north kansas city hospital, request to amend license number … · 2019. 12. 27. · certificate of...

CERTIFICATE OF DISPOSITIO OF MATERIALS 1 ’ ICENSEE NAME AND ADDRESS

I M ~ r t t a ~ Halrh Corporadon 2790 Clny Edwards Drive., Suits 520 North Kansus City, MO 64116

A. LI ENSEISTATUS (Check 2 This license has expired. This l i c & t has not yet explred, plc E. D18P6SAL OF RADIOAI

check the #mpd=te boxee end ccunpla ea notuvry . IfeWtimwispace k ha: licensee. or any indlvldual executing thla csrtitificate on behalf of the lice

I

1 No radloaetlve materials have ever b

0 b. Dispofal of radioactive materials: 1. DIrectly by the licensee:

24-32275-01 Lh&&tkj73674 UCENSE EXPIRATION DATE

I OlNlL2Oll

2. By Ilcensed dispoeal site: 1

c] 3. By waste contractor:

0 c. All radioactive materials have been such that any rem ining residual radioadvity is withln the limits of l o CFR Part 20. Subpart E, and is ALARA.

1. ~radlatlonsurveywasconduCted

0 b. that any rernalnlng residual

a. is attached; or b. is not

#24-18628-01, North Kansas City 0. the absence of licensed radioactive rimrials

2. A copy of the radiation sumy results:

pns 3. A mdlatbn survey is not

I I he person to be contacted regarding the informstfan prodidsd on thls form: 1 AME I 1 ITELEPHONE h % d t 3 A m c o d s l (E-MAIL ADDRESS

le appmptlata box) ne terminate it.

rivE MTERIAL iudd, prod& atlecltments) Be, cefflfles that: 1 the licensee vlder this license.

flue materials procured and/or possessed by the limngee I followlng mmner.

; Phone 116-691-5343 or Cell #913-70&9200

PRI- ON RECYCLED PAPER RC FQRM 314 (MW)

TOTRL P.02

Toye L. Simmons Materials Licensing Branc'i, 2443 Warrenville Rd Suite Lisle, lllinols 005332-4352

S in ce rely,

Region Ill 210 1

North Kansas City MO 6

816 691 5343 Departme

Radiation Safety Officer

913 706 9200 Cell 816 346 7869 Fax