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TRANSCRIPT
llI lll II111 1 IIIII 1111 I1I111111111 IIIII 11I11 111111 11111 IIIIIll I 111lHiii11 ti 11111IIIt III! lll l liltIIIGL-705530-2011/03/2015
NRC FORM 664
07 - 201510 CFR 31.5
APPROVED BY 0MB" NO. 31 50-01 98
SECTION 1PAGE 1 of 2
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 toensure a higher level of device accountability. Send comments regarding burden estimate to the FOIA, Privacy, and Information Collections Branch (T-5 F53), U. S. NuclearRegulatory Commission, Washington, DC 20555-0001, or by internet e-mail to Infocollects.Resource~nrc.gov, and to the Desk Officer, Office of Information and RegulatoryAffairs, NEOB-1 0202, (3150-0198), Office of Management and Budget, Washington, DC 20503. If a means used to impose an information collection does not display acurrently valid 0MB 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 thechanges in the applicable boxes. USE CAPITAL LETTERS.
General LicenseRegistration NumberGL-705530-20
SECTION 1 - GENERAL LICENSEE INFORMATION
Enter the company name and the street add resslphysical location of use for your device(s). Forportable devices, specify the primary storage location. Do not use a P.O. Box address.
Company Name: MARYSVI LLE HYDROCARBONS
Department: HEALTH AND SAFETY
Address Line 1: 2510 BUSHA HIGHWAY
Address Line 2:
City: MARYSVI LLE
State: Ml Zip Code: 48040 -1904 I 'Lw:For NRC Use Only. cateor'
...... ,,i: :Packet Rece~ipt Date (MMDDYYY): i:
Accesio Nuber
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SECTION 1PAGE 2 of 2
SECTION 1 - GENERAL LICENSEE INFORMATION (Continued)Enter the name, teleiphone number and title of the person who is the responsible individual for the device(s).
Last Name: HALLIGAN
First Name: DENNIS Middle Initial: P
Telephone: (810) 388-2084 Extension:
Title: SENIOR HEALTH & SAFETY CO
s~lPJ-AM• sQuP Rk>V)JS•
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: ADMINISTRATION
Address Line 1.: 2510 BUSHA HIGHWAY
Address Line 2:
City: MARYSVILLE
Stt:M I Zr Zi Coe:484I-90
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11/03/2015 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 14
NRC Device Key 591333 (Internal Control Number)
Distributor/Distributed By: KAY-RAY/SENSALL, INC.
Distributor License Number: IL-01010-02
Manufacturer Name: KAY-RAY/SENSALL, INC.
Device Model (Not Source Model): 7063P
Device Serial Number: $98F0503
Transfer Date (Receipt Date): 05/I5 119 9 8
I I [•• • • L•Not in possession of device (AlsoD] complete Section 4.)
MM DD YYYY
Isotope (e.g. AM241) Activity (e.g. 100) Unit (e.g. mCi)
1 CS137 500.000000000
ED2
3
4
5
6
A
mCi
DIIDIIDIDDIEDIEDIE
A
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Our records indicate that you have these devices. Please update the information as necessary. PAGE 2 of 14
NRC Device Key 591336 (Internal Control Number)
Distributor/Distributed By: KAY-RAY/SENSALL, I NC.
Distributor License Number: IL-01010-02
Manufacturer Name: KAY-RAY/SENSALL, INC.
Device Model (Not Source Model): 7063P
Device Serial Number: S98M2904
Transfer Date (Receipt Date): 11/1 5/1 998I I II I I INot in possession of device (AlsoD] complete Section 4.)
MM DD YYYY
Isotope (e.g. AM241) Activity (e.g. 100) Unit (e.g. mCi)
1 CS137 200.000000000
2
3
4
5
6
K~Ih
A
mCi
DIDDiiDiiDiiDiiDID
A
GL-705530-2011/0312015 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 14
NRC Device Key 591337 (Internal Control Number)
Distributor/Distributed By: KAY-RAY/SENSALL, INC.
Distributor License Number: .I L-01 010-02
Manufacturer Name: KAY-RAY/SENSALL, INC.
Device Model (Not Source Model): 7063P
Device Serial Number: $98M2905
Transfer Date (Receipt Date): 11/15/1998l__ • l 1 • • •Not in possession ofdevice (Also
D] complete Section 4.)ED Di Dii
MM DD YYYY
Isotope (e.g. AM241) Activity (e.g. 100) Unit (e.g. mCi)
1 CS137 200.000000000 mCi
2
3
4
5
6
Dii
DiiDiiDiiDiiDiiDii
A
GL-705530-20
11/03/2015 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SEC
Our records indicate that you have these devices. Please update the information as necessary. PAGE
NRC Device Key 591338 (Internal Control Number)
Distributor/Distributed By: KAY-RAY/SENSALL, INC.
Distributor License Number: IL-01010-02
Manufacturer Name: KAY-RAY/SENSALL, INC.
- Device Modei (Not Source Model): 7063P
Device Serial Number: $98M2906
Transfer Date (Receipt Date): 11/1 5/1 998I I E__MZ JNotin possession ofdeviceo(Also
D] complete Section 4.)
MM DD YYYY
IDIhIIIII.3TION 2
4 4of14
Isotope (e.g. AM241 )
1 CS137
2
3
WEW I4
5
6
Activity (e.g. 100)
200.000000000
Unit (e.g. mCi)
mCi
WE_[
WEU
WEU
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Our records indicate that you have these devices. Please update the information as necessary.
NRC Device Key 591339 (Internal Control Number)
Distributor/Distributed By: KAY-RAY/SENSALL, INC.
Distributor License Number: I L-01 010-02
Manufacturer Name: KAY-RAY/SENSALL, INC.
Device Model (Not Source Model): 7063P
Device Serial Number: $98M2907
Transfer Date (Receipt Date): 11/1 5/1 998Not in possession of devicII I IkJ2JD complete Section4.)
MM DD YYYY
III nnll miI niI IIIISECTION 2
PAGE 5 of 14
L
1
ii:e (Also
Isotope (e.g. AM241)
1 CS137
2
3
4
5
6
Activity (e.g. 100)
200.000000000
Unit (e.g. mCi)
mCi
LW•
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11/03/2015 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2
Our records indicate that you have these devices. Please update the information as necessary. PAGE 6 of 14
NRC Device Key 591316 (Internal Control Number)
Distributor/Distributed By: KAY-RAY/SENSALL, INC.
Distributor License Number: I L-0 1010-02
Manufacturer Name: KAY-RAY/SENSALL, INC.
Device Model (Not Source Model): 7062BP
Device Serial Number: $99G0102
Transfer Date (Receipt Date): 08/15/1999• [___• • ___• ~ m• •Not in possession of device (Also
D] complete Section 4.)
MM DD YYYY
Isotope (e.g. AM241) Activity (e.g. 100) Unit (e.g. mCi)
1 CS137 100.000000000
2
3
4
5
6
,A
mCi
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Our records indicate that you have these devices. Please update the information as necessary. PAGE 7 of 14
NRC Device Key 591317 (internal Control Number)
Distributor/Distributed By: KAY-RAY/SENSALL, INC.
Distributor License Number: I L-01 010-02
Manufacturer Name: KAY-RAY/SENSALL, INC.
Device Model (Not Source Model): 7062BP
Device Serial Number: S99G0103
Transfer Date (Receipt Date): 08/15/1999Not in possession of device (Also
I--D complete Section 4.)
MM DD YYYY
Isotope (e.g. AM241) Activity (e.g. 100) Unit (e.g. mCi)
1 CS137 100.000000000
2
3
4
5J
6
WEIE
A
mCi
WEWEWEWEWEWE
A
GL-705530-20
11/03/2015 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 14
NRC Device Key 591318 (Internal Control Number)
Distributor/Distributed By: KAY-RAY/SENSALL, INC.
Distributor License N umber: IL-Cl1010-02
Manufacturer Name: KAY-RAY/SENSALL, INC.
Device Model (Not Source Model): 7062BP
Device Serial Number: $99G0104
Transfer Date (Receipt Date): 08/1 5/1 999Not in possession of device (AlsoI 1 11 1 •D complee Seoction4.)
MM DD YYYY
Isotope (e.g. AM241)
1 CS137
2
3
4
5
6
Activity (e.g. 100)
100.000000000
Unit (e.g. mCi)
mCi
EmDDEEWDDEDDEDDE
A A
GL-705530-20
11/03/2015 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2
Our records indicate that you have these devices. Please update the information as necessary. PAGE 9 of 14
NRC Device Key 667440 (Internal Control Number)
Distributor/Distributed By: KAY-RAY/SENSALL, INC.
I I I I L I
Distributor License Number: IL-Ol1010-02
Manufacturer Name: KAY-RAY/SENSALL, INC.
Device Model (Not Source Model): 7062BP
Device Serial Number: $00C1301
Transfer Date (Receipt Date): 03/16/2000L___• •-• •Not in possession of device (Also
[]complete Section 4.)
MM DD YYYY
Isotope (e.g. AM241) Activity (e.g. 100) Unit (e.g. mCi)
1 CS137
2
3
4
5 zww6 Dfflw
A
100.0000000Imi WEWEWEWEWEWE
A
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Our records indicate that you have these devices. Please update the information as necessary. PAGE 10 of 14
NRC Device Key 667442 (Internal Control Number)
Distributor/Distributed By: KAY-RAY/SENSALL, INC.
Distributor License Number: IL-01010-02
Manufacturer Name:
Device Model (Not Source Model): 7063P
Device Serial Number: S00D2703
Transfer Date (Receipt Date): 05/1 5/2000• __J • • • • L•Not in possession of device (Also
D] complete Section 4.)
MM DD YYYY
Isotope (e.g. AM241) Activity (e.g. 100) Unit (e.g. mCi)
1 CS137 200.000000000
2
3
~ii
4
5
6
,A
mCi
DiiDiiDiiDiiDiiDii
A
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11/03/2015 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2Our records indicate that you have these devices. Please update the information as necessary. PAGE 11 of 14
NRC Device Key 667443 (Internal Control Number) 4,=--
Distributor/Distributed By: KAY-RAY/SENSALL, INC.
Distributor License Number: IL-O01010-02
Manufacturer Name: KAY-RAY/SENSALL, INC.
Device Model (Not Source Model): 7062BP
Device Serial Number: B79
Transfer Date (Receipt Date): 03/22/2001• ._j _• •Not in possession of device (AlsoLII complete Section 4.)
MM DD YYYY
Isotope (e.g. AM241) Activity (e.g. 100) Unit (e.g. mCi)
1 0S137 100.000000000
2
3
4
5
6
mCi
DiiDiiDiiDiiDiiDiD
A
GL-705530-20*11/03/2015 SECTION 2 - DEVICES SUBJECT TO REGISTRATION
Our records indicate that you have these devices. Please update the information as necessary.
NRC Device Key 730961 (Internal Control Number)
Distributor/Distributed By: TH-ERMO FISCHER SCIENTIFIC
Distributor License Number: L03524
Manufacturer Name: THERMO MEASURETECH
Device Model (Not Source Model): 7062BP
Device Serial Number: $97G0801
Transfer Date (Receipt Date): 05/25/2004I I I •Not in possession of de
El complete Section 4.)
MM DD YYYY
IIIIIIIIII iIIIIII IISECTION 2
PAGE 12 of 14
]
]
]
.vice (Also
Isotope (e.g. AM241 )
1 CS137
2
3
4
5
6
Activity (e.g. 100)
50.000000000
Unit (e.g. mCi)
mCi
WEL
WEU
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Our records indicate that you have these devices. Please update the information as necessary. PAGE 13 of 14
NRC Device Key 730962 (Internal Control Number)
Distributor/Distributed By: THERMO FISCHER SCIENTIFIC
Distributor License Number: L03524
Manufacturer Name: THERMO MEASURETECH
Device Model (Not Source Model): 7062BP
Device Serial Number: $98F2509
Transfer Date (Receipt Date): 05/25/2004[ • Not in possession of device (Also
D] complete Section 4.)
MM DD YYYY
Isotope (e.g. AM241) Activity (e.g. 100) Unit (e.g. mCi)
1 CS137 50.000000000 mCi
2
3
4
5
6
A
WirDiiI
Diil
A
GL-705530-20
11/03/2015 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 14
NRC Device Key 722825 (Internal Control Number)
Distributor/Distributed By: TH ERMO FISCH ER SCIENTI FIC
Distributor License Number: L03524
Manufacturer Name: TH ERMO MEASURETECH
Device Model (Not Source Model): 5202"
Device Serial Number: B2798
Transfer Date (Receipt Date): 12/15/2004I I LN ot in possesson ofdevie,(Also
D] complete Section 4.)
•MM DD YYYY
Isotope (e.g. AM241) Activity (e.g. 100) Unit (e.g. mCi)
1 CS137
2
4
5
6
A
200.000000000mi
DiiDiiDiiDiiiDiDii
A
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SECTION 3 - ADDITIONAL DEVICES SUBJECT TO REGISTRATION PAGE 1 of 1Provide information about other devices you have that are subject to registration. Do not report specifically licensed devices.
Manufacturer Name
Initial Transferor Name
Initial Transferor License Number (if known)
Device Model Number (Not Source Modei)
Device Serial Number
II
I
0 Manufacturer/initial Transferor listed aboveHow acquired and date (e.g.,from a distributor/manufacturer, 0 Other General Licensee Date Transferred: L71_J L i K ulhi
oteOiese ohrsuc) Other Source (Received) MM DD YYYY
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Isotope (e.g. AM241 )
W~IE
KKKKKKKK
Activity (e.g. 100)
I I I I
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Activity (e.g. 100)
I I I
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wIEDlIIIIEDIIDEDlEDI
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I I
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ilIIIIII
LIIIIIII
Unit (e.g. mCi)
WELWDIDLWWEWEWEWEWEWE
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I I I I
I I I I I I
I I I [
I I [ I I I
I I Im I I I I I
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GL-705530-20 SECTION 4 - NOT IN POSSESSION OF DEVICE SECTION 41110312015Provide information about devices listed in Section 2 or 6, but no longer in your possession. PAGE 1 of 1
Part 1 Transfer Date:
NRC Device Key: _ L L•
(from Section 2 or 6) E D WlMM DD YYYY
Location of the Device:
O Whereabouts Unknown (complete Part 1 only) 0 Transferred to another general licensee (complete Parts 2 and 3)
o Never Possessed the Device (complete Part 1 only) 0 Transferred to a Specific Licensee (Not the manufacturer)
O Returned to Manufacturer (complete Part 1 only) (complete Part 2)
Part 2 License Number of Recipient (if transferred to a specific licensee):
Company Name:
Department:
Adrs Line 1:
Address Line 2:
City:
State: Zip Code: WIDE - EEPart 3 Enter the name of the individual responsible for this device:
Last Name:
First Name: Middle Initial:
Title:
A A
I11111111IIi]llIIIIIIIII Oi i Ii 11111l11111II1011I1I11 II111I11 liiii11IIIIIIIIII 1110111IGL-705530-20 SECTION 5 - CERTIFICATION SECTION 511/03/2015 PAGE 1 of 1
I hereby certify that:
A. All information contained in this registration is true and complete to the best of my knowledge and belief.
B. A physical inventory of the devices subject to registration has been completed, and the device information on
this form has been checked against the device labeling.
C. I am aware of the requirements of the general license, provided in 10 CFR 31.5.(Copies of pl ble regul tor s may be viewed at the NRC websiteat
http/ .n v/e in r oc-o oscr
SIGNATURE - E-SPONS L INDIVIDUAL (Listed in Section 1) DATE
WARNING: FALSE STATEMENTS MAY BE SUBJECT TO CIVILAND/OR CRIMINAL PENALTIES. NRC
REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRC BE COMPLETE AND ACCURATE IN ALL
MATERIALASPECTS. 18 U.S.C. SECTION 1001 MAKES ITA CRIMINAL OFFENSE TO MAKEAWILLFULLY
WRONG STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED
STATES AS TO ANY MATTER IN ITS JURISDICTION.
A A
GL-705530-20
11/03/2015 SECTION 6 - DEVICES NOT SUBJECT TO REGISTRATION SECTION 6
PAGE 1 of I
NRC Device Key: Manufacturer License No:
Manufacturer Name:
Model Number: Serial #: Transfer Date: