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MONROE IWI HOSPITAL
Materials Licensing Branch Nuclear Regulatory Commission Region III 2443 Warrenville Road Lisle Illinois 60532-4351
RE NRC License Number 13-32773-01
Gentleman
In accordance with 10 CFR 3513 and 10 CFR 3514 we are providing this notification of physician authorized user changes that were effective 1anuary 1 2013
1 The following authorized users have been added to NRC License No 13-32773-01 (Monroe Hospital) for 35100 and 35200 material and use
Gregory Sutliff MD lennifer Peterson-Goldspiel MD
These physicians are currently listed as authorized users for 35100 and 35200 material and use on Premier Healthcare NRC License No 13-32020-01 (attached)
2 The following authorized user has been added to NRC License No 13-32773-01 (Monroe Hospital) for 35100 material and uses
Andrew D Ferguson MD
Dr Ferguson is currently listed as an authorized user for 35100 material and use on Premier Healthcare NRC License No 13-32020-01 (attached)
3 The following authorized user has been added to NRC License No 13-32773-01 (Monroe Hospital) for 35200 material uses
Eric Williams MD
Dr Williams is currently listed as an authorized user for 35200 material and use on Premier Healthcare NRC License No 13-32020-01 (attached)
RECEIVED FEB 2 1 21113
Thank you for your consideration If you have any questions regarding this information please contact the Monroe Radiation Safety Officer Robert T Anger Jr MS (317-370-2750)
Sincerely
Ashley Everett Cardiopulmonary Manager
Enclosure Premier Healthcare LLC NRC License No 13-32020-01
2013-01-17 0831 PREMIER CVT 8123556916 raquo P 23
NRC FORM 374 PAGE OF ~ PAGES
US NUCLEAR REGULATORY COMMISSION Amendment No 13
MATERIALS LICENSE Pursuant to the Atomic Energy Act of 1954 85 amended the Energy Reorganlzltltlon Act of 1974 (Public Law 93-438) and Title 10 Code of Federal Regulations Chapter 1 Parts 30 31 32 33 34 35 36 39 40 and 70 and in reliance on statements and representations heretofore made by the licensee a license is hereby issued authorizing the licensee to receive acquire possess and transfer byproduct source and special nuclear material designated below to use such material for the purpose(s) end at the place(s) designated below to deliver or transfer such material to persons authorized to receive it in accordance with the regulations of the applicable Part(s) (his license shall be deemed to contain the conditions speclfled 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 Regulatory Commission now or hereafter In effect and to any conditions specified below
Licensee middot
1 Premier Healthcare LLC
2 550 Landmark Avenue
SloomingtonIN 47403
In accordance with application dated April 10 2012 3 License number 13-32020-01 is renewed in its entirety to read as followsmiddot
4 Expiration date October 31 2022
5 Docket No 030-34523 Reference No
6 Syproduct source andor special nuclear material
7 Chemical andor physi~1 form 8 Maximum amount that licensee may possess at anyone time under this
license bulllt_
A Any byproduct materia middot permitted by 10 CFFlt 3~1 OO~
A Any
-~
-A As needed
B Any byproduct material-
bull B A6y
_ B As needed
permitted by 10 CFR 35200
- shyC Gadolinium-153 permitted bi
C middotmiddotSealedsourcesmiddot middot
C Not to exceed 40 millicuries 10 CFFlt 35500
-(ADAC Laboratories a Philips Medical Systems CompanYi Isotope Productsmiddotmiddot Laboratories Modelmiddot
No NES8497)
per source total possession not to exceed 1000 millicuries
9 Authorized use
~
A Any uptake dilution and excretion studypermitted by 10 CFR 35100 _ -
S Any imaging and localization study permitted by 10 CFR 35200
C Diagnostic memiddotdical use of sealed sources permitted by 10 CFR 35500 in an AOAC Laboratories CardioMD-AC attenuation cor~ection device shy
CONDITIONS
10 Licensed material may be used or stored only at the licensees facilities located at 550 Landmark Avenue Bloomington Indiana
11 The Radiation Safety Officer for this license is Gregory M Sutliff MD
2013-01-17 0831 PREMIER CVT 8123556916 raquo P 33
NRC FORM 374A US NUCLEAR REGULATORY COMMISSION PAGE 2 of 2 PAGES
Liconse Number 13-32020-01
MATERIALS LICENSE SUPPLEMENTARY SHEEr
Docket or Roforonco Number 030-34523
Amendment No 13
12 Licensed material is only authorized for use by or under the supervision of
A Individuals permitted to work as an authorized user in accordance with 10 CFR 3513 and 3514
B The following individuals are authorized users for medical use as indicated
Authorized Users
Gregory M Sutliff MD 10 CFR 35100 and 35200
Jennifer Petersen-Goldspiel MD 10 CFR 35100 and 35200
Louis~e Annette Alpert MD 10 CFR 35100 and 35200
AndrewD Ferguson MD 10 CFR 35100
Eric Williams IVI D 10 CFR 35200
13 In addtion to the possessior1 limits in Item 8 the licensee shall further restrict the possessionoflicensed material to quantities below the minimum limit specrried in 10 CFR 3035(d)forestablishing decommissioning financial assurance
-_
14 Sealed sources containing licensed material~~ll notbe opened by thelice~see
15 The licensee is authorized to transport licensed material in accordancelwithmiddotthe provisions of 10 CFR Part 71 Packagi~g and Transportati9n ~f Radioactive Materi~ll~middot
- middote_ middotmiddot - -
16 Except as specifically provided otherWise In this license the licensee s~all conduct its program in accordance with the statements representations and procedures contained in the documents including
any enclosures listedbelow This license condition applies only to those procedures that are required to be submitted in accordance with the regulations Additionallythfs license condition does not limitthe licensees ability to make changes to the radiation protection program as provided for in 1 0 CFR~526 The U8 NuclearRegulatory Commissions regulations shall govern unless the statements represeTtations middotand procedures inthe icel)sees application and correspondence are more restrictive than the regulations -
A Appl ication dated April 10 2012 and I I
~-
B Letter dated August 15 2012
FOR THE US NUCLEAR REGULATORY COMMISSION
-shy
Sf 2 4 ZD12 Date ________ - B~i~~i~~-J
Materials Licensing Branch Region III
2013-01-17 0831 PREMIER CVT 8123556916 raquo P 23
NRC FORM 374 PAGE 1 OF -Z- PAGES
US NUCLEAR REGULATORY COMMISSION Amendment No 13
MATERIALS LICENSE Pursuant to the Atomic Energy Act of 1954 as amended the Energy Reorganization Act of 1974 (Public Law 93438) and Title 10 Code of Federal Regulations Chapter I Parts 30 31 32 33 34 35 36 39 40 and 70 and in reliance on statements and representations heretofore made by the licensee a license is hereby issued authorizing the licensee to receive acquire possess and transfer byproduct source and special 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 to persons authorized to receive it in accordance with the regulations of the applicable Part(s) (his license shall be deemed to contain the conditions speclf1ed 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 Regulatory Commission now or hereafter In effect and to any conditions specified below
Licensee
1 Premier Healthcare~ LLC
2 550 Landmark Avenue
Bloomington IN 47403
In accordance with application dated April 10 2012 3 License number 13-32020-01 is renewed in its entirety to read as follows
4 Expiration date October 31 2022
5 Docket No 030-34523 Reference No
6 Byproduct source andor special nuclear material
7 Chemical andor physical form 8 Maximum amount that licensee may possess at anyone time under this
license middotmiddot
A Ariy byproduct material permitted by 10 CFR 35100
A Any ~
~ -A middot As needed
S Any byproduct material~
permitted by 10 CFR 35200 B Any
S As needed
shy
C Gadolinium-153 permitted by
CSealedsources
C Not to exceed 40 millicuries 10 CFR 35500
(ADAC Laboratories a Phifips Medical Systems Company Isotope Products Laboratories Model
per source total possession not to exceed 1000 millicuries
No NES8497)
9 Authorized use
~
A Any uptake dilution and excretion studYpermitted by 10 CFR 35100 _
B Any imaging and localization study permitted by 10 CFR 35200
C Diagnostic medical use of seaJed sources permitted by 10 CFR 35500 in an ADAC Laboratories CardioMD-AC attenuation corraction device
CONDITIONS
10 Licensed material may be used or stored only at the licensees facilities located at 550 Landmark Avenue Bloomington Indiana
11 The Radiation Safety Officer for this license is Gregory M Sutliff M D
2013-01-17 0831 PREMIER CVT 8123556916 raquo P 33
NRC FORM 374A US NUCLEAR REGUlATORY COMMISSION PAGE 2 of 2 PAGES
License Number 13-32020-01
MATERIALS LICENSE SUPPLEMENTARY SHEEr
Docket or Reference Number 030-34523
Amendment No 13
12 Licensed material is only authorized for use by or under the supervision of
A Individuals permitted to work as an authorized user in accordance with 10 CFR 3513 and 3514
B The following individuals are authorized users for medicaluse as indicated
Authorized Users - Materfal and Use
Gregory M $utliffM D 10 CFR 35100 and 35200
Jennifer Petersen-Goldspiel MD 10 CFR 35100 and 35200
Louise Annette Alpert MD 10 CFR 35100 and 35200
AndrewD Ferguson MD 10 CFR 35100
Eric Williams MD 10 CFR 35200 I bull bull bull
13 In addJtion to the posseSSion limits in Item 8 the licensee shall further restrict the possessionoflicensed material to quantities below-the minimum limit specified in 10 CFR 3035(d)for establishing decommiSSioning financial assurance
--~ - ~ - -
14 Sealed sources containing licensed materiaLsfla11 not be opened by thEilicensee
15 The licensee is authorized to transport licensed material in accordance with the provisions of 10 CF~ Part 71 Packagi~g an~d Transportati~n C)f Radioactive Materf~il~
- bull ~ ishy
16 Except as specifically provided ~the~ise in this license the licenseeshall conduct its program in accordance with the statements representations and procedures contained in the documents including
any enclosures listed below This license condition applies only tothose procedures that are required to be submitted in accordance with the regulations Additionallythfs license conditjor) does not limiUhe licensees ability tomake changes to the radiation protection program as provided for in 10 CFR3526 The US NuclearRegulatory Commissions regulations shall govern unless the statements representations and procedures intheJiceosees appicati~m and correspondence are more restrictive than the regulations bull -
A Appliction dated April 10 2012 and - shy
B Letter dated August 15 2012
FO~ THE US NUCLEAR REGULATORY COMMISSION
Materials Licensing Branch Region III
SEP 2 4 Z012 Date _______________
Thank you for your consideration If you have any questions regarding this information please contact the Monroe Radiation Safety Officer Robert T Anger Jr MS (317-370-2750)
Sincerely
Ashley Everett Cardiopulmonary Manager
Enclosure Premier Healthcare LLC NRC License No 13-32020-01
2013-01-17 0831 PREMIER CVT 8123556916 raquo P 23
NRC FORM 374 PAGE OF ~ PAGES
US NUCLEAR REGULATORY COMMISSION Amendment No 13
MATERIALS LICENSE Pursuant to the Atomic Energy Act of 1954 85 amended the Energy Reorganlzltltlon Act of 1974 (Public Law 93-438) and Title 10 Code of Federal Regulations Chapter 1 Parts 30 31 32 33 34 35 36 39 40 and 70 and in reliance on statements and representations heretofore made by the licensee a license is hereby issued authorizing the licensee to receive acquire possess and transfer byproduct source and special nuclear material designated below to use such material for the purpose(s) end at the place(s) designated below to deliver or transfer such material to persons authorized to receive it in accordance with the regulations of the applicable Part(s) (his license shall be deemed to contain the conditions speclfled 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 Regulatory Commission now or hereafter In effect and to any conditions specified below
Licensee middot
1 Premier Healthcare LLC
2 550 Landmark Avenue
SloomingtonIN 47403
In accordance with application dated April 10 2012 3 License number 13-32020-01 is renewed in its entirety to read as followsmiddot
4 Expiration date October 31 2022
5 Docket No 030-34523 Reference No
6 Syproduct source andor special nuclear material
7 Chemical andor physi~1 form 8 Maximum amount that licensee may possess at anyone time under this
license bulllt_
A Any byproduct materia middot permitted by 10 CFFlt 3~1 OO~
A Any
-~
-A As needed
B Any byproduct material-
bull B A6y
_ B As needed
permitted by 10 CFR 35200
- shyC Gadolinium-153 permitted bi
C middotmiddotSealedsourcesmiddot middot
C Not to exceed 40 millicuries 10 CFFlt 35500
-(ADAC Laboratories a Philips Medical Systems CompanYi Isotope Productsmiddotmiddot Laboratories Modelmiddot
No NES8497)
per source total possession not to exceed 1000 millicuries
9 Authorized use
~
A Any uptake dilution and excretion studypermitted by 10 CFR 35100 _ -
S Any imaging and localization study permitted by 10 CFR 35200
C Diagnostic memiddotdical use of sealed sources permitted by 10 CFR 35500 in an AOAC Laboratories CardioMD-AC attenuation cor~ection device shy
CONDITIONS
10 Licensed material may be used or stored only at the licensees facilities located at 550 Landmark Avenue Bloomington Indiana
11 The Radiation Safety Officer for this license is Gregory M Sutliff MD
2013-01-17 0831 PREMIER CVT 8123556916 raquo P 33
NRC FORM 374A US NUCLEAR REGULATORY COMMISSION PAGE 2 of 2 PAGES
Liconse Number 13-32020-01
MATERIALS LICENSE SUPPLEMENTARY SHEEr
Docket or Roforonco Number 030-34523
Amendment No 13
12 Licensed material is only authorized for use by or under the supervision of
A Individuals permitted to work as an authorized user in accordance with 10 CFR 3513 and 3514
B The following individuals are authorized users for medical use as indicated
Authorized Users
Gregory M Sutliff MD 10 CFR 35100 and 35200
Jennifer Petersen-Goldspiel MD 10 CFR 35100 and 35200
Louis~e Annette Alpert MD 10 CFR 35100 and 35200
AndrewD Ferguson MD 10 CFR 35100
Eric Williams IVI D 10 CFR 35200
13 In addtion to the possessior1 limits in Item 8 the licensee shall further restrict the possessionoflicensed material to quantities below the minimum limit specrried in 10 CFR 3035(d)forestablishing decommissioning financial assurance
-_
14 Sealed sources containing licensed material~~ll notbe opened by thelice~see
15 The licensee is authorized to transport licensed material in accordancelwithmiddotthe provisions of 10 CFR Part 71 Packagi~g and Transportati9n ~f Radioactive Materi~ll~middot
- middote_ middotmiddot - -
16 Except as specifically provided otherWise In this license the licensee s~all conduct its program in accordance with the statements representations and procedures contained in the documents including
any enclosures listedbelow This license condition applies only to those procedures that are required to be submitted in accordance with the regulations Additionallythfs license condition does not limitthe licensees ability to make changes to the radiation protection program as provided for in 1 0 CFR~526 The U8 NuclearRegulatory Commissions regulations shall govern unless the statements represeTtations middotand procedures inthe icel)sees application and correspondence are more restrictive than the regulations -
A Appl ication dated April 10 2012 and I I
~-
B Letter dated August 15 2012
FOR THE US NUCLEAR REGULATORY COMMISSION
-shy
Sf 2 4 ZD12 Date ________ - B~i~~i~~-J
Materials Licensing Branch Region III
2013-01-17 0831 PREMIER CVT 8123556916 raquo P 23
NRC FORM 374 PAGE 1 OF -Z- PAGES
US NUCLEAR REGULATORY COMMISSION Amendment No 13
MATERIALS LICENSE Pursuant to the Atomic Energy Act of 1954 as amended the Energy Reorganization Act of 1974 (Public Law 93438) and Title 10 Code of Federal Regulations Chapter I Parts 30 31 32 33 34 35 36 39 40 and 70 and in reliance on statements and representations heretofore made by the licensee a license is hereby issued authorizing the licensee to receive acquire possess and transfer byproduct source and special 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 to persons authorized to receive it in accordance with the regulations of the applicable Part(s) (his license shall be deemed to contain the conditions speclf1ed 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 Regulatory Commission now or hereafter In effect and to any conditions specified below
Licensee
1 Premier Healthcare~ LLC
2 550 Landmark Avenue
Bloomington IN 47403
In accordance with application dated April 10 2012 3 License number 13-32020-01 is renewed in its entirety to read as follows
4 Expiration date October 31 2022
5 Docket No 030-34523 Reference No
6 Byproduct source andor special nuclear material
7 Chemical andor physical form 8 Maximum amount that licensee may possess at anyone time under this
license middotmiddot
A Ariy byproduct material permitted by 10 CFR 35100
A Any ~
~ -A middot As needed
S Any byproduct material~
permitted by 10 CFR 35200 B Any
S As needed
shy
C Gadolinium-153 permitted by
CSealedsources
C Not to exceed 40 millicuries 10 CFR 35500
(ADAC Laboratories a Phifips Medical Systems Company Isotope Products Laboratories Model
per source total possession not to exceed 1000 millicuries
No NES8497)
9 Authorized use
~
A Any uptake dilution and excretion studYpermitted by 10 CFR 35100 _
B Any imaging and localization study permitted by 10 CFR 35200
C Diagnostic medical use of seaJed sources permitted by 10 CFR 35500 in an ADAC Laboratories CardioMD-AC attenuation corraction device
CONDITIONS
10 Licensed material may be used or stored only at the licensees facilities located at 550 Landmark Avenue Bloomington Indiana
11 The Radiation Safety Officer for this license is Gregory M Sutliff M D
2013-01-17 0831 PREMIER CVT 8123556916 raquo P 33
NRC FORM 374A US NUCLEAR REGUlATORY COMMISSION PAGE 2 of 2 PAGES
License Number 13-32020-01
MATERIALS LICENSE SUPPLEMENTARY SHEEr
Docket or Reference Number 030-34523
Amendment No 13
12 Licensed material is only authorized for use by or under the supervision of
A Individuals permitted to work as an authorized user in accordance with 10 CFR 3513 and 3514
B The following individuals are authorized users for medicaluse as indicated
Authorized Users - Materfal and Use
Gregory M $utliffM D 10 CFR 35100 and 35200
Jennifer Petersen-Goldspiel MD 10 CFR 35100 and 35200
Louise Annette Alpert MD 10 CFR 35100 and 35200
AndrewD Ferguson MD 10 CFR 35100
Eric Williams MD 10 CFR 35200 I bull bull bull
13 In addJtion to the posseSSion limits in Item 8 the licensee shall further restrict the possessionoflicensed material to quantities below-the minimum limit specified in 10 CFR 3035(d)for establishing decommiSSioning financial assurance
--~ - ~ - -
14 Sealed sources containing licensed materiaLsfla11 not be opened by thEilicensee
15 The licensee is authorized to transport licensed material in accordance with the provisions of 10 CF~ Part 71 Packagi~g an~d Transportati~n C)f Radioactive Materf~il~
- bull ~ ishy
16 Except as specifically provided ~the~ise in this license the licenseeshall conduct its program in accordance with the statements representations and procedures contained in the documents including
any enclosures listed below This license condition applies only tothose procedures that are required to be submitted in accordance with the regulations Additionallythfs license conditjor) does not limiUhe licensees ability tomake changes to the radiation protection program as provided for in 10 CFR3526 The US NuclearRegulatory Commissions regulations shall govern unless the statements representations and procedures intheJiceosees appicati~m and correspondence are more restrictive than the regulations bull -
A Appliction dated April 10 2012 and - shy
B Letter dated August 15 2012
FO~ THE US NUCLEAR REGULATORY COMMISSION
Materials Licensing Branch Region III
SEP 2 4 Z012 Date _______________
2013-01-17 0831 PREMIER CVT 8123556916 raquo P 23
NRC FORM 374 PAGE OF ~ PAGES
US NUCLEAR REGULATORY COMMISSION Amendment No 13
MATERIALS LICENSE Pursuant to the Atomic Energy Act of 1954 85 amended the Energy Reorganlzltltlon Act of 1974 (Public Law 93-438) and Title 10 Code of Federal Regulations Chapter 1 Parts 30 31 32 33 34 35 36 39 40 and 70 and in reliance on statements and representations heretofore made by the licensee a license is hereby issued authorizing the licensee to receive acquire possess and transfer byproduct source and special nuclear material designated below to use such material for the purpose(s) end at the place(s) designated below to deliver or transfer such material to persons authorized to receive it in accordance with the regulations of the applicable Part(s) (his license shall be deemed to contain the conditions speclfled 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 Regulatory Commission now or hereafter In effect and to any conditions specified below
Licensee middot
1 Premier Healthcare LLC
2 550 Landmark Avenue
SloomingtonIN 47403
In accordance with application dated April 10 2012 3 License number 13-32020-01 is renewed in its entirety to read as followsmiddot
4 Expiration date October 31 2022
5 Docket No 030-34523 Reference No
6 Syproduct source andor special nuclear material
7 Chemical andor physi~1 form 8 Maximum amount that licensee may possess at anyone time under this
license bulllt_
A Any byproduct materia middot permitted by 10 CFFlt 3~1 OO~
A Any
-~
-A As needed
B Any byproduct material-
bull B A6y
_ B As needed
permitted by 10 CFR 35200
- shyC Gadolinium-153 permitted bi
C middotmiddotSealedsourcesmiddot middot
C Not to exceed 40 millicuries 10 CFFlt 35500
-(ADAC Laboratories a Philips Medical Systems CompanYi Isotope Productsmiddotmiddot Laboratories Modelmiddot
No NES8497)
per source total possession not to exceed 1000 millicuries
9 Authorized use
~
A Any uptake dilution and excretion studypermitted by 10 CFR 35100 _ -
S Any imaging and localization study permitted by 10 CFR 35200
C Diagnostic memiddotdical use of sealed sources permitted by 10 CFR 35500 in an AOAC Laboratories CardioMD-AC attenuation cor~ection device shy
CONDITIONS
10 Licensed material may be used or stored only at the licensees facilities located at 550 Landmark Avenue Bloomington Indiana
11 The Radiation Safety Officer for this license is Gregory M Sutliff MD
2013-01-17 0831 PREMIER CVT 8123556916 raquo P 33
NRC FORM 374A US NUCLEAR REGULATORY COMMISSION PAGE 2 of 2 PAGES
Liconse Number 13-32020-01
MATERIALS LICENSE SUPPLEMENTARY SHEEr
Docket or Roforonco Number 030-34523
Amendment No 13
12 Licensed material is only authorized for use by or under the supervision of
A Individuals permitted to work as an authorized user in accordance with 10 CFR 3513 and 3514
B The following individuals are authorized users for medical use as indicated
Authorized Users
Gregory M Sutliff MD 10 CFR 35100 and 35200
Jennifer Petersen-Goldspiel MD 10 CFR 35100 and 35200
Louis~e Annette Alpert MD 10 CFR 35100 and 35200
AndrewD Ferguson MD 10 CFR 35100
Eric Williams IVI D 10 CFR 35200
13 In addtion to the possessior1 limits in Item 8 the licensee shall further restrict the possessionoflicensed material to quantities below the minimum limit specrried in 10 CFR 3035(d)forestablishing decommissioning financial assurance
-_
14 Sealed sources containing licensed material~~ll notbe opened by thelice~see
15 The licensee is authorized to transport licensed material in accordancelwithmiddotthe provisions of 10 CFR Part 71 Packagi~g and Transportati9n ~f Radioactive Materi~ll~middot
- middote_ middotmiddot - -
16 Except as specifically provided otherWise In this license the licensee s~all conduct its program in accordance with the statements representations and procedures contained in the documents including
any enclosures listedbelow This license condition applies only to those procedures that are required to be submitted in accordance with the regulations Additionallythfs license condition does not limitthe licensees ability to make changes to the radiation protection program as provided for in 1 0 CFR~526 The U8 NuclearRegulatory Commissions regulations shall govern unless the statements represeTtations middotand procedures inthe icel)sees application and correspondence are more restrictive than the regulations -
A Appl ication dated April 10 2012 and I I
~-
B Letter dated August 15 2012
FOR THE US NUCLEAR REGULATORY COMMISSION
-shy
Sf 2 4 ZD12 Date ________ - B~i~~i~~-J
Materials Licensing Branch Region III
2013-01-17 0831 PREMIER CVT 8123556916 raquo P 23
NRC FORM 374 PAGE 1 OF -Z- PAGES
US NUCLEAR REGULATORY COMMISSION Amendment No 13
MATERIALS LICENSE Pursuant to the Atomic Energy Act of 1954 as amended the Energy Reorganization Act of 1974 (Public Law 93438) and Title 10 Code of Federal Regulations Chapter I Parts 30 31 32 33 34 35 36 39 40 and 70 and in reliance on statements and representations heretofore made by the licensee a license is hereby issued authorizing the licensee to receive acquire possess and transfer byproduct source and special 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 to persons authorized to receive it in accordance with the regulations of the applicable Part(s) (his license shall be deemed to contain the conditions speclf1ed 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 Regulatory Commission now or hereafter In effect and to any conditions specified below
Licensee
1 Premier Healthcare~ LLC
2 550 Landmark Avenue
Bloomington IN 47403
In accordance with application dated April 10 2012 3 License number 13-32020-01 is renewed in its entirety to read as follows
4 Expiration date October 31 2022
5 Docket No 030-34523 Reference No
6 Byproduct source andor special nuclear material
7 Chemical andor physical form 8 Maximum amount that licensee may possess at anyone time under this
license middotmiddot
A Ariy byproduct material permitted by 10 CFR 35100
A Any ~
~ -A middot As needed
S Any byproduct material~
permitted by 10 CFR 35200 B Any
S As needed
shy
C Gadolinium-153 permitted by
CSealedsources
C Not to exceed 40 millicuries 10 CFR 35500
(ADAC Laboratories a Phifips Medical Systems Company Isotope Products Laboratories Model
per source total possession not to exceed 1000 millicuries
No NES8497)
9 Authorized use
~
A Any uptake dilution and excretion studYpermitted by 10 CFR 35100 _
B Any imaging and localization study permitted by 10 CFR 35200
C Diagnostic medical use of seaJed sources permitted by 10 CFR 35500 in an ADAC Laboratories CardioMD-AC attenuation corraction device
CONDITIONS
10 Licensed material may be used or stored only at the licensees facilities located at 550 Landmark Avenue Bloomington Indiana
11 The Radiation Safety Officer for this license is Gregory M Sutliff M D
2013-01-17 0831 PREMIER CVT 8123556916 raquo P 33
NRC FORM 374A US NUCLEAR REGUlATORY COMMISSION PAGE 2 of 2 PAGES
License Number 13-32020-01
MATERIALS LICENSE SUPPLEMENTARY SHEEr
Docket or Reference Number 030-34523
Amendment No 13
12 Licensed material is only authorized for use by or under the supervision of
A Individuals permitted to work as an authorized user in accordance with 10 CFR 3513 and 3514
B The following individuals are authorized users for medicaluse as indicated
Authorized Users - Materfal and Use
Gregory M $utliffM D 10 CFR 35100 and 35200
Jennifer Petersen-Goldspiel MD 10 CFR 35100 and 35200
Louise Annette Alpert MD 10 CFR 35100 and 35200
AndrewD Ferguson MD 10 CFR 35100
Eric Williams MD 10 CFR 35200 I bull bull bull
13 In addJtion to the posseSSion limits in Item 8 the licensee shall further restrict the possessionoflicensed material to quantities below-the minimum limit specified in 10 CFR 3035(d)for establishing decommiSSioning financial assurance
--~ - ~ - -
14 Sealed sources containing licensed materiaLsfla11 not be opened by thEilicensee
15 The licensee is authorized to transport licensed material in accordance with the provisions of 10 CF~ Part 71 Packagi~g an~d Transportati~n C)f Radioactive Materf~il~
- bull ~ ishy
16 Except as specifically provided ~the~ise in this license the licenseeshall conduct its program in accordance with the statements representations and procedures contained in the documents including
any enclosures listed below This license condition applies only tothose procedures that are required to be submitted in accordance with the regulations Additionallythfs license conditjor) does not limiUhe licensees ability tomake changes to the radiation protection program as provided for in 10 CFR3526 The US NuclearRegulatory Commissions regulations shall govern unless the statements representations and procedures intheJiceosees appicati~m and correspondence are more restrictive than the regulations bull -
A Appliction dated April 10 2012 and - shy
B Letter dated August 15 2012
FO~ THE US NUCLEAR REGULATORY COMMISSION
Materials Licensing Branch Region III
SEP 2 4 Z012 Date _______________
2013-01-17 0831 PREMIER CVT 8123556916 raquo P 33
NRC FORM 374A US NUCLEAR REGULATORY COMMISSION PAGE 2 of 2 PAGES
Liconse Number 13-32020-01
MATERIALS LICENSE SUPPLEMENTARY SHEEr
Docket or Roforonco Number 030-34523
Amendment No 13
12 Licensed material is only authorized for use by or under the supervision of
A Individuals permitted to work as an authorized user in accordance with 10 CFR 3513 and 3514
B The following individuals are authorized users for medical use as indicated
Authorized Users
Gregory M Sutliff MD 10 CFR 35100 and 35200
Jennifer Petersen-Goldspiel MD 10 CFR 35100 and 35200
Louis~e Annette Alpert MD 10 CFR 35100 and 35200
AndrewD Ferguson MD 10 CFR 35100
Eric Williams IVI D 10 CFR 35200
13 In addtion to the possessior1 limits in Item 8 the licensee shall further restrict the possessionoflicensed material to quantities below the minimum limit specrried in 10 CFR 3035(d)forestablishing decommissioning financial assurance
-_
14 Sealed sources containing licensed material~~ll notbe opened by thelice~see
15 The licensee is authorized to transport licensed material in accordancelwithmiddotthe provisions of 10 CFR Part 71 Packagi~g and Transportati9n ~f Radioactive Materi~ll~middot
- middote_ middotmiddot - -
16 Except as specifically provided otherWise In this license the licensee s~all conduct its program in accordance with the statements representations and procedures contained in the documents including
any enclosures listedbelow This license condition applies only to those procedures that are required to be submitted in accordance with the regulations Additionallythfs license condition does not limitthe licensees ability to make changes to the radiation protection program as provided for in 1 0 CFR~526 The U8 NuclearRegulatory Commissions regulations shall govern unless the statements represeTtations middotand procedures inthe icel)sees application and correspondence are more restrictive than the regulations -
A Appl ication dated April 10 2012 and I I
~-
B Letter dated August 15 2012
FOR THE US NUCLEAR REGULATORY COMMISSION
-shy
Sf 2 4 ZD12 Date ________ - B~i~~i~~-J
Materials Licensing Branch Region III
2013-01-17 0831 PREMIER CVT 8123556916 raquo P 23
NRC FORM 374 PAGE 1 OF -Z- PAGES
US NUCLEAR REGULATORY COMMISSION Amendment No 13
MATERIALS LICENSE Pursuant to the Atomic Energy Act of 1954 as amended the Energy Reorganization Act of 1974 (Public Law 93438) and Title 10 Code of Federal Regulations Chapter I Parts 30 31 32 33 34 35 36 39 40 and 70 and in reliance on statements and representations heretofore made by the licensee a license is hereby issued authorizing the licensee to receive acquire possess and transfer byproduct source and special 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 to persons authorized to receive it in accordance with the regulations of the applicable Part(s) (his license shall be deemed to contain the conditions speclf1ed 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 Regulatory Commission now or hereafter In effect and to any conditions specified below
Licensee
1 Premier Healthcare~ LLC
2 550 Landmark Avenue
Bloomington IN 47403
In accordance with application dated April 10 2012 3 License number 13-32020-01 is renewed in its entirety to read as follows
4 Expiration date October 31 2022
5 Docket No 030-34523 Reference No
6 Byproduct source andor special nuclear material
7 Chemical andor physical form 8 Maximum amount that licensee may possess at anyone time under this
license middotmiddot
A Ariy byproduct material permitted by 10 CFR 35100
A Any ~
~ -A middot As needed
S Any byproduct material~
permitted by 10 CFR 35200 B Any
S As needed
shy
C Gadolinium-153 permitted by
CSealedsources
C Not to exceed 40 millicuries 10 CFR 35500
(ADAC Laboratories a Phifips Medical Systems Company Isotope Products Laboratories Model
per source total possession not to exceed 1000 millicuries
No NES8497)
9 Authorized use
~
A Any uptake dilution and excretion studYpermitted by 10 CFR 35100 _
B Any imaging and localization study permitted by 10 CFR 35200
C Diagnostic medical use of seaJed sources permitted by 10 CFR 35500 in an ADAC Laboratories CardioMD-AC attenuation corraction device
CONDITIONS
10 Licensed material may be used or stored only at the licensees facilities located at 550 Landmark Avenue Bloomington Indiana
11 The Radiation Safety Officer for this license is Gregory M Sutliff M D
2013-01-17 0831 PREMIER CVT 8123556916 raquo P 33
NRC FORM 374A US NUCLEAR REGUlATORY COMMISSION PAGE 2 of 2 PAGES
License Number 13-32020-01
MATERIALS LICENSE SUPPLEMENTARY SHEEr
Docket or Reference Number 030-34523
Amendment No 13
12 Licensed material is only authorized for use by or under the supervision of
A Individuals permitted to work as an authorized user in accordance with 10 CFR 3513 and 3514
B The following individuals are authorized users for medicaluse as indicated
Authorized Users - Materfal and Use
Gregory M $utliffM D 10 CFR 35100 and 35200
Jennifer Petersen-Goldspiel MD 10 CFR 35100 and 35200
Louise Annette Alpert MD 10 CFR 35100 and 35200
AndrewD Ferguson MD 10 CFR 35100
Eric Williams MD 10 CFR 35200 I bull bull bull
13 In addJtion to the posseSSion limits in Item 8 the licensee shall further restrict the possessionoflicensed material to quantities below-the minimum limit specified in 10 CFR 3035(d)for establishing decommiSSioning financial assurance
--~ - ~ - -
14 Sealed sources containing licensed materiaLsfla11 not be opened by thEilicensee
15 The licensee is authorized to transport licensed material in accordance with the provisions of 10 CF~ Part 71 Packagi~g an~d Transportati~n C)f Radioactive Materf~il~
- bull ~ ishy
16 Except as specifically provided ~the~ise in this license the licenseeshall conduct its program in accordance with the statements representations and procedures contained in the documents including
any enclosures listed below This license condition applies only tothose procedures that are required to be submitted in accordance with the regulations Additionallythfs license conditjor) does not limiUhe licensees ability tomake changes to the radiation protection program as provided for in 10 CFR3526 The US NuclearRegulatory Commissions regulations shall govern unless the statements representations and procedures intheJiceosees appicati~m and correspondence are more restrictive than the regulations bull -
A Appliction dated April 10 2012 and - shy
B Letter dated August 15 2012
FO~ THE US NUCLEAR REGULATORY COMMISSION
Materials Licensing Branch Region III
SEP 2 4 Z012 Date _______________
2013-01-17 0831 PREMIER CVT 8123556916 raquo P 23
NRC FORM 374 PAGE 1 OF -Z- PAGES
US NUCLEAR REGULATORY COMMISSION Amendment No 13
MATERIALS LICENSE Pursuant to the Atomic Energy Act of 1954 as amended the Energy Reorganization Act of 1974 (Public Law 93438) and Title 10 Code of Federal Regulations Chapter I Parts 30 31 32 33 34 35 36 39 40 and 70 and in reliance on statements and representations heretofore made by the licensee a license is hereby issued authorizing the licensee to receive acquire possess and transfer byproduct source and special 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 to persons authorized to receive it in accordance with the regulations of the applicable Part(s) (his license shall be deemed to contain the conditions speclf1ed 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 Regulatory Commission now or hereafter In effect and to any conditions specified below
Licensee
1 Premier Healthcare~ LLC
2 550 Landmark Avenue
Bloomington IN 47403
In accordance with application dated April 10 2012 3 License number 13-32020-01 is renewed in its entirety to read as follows
4 Expiration date October 31 2022
5 Docket No 030-34523 Reference No
6 Byproduct source andor special nuclear material
7 Chemical andor physical form 8 Maximum amount that licensee may possess at anyone time under this
license middotmiddot
A Ariy byproduct material permitted by 10 CFR 35100
A Any ~
~ -A middot As needed
S Any byproduct material~
permitted by 10 CFR 35200 B Any
S As needed
shy
C Gadolinium-153 permitted by
CSealedsources
C Not to exceed 40 millicuries 10 CFR 35500
(ADAC Laboratories a Phifips Medical Systems Company Isotope Products Laboratories Model
per source total possession not to exceed 1000 millicuries
No NES8497)
9 Authorized use
~
A Any uptake dilution and excretion studYpermitted by 10 CFR 35100 _
B Any imaging and localization study permitted by 10 CFR 35200
C Diagnostic medical use of seaJed sources permitted by 10 CFR 35500 in an ADAC Laboratories CardioMD-AC attenuation corraction device
CONDITIONS
10 Licensed material may be used or stored only at the licensees facilities located at 550 Landmark Avenue Bloomington Indiana
11 The Radiation Safety Officer for this license is Gregory M Sutliff M D
2013-01-17 0831 PREMIER CVT 8123556916 raquo P 33
NRC FORM 374A US NUCLEAR REGUlATORY COMMISSION PAGE 2 of 2 PAGES
License Number 13-32020-01
MATERIALS LICENSE SUPPLEMENTARY SHEEr
Docket or Reference Number 030-34523
Amendment No 13
12 Licensed material is only authorized for use by or under the supervision of
A Individuals permitted to work as an authorized user in accordance with 10 CFR 3513 and 3514
B The following individuals are authorized users for medicaluse as indicated
Authorized Users - Materfal and Use
Gregory M $utliffM D 10 CFR 35100 and 35200
Jennifer Petersen-Goldspiel MD 10 CFR 35100 and 35200
Louise Annette Alpert MD 10 CFR 35100 and 35200
AndrewD Ferguson MD 10 CFR 35100
Eric Williams MD 10 CFR 35200 I bull bull bull
13 In addJtion to the posseSSion limits in Item 8 the licensee shall further restrict the possessionoflicensed material to quantities below-the minimum limit specified in 10 CFR 3035(d)for establishing decommiSSioning financial assurance
--~ - ~ - -
14 Sealed sources containing licensed materiaLsfla11 not be opened by thEilicensee
15 The licensee is authorized to transport licensed material in accordance with the provisions of 10 CF~ Part 71 Packagi~g an~d Transportati~n C)f Radioactive Materf~il~
- bull ~ ishy
16 Except as specifically provided ~the~ise in this license the licenseeshall conduct its program in accordance with the statements representations and procedures contained in the documents including
any enclosures listed below This license condition applies only tothose procedures that are required to be submitted in accordance with the regulations Additionallythfs license conditjor) does not limiUhe licensees ability tomake changes to the radiation protection program as provided for in 10 CFR3526 The US NuclearRegulatory Commissions regulations shall govern unless the statements representations and procedures intheJiceosees appicati~m and correspondence are more restrictive than the regulations bull -
A Appliction dated April 10 2012 and - shy
B Letter dated August 15 2012
FO~ THE US NUCLEAR REGULATORY COMMISSION
Materials Licensing Branch Region III
SEP 2 4 Z012 Date _______________
2013-01-17 0831 PREMIER CVT 8123556916 raquo P 33
NRC FORM 374A US NUCLEAR REGUlATORY COMMISSION PAGE 2 of 2 PAGES
License Number 13-32020-01
MATERIALS LICENSE SUPPLEMENTARY SHEEr
Docket or Reference Number 030-34523
Amendment No 13
12 Licensed material is only authorized for use by or under the supervision of
A Individuals permitted to work as an authorized user in accordance with 10 CFR 3513 and 3514
B The following individuals are authorized users for medicaluse as indicated
Authorized Users - Materfal and Use
Gregory M $utliffM D 10 CFR 35100 and 35200
Jennifer Petersen-Goldspiel MD 10 CFR 35100 and 35200
Louise Annette Alpert MD 10 CFR 35100 and 35200
AndrewD Ferguson MD 10 CFR 35100
Eric Williams MD 10 CFR 35200 I bull bull bull
13 In addJtion to the posseSSion limits in Item 8 the licensee shall further restrict the possessionoflicensed material to quantities below-the minimum limit specified in 10 CFR 3035(d)for establishing decommiSSioning financial assurance
--~ - ~ - -
14 Sealed sources containing licensed materiaLsfla11 not be opened by thEilicensee
15 The licensee is authorized to transport licensed material in accordance with the provisions of 10 CF~ Part 71 Packagi~g an~d Transportati~n C)f Radioactive Materf~il~
- bull ~ ishy
16 Except as specifically provided ~the~ise in this license the licenseeshall conduct its program in accordance with the statements representations and procedures contained in the documents including
any enclosures listed below This license condition applies only tothose procedures that are required to be submitted in accordance with the regulations Additionallythfs license conditjor) does not limiUhe licensees ability tomake changes to the radiation protection program as provided for in 10 CFR3526 The US NuclearRegulatory Commissions regulations shall govern unless the statements representations and procedures intheJiceosees appicati~m and correspondence are more restrictive than the regulations bull -
A Appliction dated April 10 2012 and - shy
B Letter dated August 15 2012
FO~ THE US NUCLEAR REGULATORY COMMISSION
Materials Licensing Branch Region III
SEP 2 4 Z012 Date _______________
