1111111111111111111111 11111 111111111111111 IIIII IIII ... · 1111111111111111111111 11111 111111111111111 iiiii iiii 1111111111111111111 gl-706899-24 01/15/2019 nrc form 664 (04-2018)

1111111111111111111111 11111 111111111111111 IIIII IIII 1111111111111111111 GL-706899-24 01/15/2019

NRC FORM 664 (04- 2018)

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111111111111111111 IIII IIIIIII Ill llll IHI SECTION 1 PAGE 1 of 2

U.S. NUCLEAR REGULARTORY COMMISSION

10 CFR 31.5 GENERAL LICENSEE REGISTRATION

APPROVED BY 0MB: NO. 3150-0{98 0MB EXPIRATION DATE: 02/28/2019 Estimated burden per response to comply with this mandatory collection request 20 minutes. NRG will use this informationto track general licencees and their devices to ensure a higher level of device accountability. Send comments regarding burden estimate to the FOIA, Privacy, and Information Collection Branch (T-5 F53), U.S. Nuclear Regulatory Commission, Washington, DC 205555-0001., or by internet e-mail to lnfocollects. [email protected], and to the DeskOfficer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0198), Office ·of Management and Budget, Washington, DC 20503. If a means used to impose an information Collection does not display a currently valid 0MB control number,, the NRG may not conduct or sponsor, and a person is not required to respond to, the information collection.

Complete all six sections of this registration form. If any of the preprinted information is incorrect, provide the changes in the applicable boxes. USE CAPITAL LETTERS.

Gen·eral License Retjistration Number

, -GL-706899-24

SECTION 1 - GENERAL LICENSEE INFORMATION

Enter the company name and the street address for the physical location of use for your device(s). For portable devices, specify the primary storage location. Do not use P .0. Boxes.

Company Name: SEKISUI VOLTEK LLC

· 1. I 1 · I · I I ·1 1 · 1 I I I ·I' Department:

' ' ,'

Address Line 1: 17 ALLEN AVENUE

Address Line 2:

1 · I: l l I r· · · 1 l I I I I r I - J :J_ - I -r · I · I ·1 :··: r ·_ :-l ·, I City: COLDWATER ,

· 1111111111111111111111111111111111111111111111111111111111111111111111 1111111111111 IIHI llll lllllll 11111111111 GL-706899-24

-0'1 /15/2019

SECTION 1 - GENERAL LICENSEE INFORMATION (Continued) .

SECTION 1 PAGE 2 of 2

Enter the name, telephone number and title of the person who is the responsible individual for the device(s) .

. Last Name: OSTRANDER

I r·. ·1 I I l I L :I'. I r· J 1· .: J I -l J .. l L . I 1-- I' .. ~l J.

First Name: DONALD Middle Initial: R

1 _ -r r J ··1. 1· I' I I :. [ l ·1 -l · I D -s'usiness Telephone Number: (517) 279-3527 Extension:

t . I I · 1 r I I IL I I. I I I ··1 l : I I :.1 · Title: MAINTENANCE MANAGER

. .

Enter the mailing address where correspondence regarding your device(s) should be sent.

Department: ·

Address Line 1: 17 ALLEN AVENUE

, ·Address Line 2:

City: COLDWATER -r·, J 11 -r 1-:--1 ·.r,_.:1·- 1 1. 1 ·1:·<:i,···J--.1·~:-1.·, --1· _[.-.1:.,«'r--1 ., ' ' , ¥

. State: Ml rn. Zip Code: 49036 r_:· __ -1:;_·:r:. ·r ·: ·I r~ J.}·J __ ;··_r: -J:. :r

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. 01/15/2019 s·EcTiON 2 - DEVICES SUBJECT TO REGISTRATION bur re·cords indicate that:you have these d~vices. Please updtae the··information as necessary. ·

Sl=CTION 2 ....... PAGE 1 of 9

NRC Device Key 634666. - (Internal Control Number) . '.' ' . . '

Oistributbr/Dustributed By: Honeywell International, Inc. Radiological Operations . .. . _

r:--/J··_:_: .J:~~{···l'. --~-;.l' ,--:; Ji;isl_ · :.f >.::r·· -·•J-.>·.::1..·~;'.Jt ~~ ::J_·:;;:1:;:,:::,~l:k~~J:;:\.T,:;:: · f:i;'·~t: '~·J_:·~'.>J.:.~~->t: :\:f :_;:~<l:··. • ., • ,.·. • ., "' •• ,.·.:..,.'" ••~ ,, ••. '">.., .,·~-,1...,·••',;~,';''·._,. ,'•,,•';,:,\.:,~,J , .. ,,1,-?C,,~~-, • ."._..; .. •.>',"',,,,;•,•,,•"•.'

Distributor License Number: 1856-43 Gl

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l\llam.:ifacturer name: HONEYWELL INTERNATIONAL, INC.

°.~vr7e ~~-de~ (~ot Source ~odel): 2~0t . . . _ . . . . __ . . .• .. .. . . _ _ . . , __ :: ·: ·· _ .e

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Devk:e Serial Number: 10208G , : · · ·

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Transfer Date: · 06/01/2001

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SECTION 2 - DEVICES SUBJECT TO REGISTRATION 01/15/2019 bur records indicate that you have these devices. Please updtae the information as necessary.

NRC Device Key 697398 (Internal Control Number)

Distributor/Dustributed By: INDEV GAUGING SYSTEMS

I I I I' t. 1> I _ I r I, I ,I I:- I . I_ "J· I I I 1 I I _ ·;1 ·. l Distributor License Number: IL-02050~01

11-11 ILi Irr I lll Manufacturer name: INDEV GAUGING SYSTEMS

Device Model (Not Source Model): 015202

I l I I' I I I ·1 . r I f J I 1 · I f f I 1 I 1· ·1· I I Device Serial Number: LP357

I I ·1 · I · I · 1 _ J I I I I I I I·_ I : I ·I , 1 _· ,l ~I I ~ I . ,_I J Transfer Date: 08/22/2003

SECTION 2

PAGE 2 of9

ITJITJI J I I I JNot in possession of device (Also ~ complete Section 4.)

MM DD YYYY

Isotope (e.g. AM241) Activity (e.g. 1005) Unit (e.g. mCi)

1 SR90 100 mCi

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· 01/15/2019 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 Oi:.fr records indicate that you have these devices. Please updtae the information as necessary. .. ' : . . PAGE 3 of 9


bistributor/Dustributed By: Honeywell International, Inc. Radiological Operations

1 ...• J ·. J. l ··.t ·•··.· I. J J ·J JJ ... J .l{ I <]:.:I :·1:,J~s:i F~l:'J,A *I;· Distributor License Number: 7-513

Manufacturer name: HONEYWELL INTERNATIONAL, INC. .

Device Model (Not Source Model): 4203 . ; .

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Device Serial Number: NB363 .· . . . ·· , ,

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Transfer Date: · 10/12/2005

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D Not in possession of device (Also complete Section 4;)

. :· Isotope (~.g:AM241)

1- :, SR90. . .

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SECTION 2 - DEVICES SUBJECT TO REGISTRATION 01/15/2019 Our records·indicate that you have these devices. Please updtae the information as necessary.

NRC Device Key 740005 (Internal Control Numbe~)

Distributor/Dustributed By: Honeywell International, Inc. Radiological Operations

1 - I I- I I: . I I l I l I ·:I I -I t·-- ·1 t I I :I . I t . · 1 __ -I Distributor License Number: 7-513

I J J I I I I l 1· I I · I I I Manufacturer name: HONEYWELL INTERNATIONAL, INC.

I I ! -I I I I I I l I ··1 I L l l I l ·l ·1 l -·r . l ,, ·1 • ~ • • ' • ' ' T ' ,' • • • • ' ' < • ; ' • • 0


I - -1 I I I I - ·I l .. I I I I I - -1 l l .I I -l r I :J I: I Device Serial Number: LV742

Transfer Date: 10/24/2005

SECTION 2

PAGE 4 of 9

- CDITJI I I 11 D Not in possession of device (Also complete Section 4.)

MM DD YYYY

. Isotope (e.g. AM241) Activity (e.g. 1005) Unit (e.g. mCi)

1 SR90 50 niCi

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PAGE 5 of9 Our records indicate that you have these devices. Please updtae the information as necessary.


Distributor/Dustributed By: Honeywell International, Inc. Radiological Operations

I. I l l· [ ·1 .,J .. l 'J.- .. -1 .:I J I ·1~ .:1:_J __ .:.1 >l l -1 l l._-1. I Distributor License Number: 7-513

r: -I l J . I l I ', I '. r . r J I J_ . I Manufacturer name: HONEYWELL INTERNATIONAL, INC.


I ·1 I I r l. I I' r I ·. I I I · f -r I · I; r - , I . r·.- 'l.'; , r> l Device Serial Number: NP425

Tra·nsfer' Date: 03/02/2006

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Our records indicate that you have these devices. Please updtae the information as necessary. PAGE 6 of g


bistributor/Dustributed By: Honeywell International, Inc. Radiological Operations

I ·1 I I f: ·1 I 1 I!: I .I .'I I. .. -I .1 ·J I l I · 1 I ·_ 1 · 1 · I Distributor License Number: 7-513

Manufacturer name: HONEYWELL INTERNATIONAL, INC.

I 1 I 1· r I ] I I I · 1 I r I . I I I l l 1.· I I 1 l ' ·' - . . . ,• .. ' . ,, ,.•' " ...... ·-:

Device Model (Not Source Model}: 4203

I I -·1 I I I I I I : l . I r l I. - 1 .. · r _ I I I r J , . . I . I Device Serial Number: NP426

· Transfer Date: 03/09/2006

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1 SR90

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NRC Device Key . 750793 (Internal Control Number)

Distril::5utor/Dustributed By: Honeywell International, Inc. Radiological Operations · · · .

1. J .. 11. . l .. 1. r :,1.:.. u.,r = 1\,1 .. J t ·I : · t;J,: r] _,~J ;:Jb·?t .. ,.:~,jJ{tff · · Distribut0r License Number: 7-513

Manufacturer ·name: HONEYWELL. INTERNATIONAL, INC.

Device ·Model (Not Source Model): 4203

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Device:Serial Nur'nher: NP427 . · _ ..

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24· SECTION 2 - 01:v1cEs s(JBJECT to REGISTRATION, : ·· ,· · . sEcT10N 2

Our records indicate that you have these devices. Please updtae the information as necessary.. .' . , . PAGE a of 9·

. NRC Device Key. 829017 (Internal Control Nu'mber)

Distrib.titor/Dustributed By: Honeywell International , .

1 .. 1.1 .• r . t LrL.·l :.1:011.1 .. 1_;,e.1;·1.x1.;1:1Ja.rc1· · Distributor License Nurnber: GA 832-1 G

Manufacturer name: HONEYWELL INTERNATION, INC.


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Device Serial Number: AB9014. . .

1 • .•. J. J J .. [ vJ. [:.,n.1.;: L'l :I f :·t ,b:iJHVl:rJjJ :f ,:t:;(l < . Transfer bate: '.09/06/2013

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yyyy

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GL-70E>8.99-24 01/15/2019 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2

Our re'cords indicate that you have these devices. Please updtae the information as necessary. · PAGE g of g

NRG 'Device Key 850782 (Internal Control Number)

Dfsfribufor/Dustributed By: · Honeywell International • •. • • - - "• < -• • ,.,' • , __ • ••• •' • " • - ,• ••• - ,•,.. • •-•• - C -, • - •• ••• •••' • > ' • -• • •~°' • ' < ••• •• • •• :. • -·' •• •., •••• ••••• ••• o• • - - - - ·- --~ - •• •• •• {, ,-. "••

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[· :_:J : :t: J- ··J . J_ -- f :_:_.J Cl- {\: l. -·-~1- 1~· I. ' - .. '

Manufa·cturer name: HONEYWELL INTERNATION, INC. - . ' . -

Device Model (Not Sou'ree Model): 4203

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Device Serial Number: LV747

Tra·nsfer Date: · 08/28/2018 ·

· [TI:ITJh-.J·J.·•1-.1-. D Not in possessi~~}~! device (_Also· complete Section 4,)·, · · ·

· .MM DD YYYY

. lscitope(e.g."AM241) .

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I IHIIII IIIIII II llllll lllll lllll 11111111111111111111111111111111111111 . .111111111:111111111111111111111 GL-706899°24 01,1 s,2crfa . . . . . . . . · SECTION 3

SECTION 3 - ADDITIONAL DEVICES SUBJECT TO REGISTRATl'ON . . _PAGE 1 of 1 . · Provide information about other devices you have that are subject fo registration. Do not report specifically licensed devices.

. ' . Manufacturer Name

I . 1 J I I I I I I I I I I I .:( I ·1 I I I I . I : i. · . I. I I I I Initial Transferor Name

I· I. I. I I. I I I I I I I I 1: l I I I I l I ·.J ·I: .. I .. I I I I. · . · l~_itial Transferor License Number (if known) · . . .

I .. I I . · 1 I I I I I I I I I . . .

De\iice Model Number (Not Source Model) · • · .,' ·

1 · ·1 I . I I I I I I I 11 I I I I· I I I I. I . I J- I ·I I · I I ' ' \ -

Device Serial Number . . . . . · . , : _·

I II. I I I. I I ·I I I. I I 1.J I.I I I 1.1 .... l.:J: .. -J::·1.I. ·; How acqaired ~nd date'(e.g., 0 Manufacturer/Initial Transferor lis·ted above . . _. . _"'. . . · .. '. :. · : . . . . :·

" . from a_ distributor/manufacturer, () Oth~r General Licensee ' Date Transferred: J :. I'.:·· ... +1-:c l·.:j t ; J . I I I . other hcen'see, other source)? · · · · · · ·

· . · 0 Other Sources · MM • DD · · · : · YYYY

1.

2.

lsotope·(e g. AM241)

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s·.·

6. . . .

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9 · · · .____I '--------'----'~1________.·

1_0. ·1 ~ ._______...____~I--------' ,. .

Activity (e.g. 100) : · · ·.. · Unit (e.g mCi)

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.____.___'----JI_____.I_____.· I_____.. _____.I~·~· l_,.··'··~··,J. -~-.:-· ~-~ ,____,__...___.____,I_____.____._____.I_____.· ----->----LI~· . . -----'-'J .. . '----------'---~

l . I. · _· I . .____.___.________.I ___._________.___._________.~-____._-: I'.~·-. ~-~:I ·- · · '-'---------'--~

.____.___~I ___._________.___._________.~~· · 1_____.. · I~-• --, .. · .. · · . .________.____.____.

,____,__'----JI ' I____.. . _____.____._____,_______,,~. . '~· I C 1_.-~-.L: . ' '----'--------'--'

L--'----'-· '-----'--JI 1'-----'· '-----'..I_,. '-----'-----------'I---'.. ·1-'-----'---'. . I--'-'-'--'·:. f · · '-'--' _____.____. ,____,__~I· I.._____.· ~-l___._________.~J___,_ .. I_____.. I~-J _. ~_, ,____,__l'-----'1----"--'. . ____.I~• _____,_______,,I_____._I____._· . . · I_____.: .1_.. , · I' ·. .____·· ~

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1111111111111111 IIIIII IIIII IIIII IIIII IIIII IIIII IIII IIIIII IIIII IIII IIII I llllllll llll 11111111111111111 GL-706899-24

01/15/2019 SECTION 4 - NOT IN POSSESSION OF DEVICE SECTION 4

Provide information about devices listed in Section 2 or 6, but no longer in your possession. PAGE 1 of 1

Part 1 Transfer Date:

NRC Devi~e Key: 161 71 7131913 I I '0171 I ZI ~ II~ o:I 1 Ir I (from Section 2 or6) - - - - - - - - ~ · . - . · ·'- . MM DD YYYY

Location of the Device:

0 Whereabouts Unknown (Complete Part 1 only) @' Transferred to another general licensee (Complete Parts 2 and 3) 0 Never Possessed the Device (Complete Part 1 only) 0 Transferred to a Specific Licensee (Not the manufacturer) 0 · Returned to Manufacturer (Complete Part 1 only) (Complete Part 2)

· Part 2 License Number of Recipient (if transferred to a specific licensee):

ll l8l3ltl-lYIJ I l~l:LI l I I Company Name:

1/flolPlc1YlwlJ3:I LJt, I 1:J?IPl1]§1'11-1011~1J:J oj/t;'Jlfl?J tj:}v\cl Department:

I I I I. I I I I I I I I I I I .I I I I I I . . I I J I I I I Address Line 1:

151017111 V11A [lt11Jtifl~IEI ill/(lk1 IYI littJ?t Ir 16 1°1 I Address Line 2:

I I I I I I I I I I I I I I I I I I I .I -I I I ·1 I I I I City:

IP i lf I tr I t:C I iif I 1 · I I I I I I I I I I I I I I I I I I I State: I{; I A I Zip Code: t3 I C) k± 12 171 -I I I J I Part 3 Enter the name of the individual responsibe for this device: Last name:

1·1fl8l){IR 16lllL I I I I I I I I I I I I I I. I I I I I I I First name: Middle Initial:

I./\ It) IP I I I I I I I I I ·1 I D ~~~~:~~ Telephone J J 17 1£1 II b I ~ 11 II {? I / I y1 I ? I Extension: ~, 1~,~,~,___,, Title:

I I I I I I I I I I I I I I I I I I I I I I I I I I I

I IHllll 11111111111111 lllll lllll lllll lllll 1111111111111111111111111111 GL-706899-24

01/15/2019

I hereby certify that:

SECTION 5 - CERTIFICATION

111111111111111111111111111111

SECTION 5 PAGE 1 of 1

· A. All information contained in this registration is true and complete to the best of my knowledge and belief.

B. A physical inventory of the devices subject to registration has been completed, and the device information on

this form has been checked against the device labeling.

C. I am aware of the requirements of the general license, provided in 10 CFR 31.5.

(Copied of applicable regulations may be viewed at the NRG website at:

e,/6/;1 SIGNATURE - RESPONSIBLE INDIVIDUAL (Listed in Section 1) DATE

WARNING: FALSE STATEMENTS MAY BE SUBJECT TO CIVILAND/OR CRIMINAL PENALTIES. NRG

REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRG BE COMPLETE AND ACCURATE IN ALL

MATERIAL ASPECTS. 10 U.S.C SECTION 1001 MAKES IT A CRIMINAL Oi=FENSE TO MAKE A WILLFULLY

WRONG STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED.STATES AS TO

ANY MATTER IN ITS JURISDICTION.

. I IHIIIIHIIII II IIIIII IHII IIIII IIIII IIIIIIII II llllllllll lllll llll IHI . · Iillillll'llll,llfll llll llll Ill I GL-706899~24 .

01/15/20,19 ' SECTION 6 ~ DEVICE NOT SUBJECT TO REGiSTRATION ··.·.· .. ,:,·SECTION 6 .. : .. '·:: PAGE 1 of 1·

NR~ D«!vice Key: 732227 Manufacturer 'License 'No: 7-513

Mam1facturer Name: HONEYWELL INTERNATIONAL, INC ..

1\1108e1· Number: 4203

. l§otdpe: K~85

Serial #: LF853 ·

. Activity: 1000

'NR:C Devi~e Key: 841,250· Manufacturer Litense No: . · GL-142-02

Manufacturer Name: MAHLd CONTROLS SYSTEMS AUTOMATION

Mocief Number: 11 '-200933

. 1.~?t:0'pe: KR85

;NRC: tievi~e Key: 841251

Serial #: Af-1.:5716

Activity: 9.62

Manufacturer Licens~ Nb: GL-142-02

Manufacturer Name: ·MAH LO CONTROLS SYSTEMS AUTOMATioN

Moael Number: 11-200933

· .1s'6ttfpe::·· KRas.;.

NR'C Device Key: 846913

Serial#: AG~783

Activity: 9.62

Manufacturer License No: GL-142-02

ManUfclcturer Name: iVIAHLO CONTROLS SYSTEMS·AUTOMATION

· ·Model Number:. 1·1.:.260933. · ' ' .

. 1sotop;e:· f<Rs5: ,.:::;_,,,.. . '•

· Serial#: AJ-7105

Activity: 9.62 ·

Transfe'f "d~tf · . 03/04/2005

Unit: m'ci·

T · __ :~:. ::o····t··.···'0610112016 rans,er. a e ..

Unit· ,GBq

. : -L ,. ,: i ; : .. , Transfer Date: . : 06/0112016

·un·1t·.·.·. G. ··s·q·. ·.~..: ·. · ... :,. ·; .. ~ .,-~ ,

,". '. ~: .:. ~.: ~~ . -_ .

trahsfe~·Date/ · 08/l7/2017 . ·'

NRc:.bevice Key: 850773 . .· · · Manufacturer License NO: 2·0-6752 (MA) ..

Manufactlirer N~me: THERMO EGS GAUGING, INC. ·

-Model·Number:'··tFc:.185

·isotope:·· KR85 .

. '

l ' ~- - ,.

' ."·\ -,

Serial #: QC00124··

Activity: 1250'

_, .. ,··.' ..

ir~msf~r Date:. :0·8/28/2018

Unit:·, mCf ..

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Documents

1111111111111111111111 11111 111111111111111 IIIII IIII ... · 1111111111111111111111 11111 111111111111111 iiiii iiii 1111111111111111111 gl-706899-24 01/15/2019 nrc form 664 (04-2018)