before the expiration date of your license. You will receive a reminder notice -approximately 90 days before the expiration date. Possession of byproduct materialafter your license expires is a violation of NRC regulations. A license will notnormally be renewed, except on a case-by-case basis, in instances where licensedmaterial has never been possessed or used.
In addition, please note that NRC Form 313 requires the applicant, by his/her signature, toverify that the applicant understands that all statements contained in the application are trueand correct to the best of the applicant's knowledge. The signatory for the application shouldbe the licensee or certifying official rather than a consultant.
OFFICIAL RECORD COPY - G:\WPS\MLTR\L2917895.01 - 02/01/94
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Barnert Hospital -3-
You will be periodically inspected by the NRC. Failure to conduct your program inaccordance with NRC regulations, license conditions, and representations made in yourlicense application and supplemental correspondence with NRC will result in enforcementaction against you. This could include issuance of a notice of violation, or imposition of acivil penalty, or an order suspending, modifying or revoking your license as specified in theGeneral Policy and Procedures for NRC Enforcement Actions,10 CFR Part 2, Appendix C.Since serious consequences to employees and the public can result from failure to complywith NRC requirements, prompt and vigorous enforcement action will be taken when dealingwith licensees who do not achieve the necessary meticulous attention to detail and the highstandard of compliance which NRC expects of its licensees.
Thank you for your cooperation.
Sincerely,
0-!ginal S gned sy:Michci!3 Beardsley
Michelle R. BeardsleyNuclear Materials Safety Branch i
Division of Radiation Safety,
and Safeguards
Enclosures:1. Amendment No.142. Requirements for Materials Licensees
,
,)
DRSS:RI U,
Beardsley/ srb
2/ h94
OFFICIAL RECORD COPY - G:\WPS\MLTR\L2917895.01 - 02/01/94
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responalble for delivering it to the intended recipientIf the reader of this message is not the intended recipientor en agent
notified that you have received this document in error ,and'thatreview, dissemination, distribution, or copying of this message isyou are hereby
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201-794-6<91 FA$( DI AGil'Il1AG g P03 JAf4 05 '94 09:36'
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T EXHIBIT 2 <
SUPPLEMENT A i
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, SUPPLEMENT U.S. NUCLE AR REGULATORY COMM18SiON.i
'h . TMAINING AND EXPERIENCEAUTHORIZED U$ER OR RADIATION SAFETY OFFICER i
I*
1. NME OF PRDPOSED AUllGRIND U*etR OR RADIATlDil SAFETY OFFICLR 2. FOR PHT$1CIANS. STATt'bR ;
littA110RY WlERE LICEN$1D :
RAND J. ST)CK, M.D. New Jersey !.
|L CFRTIFICATf DN '
SPECIALTY DOARD CAT 500AV MONTH AND YEAR C8 ATIFitoA B C ,
i
AMERICAN BOARD OF . DIAGNOSTIC RADIOLOGY ELIGIBLE ['RADIOLOGY :
IS -
4. TRAINING RECElVED IN BASIC RADl0180 TOPE MANDUNG TECHN10UE8
TYPE ANO LENGTH oF TRAINING ,
'
CLOCR 1100R$ IN CLOCK.110VR$ OF |FitLo oF TRAINING LOCATloN ANO DAT1tSl oF TRAINING Ltc1 gat DR SUPERVISED '
A E LABORATORY OH-Tilt JOB '
EXPERIENCE 8
_ _ _
N.Y. Medical Collegee naciatioN Physics AND Westchester Medical Center 42 35
tik$TRUMENTATioN Metropolitan Hospital
Lincoln Hospital ,
1/90 - 6/30/92 15 156. mAciATioN rnotecTioN
:c. MATHtMATICS PERTAINING TO 15 W
THE U$$ AND MEASUREMENT '
0F RA010ACTIV8TY i
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_ i$uTOPE mtt 05tu AT Olit TtHF , LOCAllott CLOCK liOURS Tfrt 0F USE ;I-123 3 mci N Y Me' dical College 50 thyroidI-131 5 mci Westchester County Med.( tr. 20 Treatment .
Tc99 4 mci Metropolitan Hos.Ctr. 70 LungTc99 20 mci Lincoln Hospital 100 Bone scan
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Ga67 6 mci 60 Abscess, Tumor*
Kr81 10 mci 10 Lung ventilatiort
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(. .o ,' EXH8 BIT 3 (Continuhd)'
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PRorosto Pitts1CIM usta *,,
RAND J. STACK, M.D.PRECEPTOR STATEMENT / Continued)
~~
1 CLINICAL TRAINING AND EXPERIENCE OF ABOVE NAMED PNYSICIAN (Catrinuad)Num6n or
CASE s lNVOLVINO COMMENT 8 ..
#I Ak 'I #'""* "" N""''d ' W b
ISCTOPE CDADITIONC CIACNostD OR TRf ATED P ARTICIP ATION meesewtwoJa AAkap m sepeee meeaj.
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A32 TREATMENT OF POLYCYTHEulA VERA, g,
fraAsk) LEUKEMIA. AND BONE utTA$1ASES
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TRE ATMINT'OF THY Rol0 CARCINouA *6.
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TtLETHEFLAPY TRE ATM$NTg',3,$*60 TME ATMENT OP EYE DISEASE
R A010PHARuACEtJTICAL P REPARAT10N'
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:L DATES AND TOTAL NUMDER OP HOURS RECE1VED IN CLINICAL RADIC150 TOPE TRAININGLOCATION CATES C.DCT, lot!R$ CF EXPDt.itRCE
Yii,7 York Medical College , 7/89 W 9.3., 1200 -,
A. THE TRA8NING AND EXPEillENCE INDICAT& D ABOVE6 PREIEPTORT, WHATURk
WAS OBTAINED UNDER THE supe RVitt0N OF: *'
b W^' % ' '- a NAuf or sunnvisoet
RITA F. CIROLAMO. M.D. '
m, hAus cP LNgitTVTION 7. FREGPTOR'S NAME PJese 8ver er Amau
DEPT. OF RADIOLOGY ~. NY MEDICAL COLLEGE RITA 7. GIROLAMO, M.D.e. M A4L4880 ADDRES8
VALHALL, N Y 10595m ca T V 4. CATEj
c --_ _-NYS #58-6 NYC f52-5 8/16/93
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DATE OF CALL: /d -/' f 3f /A * *TBE OF CALL:
PERSON CALLED: _ IONE NO. 3 f7'
(Outgoing Call) /# -
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FACILITY NAME: " ett <MV
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LICENSE NO.: 29-/7t?st a/ DOCKET NO. /36d/o
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OFFICE RECORD COPY h 10~
S:\PENDING\TELEREC.FRM - 10/14/93
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C' ' FAIR LAWN DIAGNOSTIC |MAGING CENTER ,
BLUESTEIN. ZlMMERM AN, COOPERMAN & LEICHTER, P.A.
DePLOMATE$. AMERtCAN BOARD OF RADIOLOGY
20 19 FAIR LAWN AVENUE FAIR LAWN, NEW JERSEY 07410
(201)794 3132
S G BLutsTEIN. M D A C. DE Dios. M D. D S. LEvv. M D.'
. J S CooetaM AN. M D. T M Kots. M.D. S C. MOSES. M.D
. S M. DAtv. M D. J E. LEicHTER. M D. C. ZIMMERMAN M.D.'
,
IY0WSeptember 17, 1993 p 170 g-
,,Josephine M. Piccone, Ph.D. ,
Nuclear Materials Safety Section ADivision of Radiation Safety and SafeguardsUnited States Nuclear Regulatory ComraissionRegion 1631 Park AvenueKing of Prussia, Pa 19406
*
RE: License 17895-01
Dear Dr. Piccone:
Please amend our By-Product Materials License to include Dr. Patrick JosephHines, and Dr. Rand Jordan Stack as authorized users of By-Product Materials.Enclosed you will find Curriculum Vitae and Preceptor statements,.and acheck for $120.00 td11ch is the required fee according to the 10 CFRPart 170.
Should you require additional information, please do not hesitate to|
contact me. i
p l'dy N A N. .- c . _
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cech ib- N /I7/T '~~ -- Sincerely, j~ ~ ~ ~
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3 St t Moses, M.D. ^~1
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.:j-- Radiation Safety Officer____.~z... -
SM/ph'
Encl. 118768OCT 011993
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! RStack, R.: Peritoneal Dissentination of Hydatid Disease: A Case Report. 28 tit Artstual| $ Scienti ic Meeting, Tite Radiological Society of lite New York Medical College. Eintsford,j p . . RY. ay 16,199u.
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:Name. Pat rick .losepli I lines. M.D. ,
.lannary 7.1960@; a' Date of flirth-
)|$j Hirthplace Itockville Center New YorkjayOO Marital Status Single:kp.yBusiness Address Columbia |Jniversity ,
1 Department of Itadiology -4gY 630 West 16811: Street P&S 3-440 i-. g*! 1
New Yn k. NY 100329- kl;., SIlome Address 245 Passaic Avenue #C3
i;kh Passaic, New .lcrsey 07055
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t $ [.['e .( Imaging Course, New York. New York -k December Il-16,1989
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1%'4jTenth Annual itesidents' Iteview Course>
April 15-20.1990'
' pi.'i Armed Forces Institute of Pathology Itadiologic'
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Quarterhackf ts14 ' f Fo[mder of New York Medical College'
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Barne"rt Hospitaldba Fair Lawn Diagnostic CenterATTN Stuart Moses, M.D.20-19 Fair Lawn' AvenueFair Lawn, New Jersey 07410
Gentlemen
This refers to your letter dated September 17, 1993, for an amendment toMaterials License 29-17895-01.
We received your check for $120. Your request is subject to an amendment feeof $500 as specified in fee Category 7C of 10 CFR 170.31 of the enclosed July20, 1993, Federal Reaister notice. Payment of the additional $380 fee shouldbe made to the U.S. Nuclear Regulatory Commission and mailed to the followingaddress:
U.S. Nuclear Regulatory CommissionATTN Brenda BrownLicense Fee and Debt Collection Branch, OC/DAFMail Stop MNBB 4503,
Washington, D.C. 20555'
Your application will be processed by the Region I Licensing staff located at475 Allendale Road, King of Prussia, PA 19406. The fee, however, is requiredprior to issuance of the amendment. When submitting the additional fee,please refer to CONTROL NUMBER 118768.
If we do not receive a reply from you within 30 calendar days from the date ofthis letter, we shall assume that you do not wish to pursue your applicationand will void this action.
Sincerely,
- JF _.Brenda BrownLicense Fee and Debt Collection BranchDivision of Accounting and Financeoffice of the Controller
EnclosuresJuly 20, 1993, Federal Reaister notice
,
cc: Region I
DISTRIBUTION"Pending. Fee File
OC/DAF R/FLFDCB R/F (2)
OFFICE: OC/ F CB OC/LFDCB'NAME: BB SKimberley
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AB/As\BAMHOSP. ARC
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: INFORMATION FROM LTSi
BETWEEN: L : --~~,- --------------s, .1
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LICENSE FEE' MANAGEMENT 3 RANCH, ARM : PROGRAM CDDE: 02120AND : ST ATUS CODE: 0
REGIONAL LICENSING SECTIONS : FEE CATEGORY: 7C'
: EXP. DATE: 19940731: FEE COMMENTS: CODE 23,
Ks : DECOM FIN ASSUR REQD: N:: :: ::: :::::: :: ::::::::: : :::: ::: :::: ::
x-) LICENSE FEE TRANSMITTAL
A. REGION,
1. APPLICATION ATTACHEDAPPLICA9T/ LICENSEE: BARNERT HOSPITAL,,
kJ RECEIVE 3 DATE: 931001DOCKET 90: 3013606CONTROL NO.: 118768r3
kJ LICENSE NO.: 29-17895-01ACTION TYPE: A M E N D M E N T'
qis 2. FEE ATTLCHE
AMOUNT: ._
CHECK N3.:o ..;)
3. COMMENTS
(b SIGNED ) _/ .|_________,( 26 g'& ,........ .... __ ,
DATE ,
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1. FEE C ATE GORY AND AMOUNT: _Cs..___.w..___.._____ ..______ () f._-L,'
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2. CORRECT FEE PAID. pkIPLICATION MAY B E PROCESSED FOR: /AMENOMENTc3 ...__ ..._____
kJ RENEWAL ....___.______
LICENSE _.......______
raL' 3. OTHER ,__.....__.... ________,;.....,___
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VOID SHEET
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TO:- License Fee Management Branch
FROM: U'
SUBJECT:. VOIDED APPLICATION|t
Control Number: |I8850 -
Applicant: bnehr Nosm >
Date Voided: 11-14-93'd.mi enh a - band.lMReason for Void: hel. tan as a
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14-17895-bI ono- 1366ta,
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b^n // 29k3smw~ Signature f Dite 1
Attachment:Official Record Copy of
Voided Action
FOR LFMB USE ONLY
Final Review of VOID Completed: .
1
Refund Authorized and processed 4
No Refund Due
Fee Exempt or Fee Not Required ,
Coments: Log completed 4
Processed by: *,
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'
OFFICIAis RECORD COPY ML 10;-
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LTS WORKSHEET-40.: ;
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IDOCKET.NO':' 03013606-- LICENSE"NO :.O 29317895f1 STATUS: 0 -
,
L M AIL CONT ROU: 118850 RECEIPT DATE : 931018- A TION' TYPE: - 4 .
DU E ' DATE : 940116 |
F ED. GOVT : : N INST. CODE' ::17895 -L CENSE-REGION:'1 '!
OL ISSUE DATE: 930210 ORIGINAL DATE: 831114 PIRATION'DATE: 19940731 .
-|i.
Ni-NAME :^BARNERT HOSPITAL ~ DECOM FIN ASSUR REQD: 4
.nu SUBM:-.SA--, . O EPT/8URE AU:' _ _ _ ;, _ ;;, ;,;c.,;;;, ;,;, .,;, ;, ,,;. ; ;, ;,; ., ;, ;, - ;,- CONT; PLAN-REQD: 'N -APPRY: ._- ' '
BUILDING :' -- ----4-- - -'-- - -
[f'O STREET : 6s0 BROA0vAy
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-CITY :' PATERSON ATE:-NJ IIP:.075141472 |
CONTACT PERSON: STUART MOSESr M.D.,- 50 PHONE: 2013977j6600. ,
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' PRIMARY PGM CODE : 02120. SECO DARY PGM CODES:'02121 :.1
0 ' INSPECTION 2EGION: 1 PR RITY CO DE:'. 2 ' INSPECTION CATEGORY: G.. ;
RADIATION'SLFETY OFFICER: STUA T C. MOSE S, < M.D.
STATES WHEREt USE IS AUTHORIZ D: .1 0 % ALL LISTED STATES1,'C SAME AS STATE IN ADDRESS |O 2 e Att STATES ;
3 * NON= AGREEMENT STATESAufa RIze STATES: _ ;. ., _; .,;. _ ;,:,, _ _ _; _ .,;,; ., ; ., ; .", .c.- (UsE ONov IF Ae0vE IS zeRO) -
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DOCKET No: 33013606 LICENSE NUMBER: 29*.17893-01 i
O >AMEN : 3ARNERT H0 SPITAL' sca.<-tw. 4..u.,4 .- -4. w . ......a ....;.c ... .+ - - .a.-- < ......-.
MNOSCIL QUA' iiY"MINA'GNMNf/T PROGR'AN YEdUIRdD[ Y R'E'C'E'IVE d:#Y " NPNRUNNb[$ '#
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