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UA ELUCLEA A aaLULATORv ConenmesiONesRC F ORee 313
APPENDIX A AaROvto ev OMSna.m C F R 30. 33. 33. 3d, - APPLICATION FOR MATERIAL LICENSE 3.:068130t0 a. m, -
ad a0.
18ESTRUCTIO885: $EE THE APPROPRIATE LICENSE APPLICATION GUIDE FOR DET AILED INSTRUCTIONS FOR COWLETING APPLICAf TON SEND TWO COPIE$,
|OF THE ENTIRE COMPLETED APPLICATION TO THE NRC OFFICE SPECIFIED BELOW.
TEOGRAL AOGNCit$ FILE APPLICATIONS WITMs IF YOU ARE LOCATED IN
ILuaeOas. INot AasA, SOWA. h81CMiGAN, MeaINESOT A, teleBOURf, OMIO, OR -U $ NUCLI AR REGULATORY COMMstsiONDtyl810N 08 FUEL CYCLE AND MATERIAL SAFETY,NM55 WIGCoassese,seseO APPLICAftOef8 TO
WASHINGTON DC 30855 U.S NUCLE AR REGULATORv COMurssiON. REGION su
ALL OTHE81 P89900s$ FILE APPLICAfeOast A8 FOLLouut.4F YOU ARE M ATEIts AL$ LICENSING $4CTION790 ROOstv8LT ROADLOCAf t0 tas:- GLEN ELLYN,lL 90137
ODemstCTICUT, OELAeARE. OtSTRICT OF COLutelA, GAAINE, Malt YLANO. ARK a tsSAS. COLOR ADO, 00AMO, KaaGAS. LOUeslaasA, amerT Asea,9eESA ASat A,esAAACMWETTS. seEW JGatSE Y, esEW YORK,PsepalSYLVAssia, RMODE ISLAleO, settu A8E KICO.aeORTM OAKOTA, OKI AmaNA SOUT M 04KOT A. Tt1AS. UT AM,OR VEReICAff,9ENO A8PLICAT10808 70 OR WYOesING,Seiso APPLICATIONS 70;U S NUCLI AR REGUL ATORY COMMisslON, REGION I
U S NUCLE AR REGULATORY COMMIS$10N REGION IV -NUCLE AR MATER 6AL $ECTION G MATERI AL M ADI ATION PROTECTION SECTION83t PARK AVfNUEElteG OF PRussi A. PA 19A06 611 RVAN PLAZA ORivt.$UITE 1000
AR LINGTON. TX 70011ALASAetA. PLORIOA, OSORota, slanfTucs V, englWppFI, NOnTM CAROLaseA. AL ASK A, A Rl2ONA, CALIFOIINI A. teAWAM, estVADA. ORE 0088. WuAs;4ssectONPutRTO RICO. 00UTM CAROLeseA. TEssaltet 6, VIRotNI A, VIRGIN ISLA8eDS, Oft AseO U.S. TERRITORIES AND PONSW60818 les feet PACIFIC,88sso APPUCAT1080$UrtST VIRGIIslA,34080 APPUCAtlOess TO.
TO.U $ NUCLE AR REGULATORY COMMrssiON REGION ie U $ NUCLE AR REGULAYORY COMM185 TON. REGIOF- VMATERIAL RADIATION PROTECTION SECTION101 MARIETTa lTREET. SUITE 2900 MAf amiAL RAD AfiON PROTECTION 8tCTION
td60 MAR #A LANE.SurTE 210ATL Afst A, GA 30323 WALNUT CREEK,CA 94S96
PEReOnet LOCATED IN AGRt(40ENT STATES SGNO APPUCAfloast 70 THE U 8 NUCLEAR flEGULATORY COeAMit$iOas ONLY 17 TMEY eviSM TO POSS$5 AseO USE UCtessEO MATERIALles ST ATES SUSJECT TO U S NUCLEAR ftEQULATORY COMMISSION JURISDICTION.
1 THIS IS AN APPLICAT 04 FOR tchere asereer sw espel 2 N AME AND MAILING ADDRES8 OF APPUCANT (tacInse Ese Cases_
A NEW LICENSE21-21045-01 Kinnco, Inc.~I e AMENDMENT TO UCENsE NuMeta
P.O. Box 802-
C R NEWAL OF uCEN ENUM.ER- Traverse City, MI 496853 AJORE5&lE81 WMERE LICENSED MATERIAL WiLL St USED OR POSSt$$ED
8389 M72Williamsburg, MI 49690
4. NAME OF PERSON TD St CONT ACTED A00VT TM)$ A* PLICATION TELEPHONE NUMGER
Larry R. Kinney, RSO 616-938-2842SUBM'T ITEMC 9 THROUGM 11 ON tw a 1t~ PAPER THE TYPE AND SCOPE OF INFORMATION TO DE PROvtDED i$ DESCRipto IN THE LICENSE APPuCATION guide
6 R ADIOACTivt MATERi ALm amov t 6 PURPOSEfS1 FOR WMICH LICENSED MAftRIAL WILL St USED
e Elemen.t.e.nd. mass o. .me.er, D.c. hem.ce' andeor physics' tow, sad c maseua
~ e.,1 . .. . .e
8 ' *L '"''I'"# IM ' e TRAINI G FOR INDIVIDUALS WORKING IN OR FREQUENTING RESTRICTED ARE As7 '* 'sTRA G PE E CE
9 F ACiUTit$ AND EQUIPMENT. 10 RADI ATION $AFETY PROGRAM
13 LnCENSEE FEt$ t$ee 90 CFn 110 ene section I/O 2to j
11. W A37E MAN A*,EMENT FEt CATEGORY J NC OSED $ 60.0013 CERTIFICATION fadese ae somaseeMr Py apadecents TME APPLICANT UNDt 45Y ANDS THAT ALL ST ATEMENTS AND REPRESENT ATIONS MADE tN TMis APPLICATION ARE
!BINDING UPON TME &#PLICANTTHE APPUCANT AND ANY OFFICIAL EXECUTING TMi$ CERTIFICATION ON SEMALF OF THE APPLICANT,N AMED IN ITEM 2. CERTIFY THAT TMil APPUCAftON ISPREPARED #N CONFORMITY WITH TITLE 10. CODI OF F EDER AL REGULATIONS.PARTB30,32. 33,34. 36. AND 40 AND THAT ALL INFORMATION CONTAIN!D MEREIN,18 TRUE AND CORRECT TO TM4 atST OF TMEiR KNOWLEDGE AND SEUEFW ARNsNG 18 U S C SECTION 1001 ACT OF JUNE 25.1943 et st AT 749 MAKES IT A CR8MINAL OFFENSE TO MAKI A WILLFULLY F ALSE STATEMENT OR REPRESENTATIONTO ANY DEPAsITWENT OR AGENCY OF TME UNITED STATES As TO ANY MATTliR WITMlN IT5 JURISDICTION
StGNAT E -C E RT IF ING OP R T YPED' PRINTED NAME TIT LE DATE
""] tm & W ey Gue,M /w lo-imam w<
ff / t o V C wN* A a ' i CONOMIC D A T A ./*
e NUMOER OF EMP60v E E S (Tom e WOt/LD YOU St WiLLING TO FURNtSM COST INFORMATION Goose safer suff Asuruva mu u ni cm ,*M
'"'"' #''#''" '"88 8'ai av tsNAr ce' forntract.rst ON %ME ECONOMIC IMPACT OF CURRENT seRC REGULATIONS OR ANY FUTURE< $260K $1M-3 SM
PR,OPO,.S.ED. .N.RC, R E.GULATIONS TM.,A,T_MA.Y,_AF F EC..T.Y,OU7,.(Nac..espue,t.so.a.s .pe.rmerR., . . -..~,m. , A i. e .,,,0 ,, ,M . ,M ~ '-
. M,tRO,,tD5.mn .,M.,.
VES NO$160K-1M > $ 10M g.
I AV FOR NRC USE ONLY '" b G [? (qp p. y
TYPE Of Et FEE LO'' FEECAT "Omv COMMENT 5 * * LJ AP*ROvtD 8 Y
8421 ? % 8 L987I P' W )ggR0t. N0 Dart
CMEC. UM.bR 1 %CNm O' |1 $- UNTREC4,vtD
/b6Q( SRiv&CV ACT ST ATEMENT ON TME REvtRSE }$
8902220100 871214*
. REG 3 LIC30- - - - - _ _ _ _ 21-21045-01 pne
__-_-__-___ _-____ __
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PRIVACY ACT STATEMENT
Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by section 3 of the Privacy Act of 1974 (Public Law 93 579), the follow-ing statement is furnished to individuals who supply information to the Nuclear Regulatory Commission on NRC Form313. This information is maintained in a system of secords designated as NRC-3 and described at 40 Federal Register 45334(October 1,1975).
1, AUTHORITY: Sections 81 and 161(b) of the Atomic Energy Act of 1954, as amended (42 U.S.C. 2111 and 2201(b)),
2. PRINCIPAL PURPOSE (S): The information is evaluated by the NRC staff pursuant to the criteria set forth in 10 CFR ,
Parts 30,32,33,34,35 and 40 to determine whether the application meets the requirements of the Atomic Energy Act of1954, es amended, and the Commission's regulations, for the issuance of a radioactive material license or amendmentthereof,
3. ROUTINE USES: The information may be (a) provided to State health departments for their information and use;and (b) provided to Federal, State, and local health officials and other persons in the event of incident or exposure,for their information, investigation, and protection of the public health and safety. The information may also be dis-closed to appropriate Federal, State, and local agencies in the event that the information indicates a violation or potentialviolation of law and in the course of an administrative or judicial proceeding. In addition, this information may be trans-ferred to an appropriate Federal, State, or local agency to the extent relevant and necessary for an NRC decisior or toan appropriate Federal agency to the extent relevant and necessary for that agency's decision about you.
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVID-'
|NG INFORMATION: Disclosure of the requested information is voluntary. If the requested information is not furn.ished, however, the application for radioactive material license, or amendment thereof, will not be processed. A requestthat information be held from public inspection must be in accordance with the provisions of 10 CFR 2.790.Withhcld-ing from public inspection shall not affect the right, if any, of persons properly and directly concerned need to inspectthe document,
5. SYSTEM MANAGER (S) AND ADDRESS: U.S. Nuclear Regulatory CommissionDirector, Division of Fuel Cycle and Material SafetyOffice of Nuclear Material Safety and SafeguardsWashington, D.C. 20555
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' NRC FORM 31316
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! Pl$RCE & ASSOCIATES~
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P.O. Box 968 Kalkaska. MI 49646
(616)258 8014 Kinnco, Inc.
24 HOURS A DAY
October 1, 1987
Dear Randy,
A program concerning the " Fundamentals of Radiation Safety"
was conducted September 18, 1987. The program covered NRC
Standards, Parts 19 and 20. The undersigned attended and
successfully completed the 8 hour program.
Sincerely,;
Bill Pierce, C.S.M.
!
s, a_
ATTENDEES PRESENT (Have each sign if po ' bled
I)& A |A)}7V_4LL! a &
N ke LD. Qxut Mw C.%'
Sum L, h L1.\h| Ha mId i. Green] &s0/ b'wk/>nbj ( qNAS k (b4'ZEA| f '
^'f /
| CONTROL NO 8 4 27 2
'"(Over for additional names)
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October 1, 1987
NAME: Micheal W. Orr SS#: 376-68-5402
BIRTilDATE: 12-11-58
WORK EXPERIENCE:|
12/79 to 12/84: Worked for AMF Tuboscope as an AssistantInspector. This worked involved calibration, use, and
inspection equipment which contained gamma ray wallcarethickness meters.
06/85 to Present: Working for Kinnco Inc. as anInspector again utilizing equipment equipped with gammaray wall thickness meters.
TRAINING:
Spring 84: Sent to 40 hr Radiation Safety course inflouston by AMF Tuboscope.
09/18/87 : Attended an 8 hr Radiation Users Safety coursesponsored by Kinnco Inc. and taught by BillPierce of Pierce & Assoc. Inc.
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October 1, 1987
NAME: James Green SS#: 380-64-8389''
BIRTHDATE: 02-15-55
WORK EXPERIENCE: -
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06/78 to 06/81: Worked for AMF Tuboscope as an AssistantInspector.. This work involved the calibration, use, ;
care of inspection equipment which contained gamma ray iwall thickness metera.
06/83 to Present: Working for Kinnco Inc. as anInspector again utilizing equipment equipped.with gammaray wall thickness meters.
TRAINING:
While at AMF Tuboscope worked under Donald Wainman andreceived,on the job training.
09/18/87 : Attended an 8 hr Radiation Users Safety coursesponsored by Kinnco Inc. and taught by BillPierce of Pierce & Assoc. Inc.
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NAME LDonald Wainman SS#: 386-54-2217- 4
:EIRTHDATE: 05-13-53.* 1
4, @ ;- WORK EXPERIENCE:
12/76 to106/86:: Worked for AMF< Tub'oscope as anInspector then as Manager.'. This work; involved.thecalibration',tuse,jcare'of: inspection equipment which-' - '
contained gamma ray wall thickness meters..
112/86--to Present:'. Working for Kinnco Inc. as'anInspector again utilizing equipment equipped with gamma-ray wall thickness meters.
TRAINING:
1977, 1983, and 1985:.
JAMF Tuboscope.sent me to 3 radiation safety schools.:
09/18/87 :-Attended an 8 hr' Radiation Users Safety. course:sponsored by Kinnco Inc. and taught by. BillPierce of Pierce & Assoc. Inc.
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October 1, 1987
'NAME: Harold Green SS#: 372-64-8807
BIRTilD ATE : .01-22-54
WORK EXPERIENCE:
06/80 to 06/81: Worked for AMF Tuboscope as an ,
!Inspectors assistant. This work involved thecalibration, use, care of inspection equipment which<
contained gamma rsy wall thickness meters.
12/85 to Present: Working for Kinnco Inc. as an Ass.Inspector again utilizing equipment equipped with gammaray wall thickness meters.
TRAINING:
While at AMF Tuboscope worked under Donald Wainman andreceived on the job training.
09/18/87 : Attended an 8 hr Radiation Users Safety coursesponsored by Kinnco-Inc. and taught by BillPierce of Pierce & Assoc. Inc.
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October 1,.1987
NAME: Shawn'Keane SS#: 372-50-6304
BIRTIIDATE : ' 04-18-59
WORK EXPERIENCE:
10/82 to Present: Working for'Kinnco Inc. as anInspector then as Inspection Foreman utilir,ingequipment equipped with gamma ray wall thickness meters.
TRAINING:
09/18/87 :' Attended an 8 hr Radiation Users Safety coursesponsored by Kinnco Inc. and taught by BillPierce'of Pierce & Assoc. Inc. ,
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