APPENDIX A

APPLICATION FOR MATERIAL LICENSE R&t& Gmmtuion. Wuhinpton. Dc 20555Oo31, M by ml.rns('.-mad k bW@nrcgw. andfotheDerkOmcar, M f i w o f I n f o r m ~ 0 o n ~ n d R c g u l a l a y A ~ ~ i r r NEOB tom (3350-01?0!, Onice 01 knrgcmcnl and B u d p q WasIxngton. M) 20503 H D means used to impose an mlormabm m l h o n doar not display a currently valid OM0 C D ~ U O I numbn. NRC may no( condun or s p o o i ~ . and a -0 s not m u t i a d 10 respond Io the mlormabon colleC(lm

LICENSING ASSISTANT SECTION NUCLEAR MATERIALS SAFEW BRANCH

4PPLICATION FOR DISTRI0UTION OF EXEMPT PRODUCTS FILE APPLICATIONS WITH'

OlVISlON OF INDUSTRIAL AN0 MEDICAL NUCLEAR SAFEIY OFFICE OF NUCLEAR MATERIALS SAFETY AND SAFEGUARDS U S NUCLEAR REGULATilRY COMMISSION WASHINGTON. Dc 20555Mol

4LL OTHER PERSONS FILE APPLICATIONS AS FOLLOWS

F YOU ARE LOCATED IN'

:ONNECTICUT, DELAWARE. DISTRICT O f COLUM014 MAINE MARYLAND. HASSACHUSETTS. NEW HAMPSHIRE, NEW JERSEY. NEW YORK. PENN5YLVANIA. SHODE ISLANO. OR VERMONT. SEND APPLICATIONS TO

U S NUCLEAR REGULATORY COMMISSION REGION I IISALLENDALEROAD KINGOF PRUSSIA PA 19406-1415

IF YOU ARE LOCATED I N

ILLINOIS, INOMNA, IOWA, MICHIGAN, MINNESOTA. MISSOURI. OHIO. OR WISCONSIN SENO APPLICATIONS TO'

MATERIALS LICENSING SECTION NPZSA 3 U S NUCLEAR REGULATORY COMMISSION REGION 111 801 WARRENVILLE RD LISLE, 11 60532 4351

ALASKA ARIZONA, ARKANSAS, CALIFORNIA, COLORADO. HAWAII, IDAHO. KANSAS LOUISIANA, MONTANA, NEBRASKA. NNADA. NEW MEXICO, NORTH DAKOTA OKLAHOMA. OREGON. PACIFIC TRUST TERRITORIES. SOUTH DAKOTA TEXAS UTAH. WASHINGTON. OR WYOMING. SENO APPLICATIONS TO

4LABAMA. FLORIDA, GEORGIA. KENTUCKY, MISSISSIPPI, NORTH CAROLINA, PUERTC RICO. SOUTH CAROLINA. TENNESSEE. VIRGINIA. VIRGIN ISLANDS. OR WEST VIRGINIA. SEND APPLICATIONS TO.

SAM N i N N ATLANTA FEDERAL CENTER U S MICLEAR REGULATORY COMMISSION REGION I1 61 FCRSYTY STREET s w SUITE m a s ATLANTA GEORGIA 30303-8931

9 FAClLlTlk3 AND EOUIPMENT s&C e//& c w r k {

NUCLEAR MATERIALS LICENSING SECTION U S NUCLEAS REGULATORY COMMISSION, REGlOtC IV 611 RYANPLUA ORIVS S U E 4Di) ARLINGTON.TX 7801'-8064

10 R A D I T 2 S & F € W ' f W 4 c 4 # / /-eefi

n3/z I

N P E OF FEE

PERSONS LOCATED IN AGREEMENT STATES SEND APPLICATIONS TO-HE U S NUClEAR REGULATORY COMMISSION ONLY IF THEY WISH TO POSSESS AND USE LICE'ISED

FEE LOG I FEE CATEGORY AMOUNT RECEIVED I CHECK N U M B m I COMMENTS

MATERIAL IN STATES SUWECT TO U S NUCLEAR REGULATORY COMMISSION JURISDICTK

I THIS 15 AN I C P X A T I O N F3R (Check spprwtatr !lernl

Y € i LICENSE

AMENDMENT TO LICENSE NUMBER - RENEWAL OF LICENSE NUMBER

N P E OF FEE

3 ADORESS(ES) WHERE L CENSED MATERIAL WILL BE USE0 OR POSSESSED

S' sN&&& S k e /

FEE LOG FEE CATEGORY AMOUNT RECEIVED CHECK N U M B m ' COMMENTS

S

2 NAME AN0 UAlilNG ADDRESS OF APPLICANT (Include 219 codel

I 4 NAME OF PERSON TO BE CONTACTED ABGJTTH15

sumr ITEMS s T m o u G n I 1 ON a1n x 1 1' PAPER THE TYPE AND SCOPE OF INFORVATION TO BE PROVIDEO IS OESCRIBFD IN THE LICENSE APPLICATIOY GUIDE

c. RADIOACTIVE MATER:AL I

WARNING ANY DEPARTMENT OR AGENCY OF THE W E D STATES AS TO A N I M A l l E R WITHIN ITS JURISDICTION

18 U 5 C SECTION 1031 ACT OFJUNE 25 1948 62 STAT 748 MAKES I1 A CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMFNT OR REPRESENTATION TO

I

APPROVEDBY DATE

A- 1

C K 1 & Associates, Inc, C o NSU LTI N G EN G I N E ERS

5400 Shawnee Road. Ste 101. Alexandria. VA 22312 Phone 703-750-0606

Fax 703-912-4858

March 24,2008

#1

#2

#3

#4

#5

#6

#7

#8

#9

#10

#I 1

New License

5400 Shawnee Road, Suit 10 1 , Alexandria, Virginia 223 12

Federal ID# 541 863056

Project site (Location will be given in the later date)

Contacts: Ming Chee Ching (703-906-01 72)

See Attachment 1

See Attachment 2

See Attachment 3

See Attachment 4

See Attachment 5

See Attachment 6

See Attachment 7

C 0 N ST R U CTI 0 N MAN G E M E N I-, B R I DG E SA F ETY I N S P ECT I 0 N

A B

Element & Mass Physical Form

A. CS-137

B.Am-241: Be

C. (3-137

D. Am-241: Be

E. CS-137

F. Am-241 : Be

G. (3-137

Sealed source Troxler Electronic labs Drawing Number A 102112

Sealed source Troxler Electronic Labs Drawing Number A 10245 1

Sealed source Amersham Corporation Model# CDCW 556 Capsule Type X. 12 1 8 Model# CDCW 556 Capsule type 2CN.30 Isotope products Labs Model # HEG-137-8M

Sealed source Amersham Corporation Modelk AMNV. 997 Capsule type X.1 Isotope Products Lab Model Nos. 3021 or 3027

Sealed source CPN 131

Sealed source CPN 131

Sealed source Amersham Corporation Model# CDCW 556

Attachment 1

C

Maximum amount of radioactivity which will be possessed at any one time.

No source to exceed 9 mCi

No source to exceed 44 mCi

No source to exceed 9 mCi

No source to exceed 44 mCi

No source to exceed 10 mCi

No source to exceed 50 mCi

No source to exceed 9 mCi

Capsule type X 121 8 Model# CDCW 556 Capsule type XN. 30 Isotope Products Labs Modelft HEG 0058 Capsule type $024

Attachment 2

A&B. Used in Troxler model 3401 and 341 1 to measure physical properties of materials.

C&D. Used in Troxler model 3430 and 3440 to measure physical properties of materials.

E&F. Used in CPN, MC Series to measure physical properties of materials.

G. Used in Troxler 4640 and 4640B to measure physical properties of materials.

Attachment 3

Ming Chee Ching will be solely responsible for the Radiation Safety Program

Training:

Your credentials and qualifications.

See attached Training Certificate (VDOT Nuclear Safety and Transportation of Hazardous Materials) since 1993.

See attached resume the years of Experience.

a o m l ~ o ~ f ~ r @ ot Ptrgtnta Department of Transportatim

Nuchar safety and “ransportation of Hazardmu material3

Ccrt$cate of QuaiifEatwn For

This 16 to cerlifj thai ‘ING C- ‘”ING I- has successfully completed an examination adrmmstered by the Department

on transportation handling. safety. storage and operating procedure of nuclear gauges

- _- L STATE MATERIALS ENGINEER

NOV. 18,2004 June30,2008 EXPIRATION DATE DATE

7. Brief Resume of Key Persons, Specialists, and individual consultants anticipated for this proiect.

a. Name & Title: MING C. CHlNG

b. Project Assignment: QA & QC Project Manager

c. Name of Firm with which associated: CKI & Associates, Inc.

d. Years Experience: With This F i r m s With Other F i rms2

e. Education: Degree(s)Near/SpeciaIization M.S./1994iTransportation and Urban Planning B.S./1984/Civil Engineering

f. Active Registration: Year First Registered/Discipline

Soil (VDOT) 1994 2008 Asphalt (VDOT) 1991 2008 Hydraulic Cement Concrete (VDOT) 1990 2008

Nuclear Safety (VDOT) 1993 2008

Bridge Painting Inspection 1996 NHI- Bridge Safety Inspection 1998 Flagger Certification 2003 2008 Erosion and Sediment Control 2005 2007

Date Certified Expiration Date

Pavement Marking (VDOT) 1994 201 0

OSHA Safety Instructor 1994

g. Other Experience and Qualifications relevant to the proposed project:

Mr. Ching has extensive experience in the field of construction inspection as Project ManagerEenior Inspector primarily on VDOT Bridges and roadway. His experience includes project showing; initiate pre-construction and construction progress meetings, bridge superstructure replacement, substructure repair, and widening, pile driving, structure steel, bolt tensioning, precast and cast-in-place deck placement, deck grooving, silica fume and latex deck overlay, integral backwall, approach roadway stabilizing and paving, retaining walls, bridge painting, prepare as-built drawings and review of Erosion and Sediment Controls. He is familiar with VDOT's documentation procedures to include; work order, source of materials (C-25) submittals, daily diary, material book, monthly estimates, sublet request evaluation and processing, EEO requirements to include C-57, certified payroll etc.and project closing documentation.

. - Responsible for six (6) nuclear portable gauge throughout the eight years Springfield Interchange Improvement Project as RSO (Radiation Safety Officer). As a design Engineer, Mr.Ching was responsible for design, estimation and preparation of design drawings for the Extension of 1-95 HOV project in Northern Virginia, supervised the preparation of detailed design drawings for the Choptank River Bridge in Maryland and was a member of the design team for the Vine Street Expressway (1 5 overpasses) in Philadelphia. Mr. Ching also performed emergency Bridge Safety Inspection of over 100 structures in Western Connecticut. He is also very proficient in the use of Microsoft Word, Excel and CWB version 6.2 and Site Manager. His experience includes the following projects:

185 over Route 619, VDOT, Quantico, VA: Complete superstructure and partial substructure removal, replacement and widening of two existing bridges carrying Rte. 95 over Rte. 619. Responsible for includes project correspondence, work order, review progress schedule, monthly progress meeting, preparation of monthly estimates, EEO requirements to include C-57, source materials (C-25), plan submittal and public inquiries. Also inspecting ail phases of bridge and roadway construction, keeping the daiiy diary, perform work zone safety checks, environmental controls checks and as-built mark-ups. Cost effective, timely manner and troubleshooting.

Rte. 7 over Rte. 50, VDOT, Fairfax, VA: Project involved four-bridge repair at the interchange of Rte 7 and Rte 50. Complete superstructure replacement of two one span mainline bridges over Rte. 50 with lightweight precast concrete deck panel. One superstructure replacement of a concrete and steel composite deck with steel concrete composite integral backwall superstructure and Latex deck overlay of the fourth bridge deck. Responsibilities included inspection of all contractor activities related to the project, project correspondence, work order, monthly progress meeting, source of materials (C-25), EEO requirements, documenting all pay quantities, keeping daily log of project activities and assuring all inspection/testing was performed in strict compliance with VDOT standards and specifications.

Fairfax County Parkway over Rte. 50, VDOT, Fairfax, VA: Two new one span steel concrete composite bridge constructions over Rte. 50, realign the Parkway and construct ramps. Bridge construction included pre-boring, pile installation, four abutments, pier constmction, structural steel Installation and the placement of concrete superstructure. Responsibilities included inspection of all contractor activities related to the construction of this project, documenting all pay quantities, keeping daily diary of project activities and assuring all inspection/testing was performed in strict compliance with VDOT standards and specifications.

Project Manager /Senior Field Engineer, HNTB. District Wide 7112.20

I 7. Brief Resume of Key Persons, Specialists, and individual consultants anticipated for this ixoiect.

Construction Inspection, Northern Virginia. Project Manager for work including construction inspection services, project showing, pre- construction meetings, design liaison, project correspondence including: work order, preparation of monthly estimates, force account, shop drawing review, inspection staff coordination for bridge rehabilitation and maintenance projects.

* .

71 t2.20

Hot Lane Improvement Project

Nuclear Safety and Transportation of Hazardous Materials

SAFETY COMMITMENT

I, - (please print name), fully understand the requirement for the

care, operation and safekeeping of the nuclear gauge when used for testing or transporting will follow

VDOT and NRC regulations at all times:

1. Storage area needs to be locked and secured at all time.

2. While performing a daily Standard Count I will attend the nuclear gauge at all times. Standard counts

will be performed on a suitable surface (00 lbs/ft3 minimum) at least 10 feet away from any building

or structure and at least 33 feet away from any other gauge or radioactive source. I will not use truck

beds, tailgates, or tabletops to perform standard counts.

3. When transporting a nuclear gauge in my vehicle, I will use the transport box provided and make

certain all required padlocks are locked. 1 will insure the 3 way locking system is used.

4. I will sign the nuclear gauge transferal & transporters log before leaving the building and sign the gauge

back in upon returning it to the storage area.

5. I will maintain the shipping papers in the vehicle and within my immediate reach.

6. I will wear my film badge outside of the clothing at the midway point of my body.

7. I will maintain the security of the instrument at all times. I will secure the gauge

immediate after I done testing and will keep the gauge locked in the vehicle when not

in use.

8. I will keep my VDOT Nulclear Certification current.

9. I will maintain the gauge in a clean condition. Any needed maintenance work will be

reported immediately.

10. I will follow all appropriate procedures in the event of an accident, theft or fire

involving the nuclear gauge.

1 1. Any violation may result in discipline Action

Signed

SIIP/6/04

Date

Nuclear Gauge Transferal & Transporter's Log

I (the undersigned) have assumed responsibility for the care and safekeeping of the following equipment for the recorded time.

Location of Assigned Storage Area: Gauge Model Number: Serial Number:

Hot Lane Improvement Project 3440

Date AgencylCompany Time Out User Project Number Vehicle License No. Time In

Attachment I

i

Traibng for individuals frequenting restricted will be successfwl completion authqrized radiation safety training class in accordance with appendix D of NURE 1556.

APPENIIIX I 3

Item No. And Title Suggested Response Alternative I Yes I Procedures I

Need Not Be Submitted PROGRAM -

TRANSPORTATION , t h s issue will be reviewed

B-5 NUREG - 1556, Vol 1. Rev 1

Attachment 5

Radioactive material will be stored in locked Steel Job Box fasteners to the Floor 15 feet away from any fbll time work station. Area will have the required postings.

Attachment 6

Radiation Safety Program

PERSONNEL MONITORING

Ensure all radioactive materials are used only by individuals who are authorized and that personal monitoring devices are worn at all times. Badges will be exchanged at intervals not to exceed 3 months and be provided by an accredited NVLAP processor. Dose reports shall be reviewed by the RSO to determine compliance with regulatory exposure limits and to confirm that personnel exposures are ALARA. The monitoring report shall be posted and the RSO will maintain a copy on file.

SEALED SOURCE LEAK TESTING

Leak tests will be performed at intervals not to exceed 6 months. Leak test samples will be analyzed by an organization authorized by the NRC or agreement state to perform analysis.

RADIATION DETECTION INSTRIJMENTS

We will possess a survey meter in the event of an incident involving the gauge. It will be calibrated annually.

MATERIAL RECIEPT AND ACCOUNTABILITY

Ensure that all terms and conditions of the license and applicable regulations are complied with. Ensure radioactive materials are properly secured against unauthorized removal. Ensure audits are of the program are performed annually and corrective action is taken. Ensure licensed is maintained current and amendment and renewal requests are submitted in a timely manner. Physical inventories of sealed sources will be conducted at intervals not to exceed 6 months. Records of receipt, transfer, and disposal of gauges will be maintained for at least 3 years. Annual audits will be performed and corrective action taken.

PUBLIC DOSE

Ensure that gauges are used, transported, and stored in a manner that no member of the public receives more than 100 mrem in one year. Ensure that the dose in any unrestricted area does not exceed 2 mrem in any one hour.

OPERATING AND EMERGENCY PROCEDURES

Locate sources

0

Seal off or cordon off a 15 fbot radius around the gauge to prevent unauthorized entry. If a vehicle is involved, it must not be moved until the extent of contamination (if any) is determined. Visually inspect the gauge to determine whether the any damage to the source, shielding, or housing has been sustained. As soon as possible notify the RSO. Describe the present conditions and follow the instructions of the RSO.

The RSO will take the following action upon notification of an incident. An incident is defined as:

1. Lost, stolen or missing sources. 2. Events that cause or threaten exposures to individuals in excess of regulatory

limits 3. Leaking or contaminated sealed sources.

Arrange for a radiation survey to be conducted as soon as possible by a knowledgeable person using the appropriate radiation detection equipment to assess the integrity of the source encapsulation and shielding, and determine the extent of contamination, if any, of personnel, equipment, and facilities, or areas. Notify regulatory authorities as required. If initial notification was made by phone, a written report must be submitted within 30 days.

MAINTENANCE

Maintenance shall be conducted by the manufacturer or other persons specifically licensed by the US Nuclear Regulatory Commission or an Agreement State to perform such services.

TRANSPORTATION

Transportation of radioactive material will be in accordance with all applicable Department of Transportation requirements. HAZMAT training will be accomplished at intervals not to exceed 3 years for ground transportation and 2 year intervals if shipping by air.

Attachment 7

No radioactive waste per se is generated by the operations conducted under this license.

Appendix B

Suggested Format for Providing Information Requested in Items 5

through I 1

APPI.3NI)IX t3

ITEMS 5 AND 6: MATERIALS TO BE POSSESSED AND PROPOSED USES

".__..,. .. .

Cesium- 1 3 7

Manufacturer or Distributor Mtdd No.

Sealed so~uce maiiufactiuer x distributor and niodel number

Device manufacturer or iistributor and iiiodcl number

13- 1

Not to exceed either the mas i mum acti\.it>. per sourcc or mas i niuin actkit! per device as specified in Sealed Source and De\ice Registration Certificate

Yes 0

Specific description of the &dUgC LiSe

7 Not ipplicable

7 Uses are

:Submit safety inalysis supporting safe ise 1

MmEG - 1556, Vol. 1, Rev. 1

Califomium- 2 52

QuanHty

Not to exceed either the maximuin activity per source or maximum activity per cic\.ice as specified in Scaled Source and !&\Ice I&&’ ’ Tistration Ceitificate

Sealed source manufacturer or distributor and model number

Device manufactL.rer or distributor and model number

Yes 0

Specific description of the gauge use:

Spec@ Other Uses Not

Listed on SSD Certificate

17 Not applicable

LJ IJses are

(Submit iafct) analysis supportiiig safe use j

I I Financial Asswance Reqiiired and Evidence of Financial Assurance Provided

NURI*;G - 1556. Vol. 1, Rev. 1 13-2

ITEMS 7 THROUGH 11: TRAINING AND EXPERIENCE, FACILITIES AND EQUIPMENT, RADIATION SAFETY PROGRAM, AND WASTE ~~~~~~A~

Item No. And Title Suggested Response

8. TRAININGFOR INDIVIDUALS WORKING IN OR FREQUENTING RESTRICTED AREAS

Before using licensed materials. authorized users u 111 ha1 e successfull) completed one of the trainin? couise dcscribed in Criteria in the section en itled ‘Tiaiiiiiig for Indi\iduals Worhing 1-1 or Freclueiiting Restncted Areas” in NUREG-1556. Vol 1, Rev 1 , dated No\ ernber 200 1

PROGRAM - AUDIT PROGRAM

10. RADIATION SAFETY PROGRAM - SURVEY INSTRUMENTS

We will eii hcr possess and use, or have access to and use. a radiation survey meter that meets the Criteria in the scction entitled “Radiation Safety Progam - Instruments” in NIJIIT~G-l55G, Vol. 1, Rev. 1, dated Novemher 200 1

Alternative Procedures ‘T Attached

Yeed Not Be Submitted With Application

B-:i NIJFEG - 1556, Vol. 1. R ~ v 1

Item No. And Title

10. RADiATlON SAFETY PROGRAM - MATERIAL RECEIPT AND ACCOUNTABILITY

IO. RADIATION SAFETY

OCCUPATIONAL DOSI\l ETR\'

PROGRAM -

IO. RADI;ATlON SAFETY PROGRAM - PUBLIC DOSE

I O . RADIAI'ION SAFETl'

OPERATING ANI) EMERGENCY PROCEDURES

PROCKA hl -

10. RADIATION SAFETY PROGKAM - LEAK TEST

~~ ~

Suggested Response Alternative Procedures Attached

NUREG - 1556; Vol. 1, €&v 1 E 3 4

This is to acknowledge the receipt of your letter!application dated

, and to inform you that the initial processing which includes an administrative review has been performed.

d T h e r e were no administrative omissions. Your application was assigned to a technical reviewer. Please note that the technical review may identify additional omissions or require additional information.

0 Please provide to this office within 30 days of your receipt of this card

A copy of your action has been forwarded to our License Fee & Accounts Receivable Branch, who will contact you separately if there is a fee issue involved.

Your action has been assigned Mail Control Number ztq 7 . When calling to inquire about this action, please refer to this control number. You may call us on (61 0) 337-5398, or 337-5260.

NRC FORM 532 (RI)

(6-96)

Sincerely, Licensing Assistance Team Leader