Huron Valley-Sinai Hospital

July I , 2011

U.S. Nuclear Regulatory Commission Region Ill Materials Licensing Branch 2443 Warrenville Road Suite 210 Lisle, Illinois 60532

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1 William Carls Drive Commerce, MI 48382-2201

Re: Amendment to 21-24652-01

Dear Madam or Sir:

We wish to amend our Materials License 21-24652-01 as follows:

AUTHORIZED USERS

Add: Seetha Sindhura Vakhariya, M.D. for 35.100, 35.200, 35.300 for

Jacqueline T. Huynh, M.D. for 35.100, 35.200, 35.300 for

Christina L.Torres, M.D. for 35.100, 35.200

Iodine-I 31 ~ 3 3 mCi

Iodine-I31 e33 mCi

In support of this request please refer to the enclosed ABR certificates dated June, 2009 noting each as “AU Eligible” for the credentials of Drs’ Vakhariya and Huynh. Please find enclosed a previous amendment of our Materials License which noted Dr. Torres as an authorized user.

We look forward to our amendment. If you have any questions please contact our Medical Nuclear Physicist, Thomas M. Kumpuris, M.S., FACR 800.321.2207 or t ku m p u r isam pcp hvsics. corn.

Sincerely,

Karen Thompson, BS Director of Radiology

-RECEIVED JUL 1 2 2011

wwwdmc.org

! May. 5. 2 0 1 1 1 : 3 4 P M I I (

Form A

diolow - P r a m Dfrector Attestati OQ

............................................... By the thns of &e ABR on$ exemination, hie epplkwpt will hpvr suceaasftrlly dompletcd the hours of training and tntpmhnm IU dind in 10 CPR 35.290 aud 39.392

Thfs a p p l k t haa taken part h 2 3 otlbee of oral ndmfnlstmtion of 1-131 therapy (S 33mC a,.... ......... ............... IBIU Iha rasidant'n @bo& of these thr*lpy experiwws (dub, dwe, md preceptor) fr altnched

The work and cxpctimc6 titerl above fbr p 35.290 whp obtained uadr the sapcruirbn of m AuthoM User (AU) who me& tht requiments under m!Vant sections of 6 35,290 or quh1ent A-snt Skhtt roquiromontS ........................................................................................................... Ths work and expericnoe dtrrd pbow for 4 35.392 wag obtaIndd under the s u p w i s h of an AWhorisd Usex (AU) wha mma die mpdrcmcnta undm 1 35,390,35392 ar 35.394 or q ~ ~ t ~ ~ p s 8 m c n t S E n t e rcqp~~...........................................................~........*.....

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I M?Y. 5. 2 0 1 1 1 : 3 4 P M !

Dose Administer&

153 nd

No. 4 6 1 1 P. 3

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May. 5. 2 0 1 1 1 : 3 4 P M No. 4611 P. 4

RESIDENT:

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1 , lfarrnington Hllls, MI 48336

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31 3M SUPPLEMENT B Page 7

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The wafitand oimsd above fix 135.392 was OMairredUnaer the 6lqmMonof a htbrkeid User (AU) whomeatr them@rmmts under 35.390,35.392 af 35.394 or cquiYalent Agreement stabezcqakmm ..........................................................................

Form B .-

Wayne State Univl Detroit Medical Center 4202521096

ProgremBtN-

AM 374 PAGE 1 OF 3 PAGES Amendment No. 25 U.S. NUCLEAR REGULATORY COMMISSION

I

f MATERIALS LICENSE Pursuant to the Atomic Energy Act of 1954, as amended, the Energy Reorganization Act of 1974 (Public Law 93-438), and Title 10, Code

Federal Regulations, Chapter I, Parts 30, 31, 32, 33, 34, 35, 36, 39,40, and 70, and in reliance on statements and representations retofore made by the licensee, a license is hereby issued authorizing the licensee to receive, acquire, possess, and transfer byproduct,

& m e , 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). 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 Regulatory Commission now or hereafter in effect and to any conditions specified

Commerce, MI 48382-2201

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111 2. I William Carls Drive

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In accordance with letters dated August 18 & 25,2003, 3. License number 21-24652-01 is amended in its entirety to read as follows: 4. Expiration date April 30, 201 1

cket No. 030-29063 Ref n& No.

-7 Byproduct, source, andlor special nuclear material . 6 q. Chemical and/or physical form 3 8 , Maximum amount that licensee may

0 mssess at anv one time under this

A. Any byproduct mater ia permitted by 10 CFR&.lOO

6. Any byproduct m permitted by 1

C. Any byproduct permitted by 10 CF

D. Iodine-125, as identifi 10 CFR 35.400

E. Palladium-103, as id in 10 CFR 35.400

C. ss needed (not to exceed -ne curie of iodine-I 31)

E. Asneeded

9. Authorized Use:

A. Any uptake, dilution and excretion study permitted by 10 CFR 35.100.

6. Any imaging and localization study permitted by 10 CFR 35.200.

C. Any diagnostic study or therapy procedure permitted by 10 CFR 35.300.

D. Medical use described in 10 CFR 35.400.

E. Medical use described in 10 CFR 35.400.

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10

11

12

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14

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ORM 374A US. NUCLEAR REGULATORY COMMISSION

MATERIALS LICENSE SUPPLEMENTARY SHEET

PAGE 2 of 3 PAGES License Number 21-24652-01 Docket or Reference Number 030-29063

Amendment No. 25

CONDITIONS

A. Licensed material may be used at the licensee's facilities located at 1 William Cads Drive, Commerce, Michigan.

B. Licensed material listed in Subitems 6.A. through 6.C. may also be used at the licensee's facilities located at 41935 W. Twelve Mile Road, Novi, Michigan.

A.

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A. The Radiation Safety Officer for this license Is Anthony R. Pucci, D. 0.

B. The Assistant

Licensed mateflal is only a

A. Individuals permitte thorized user in 0 CFR 35.13 and 35.14.

6. The following indi

Authorized Users

Carole Williams Msela 0 ana5.300 (excluding

- 9 Payadium-I 03. John K. Kelly, D.O.

Victoria A. Swegles, D.O.

Christina L. Torres, 0.0.

10 CFR 35.100 and 35.200.

10 CFR 35.100 and 35.200.

V. Elaine Arterbery, M.D.

Jeffery Forman, M.D.

Arthur Frazier, M.D.

Kenneth Levin, M.D.

Nathan Kaufman, M.D.

10 CFR 35.400, limited to Iodine-125 and Palladium-I 03.

10 CFR 35.400, limited to Iodine-1 25 and Palladium-I 03.

I O CFR 35.400, limited to Iodine-125 and Palladium-I 03.

10 CFR 35.400, limited to Iodine-125 and Palladium-I 03.

10 CFR 35.400, limited to iodine-1 25 and Palladium-I 03.

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.*ORM374A U.S. NUCLEAR REGULATORY COMMISSION *. .

I1111 MATERIALS LICENSE SUPPLEMENTARY SHEET

PAGE 3 of 3 PAGES

License Number 21-24652-01 Docket or Reference Number 030-29063

Amendment No. 25

L. Gregg Warren, D.O. 10 CFR 35.100 and 35.200.

M. Richard Krikorian, D.O. 10 CFR 35.100 and 35.200.

N. Anthony R. Pucci, D.O. 10 CFR 35. I00 and 35.200.

0. Michael Bishoff, M.D. I O CFR 35.100 and 35.200.

In addition to the possession limits in Item 8, the licensee shall further restrict the possession of licensed material to quantit decommissioning

The licensee is auth 10 CFR Part 71, "Packa

Except as specifically prdilde accordance with the s any enclosures, listed Pplow. be submitted in acco licensee's ability to The U.S. Nuclear representations, and than the regulations.

A. Application dated Ma

B. Letters dated March 18,2003.

nduct its program in

ition does not limit the ed for in 10 CFR 35.26.

FOR THE U.S. NUCLEAR REGULATORY COMMISSION

BY ..r, - x. /&-.--. Toye L. Simrrfons Materials Licensing Branch Region 111

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