Columbus Diagnostic Imaging

August 28 2012

United States Nuclear Regulatory Commission Region III 2443 Warrenville Road Suite 210 Lisle IL 60532-4352

RE Control Number 576969

Dear Colleen Carol Casey

This letter is in response to our request for additional information

Attached is the corrected termination letter in regards to License 13-26797-01 The date was corrected

1 Please see attached Close Out Survey 2 Attached are the sealed sources packing List showing receipt by an authorized entity 3 CFR 3111 materials were never possessed or in use at Columbus Diagnostic Imaging 4 Please see Certificate of Instrument Detection Efficiency

Please contact our Administrator Rhonda Lennon at 812376-1000 for further clarification if you desire

Sincerely

9aJtcJ~ Robert A DeWeese M D Radiation Safety Officer Columbus Imaging Associates dba Columbus Diagnostic Imaging

pound0 SE 10 lUll 790 Creekview Drivemiddot Columbus IN 47201middot (812) 376-1000middot (888) 689-42tttCpoundV

Fax (812) 376-6665middot wwwcolumbusimagingcom

Columbus Diagnostic Imaging

July 19 2012

United States Nuclear Regulatory Commission Region III 2443 Warrenville Road Suite 210 Lisle IL 60532-4352

RE License Number 13-26797-01

Dear Colleen Carol Casey

This is a formal request to terminate our License 13-26797-01 Attached is a Certificate of Disposition of Materials along with the Close out survey completed on July 18 2012 by William K Breeden III MS DABR

Please contact our Administrator Rhonda Lennon at 812376-1000 for further clarification if you desire

Robert A DeWeese MD Radiation Safety Officer Columbus Imaging Associates dba Columbus Diagnostic Imaging

790 Creekview Drivemiddot Columbus IN 47201middot (812) 376-1000middot (888) 689-4200 Fax (812) 376-6665middot wwwcolumbusimagingcom

APPROVED BY OMB NO 3150-0028 EXPIRES 1013112013 (02012) NRC FORM 314 US NUCLEAR REGULATORY COMMISSION

Estimated burdampn per responSamp to comply with this mandatory collection request 30 minutes 10 CFR 30360)(1) 40420)(1) This submittal is uSampd by NRC as part 01 the basis lor its determination tIlet the facility is

released for unrestricted use Send comments regardil19 burden estimate to the Information Services Branch (T -5 F53) Us Nuclear Regulatory Commission Washington DC 20555-0001 or by internet amall to InfocollectsResourcenrcgov and to the Desk Officer Office of

70 38U)(1 ) and 7254(k)(5)(1)(1)

CERTIFICATE OF DISPOSITION OF MATERIALS Information and Regulatory Affairs NEOBmiddot10202 (3150-0028) Office of Management and Budget Washington DC 20503 If a means used to Impose an Information colleCtiOn does not display a currently valid OMB control number the NRC may not conduct or sponsor and a person Is not required to respond to the Information collection

LICENSEE NAME AND ADDRESS LICENSE NUMBER DOCKET NUMBER

13-26797-01Columbus Imaging Associates dba Columbus Diagnostic Imaging 790 Creekview Drive LICENSE EXPIRATION DATE Columbus Indiana 47201

A LICENSE STATUS (Check the appropriate box)o This license has expired [] This license has not yet expired please terminate it

B DISPOSAL OF RADIOACTIVE MATERIAL (Check the appropriate boxes and complete as necessary additional space is needed provide attachments)

The licensee or any individual executing this certificate on behalf of the licensee certifies that

1 No radioactive materials have ever been procured or possessed by the licensee under this license 0 [] 2 All activities authorized by this license have ceased and all radioactive materials procured andor possessed by the licensee

under this license number cited above have been disposed of in the following manner

[] a Transfer of radioactive materials to the licensee listed below

Eckert and Ziegler Isotope Products Inc dba Isotope Products Laboratories California Lic 1509-19 Cary Renquist RSO

CIS- ac~JQ[]b Disposal of radioactive materials

[]1 Directly by the licensee

All radioactive waste that was being held for as decay-in storage has been disposed of properly as it has been held for greater than 10 half-lives and was indistinguishable from background exposure rate levels See attached log

02 By licensed disposal site

3 By waste contractor

c All radioactive materials have been removed such that any remaining residual radioactivity is within the limits of 10 CFR Part 20 Subpart E and is ALARA

C SURVEYS PERFORMED AND REPORTED

[] 1 A radiation survey was conducted by the licensee The survey confirms

[] a the absence of licensed radioactive materials

Ob that any remaining residual radioactivity is within the limits of 10 CFR 20 Subpart E and is ALARA

[] 2 A copy of the radiation survey results

[] a is attached or b is not attached (Provide explanation) or c was forwarded to NRC on - _

Date ~-

o 3 A radiation survey is not required as only sealed sources were ever possessed under this license and

[] a The results of the latest leak test are attached andor [] b No leaking sources have ever been identified

The person to be contacted regarding the information provided on this form TELEPHONE (Include Are Code) IE-MAIL ADDRESSNAME I~ITLE

812-376-1000 rhond a [ennonyahoocomRhonda Lennon Practice Manager

Mail all future colTespondence regarding this license to

Rhonda Lennon at address noted above

C CERTIFYING OFFICIAL I CERTIFY UNDER PENALTY OF PER IIIrJV TI-IAT THE FOREGOING IS TRUE AND CORRECT

~~~

I~~ ~~~ ~~~~~~ ~ ID~~~ WARNING F1tSE STATEMENTS IN THIS CERTIFICATE MAY BE SOBJECT TO CIVIL AileOR CRIMINAL PENAL TIES NRC REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRC BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECT 18 USC SECTION 1001 MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATIER WITHIN ITS JURISDICTION

NRC FORM 314 (05middot2012)

Medical Physics Survey Sealed Source Inventory

Facility Columbus Diagnostic Imaging Department Nuclear Medicine

Location Columbus Indiana Date July 18 2012

bull Nuclide

Cs-137 i

Cs-137

Cs-137

Cs-137

Co-57

I

I

i

Activity Date Model Serial No Type

I RV-137shyDose

2198uCi 8197 200V

559-162-7 Calibrator Vial

I

Rod 01065uCi i 8197 IPL 488-31-2

I

Button

10 uCi 1295 None 4646

i shy

Button

10 uCi

I 1295 None 4656

bull

I _shy

Flood 10mCi bull 917108 BM01-10 BM011008220102

Location Present

Hot Lab No returned bull to

manufacturer Hot Lab No returned

to

Ludlum Survey man ufaCturer~1

middot Yes exempt bull Meter quantity to

be sold with

bull camera

I Ludlum Survey bull Yes exempt I Meter

i

quantity to be sold with

camera Hot Lab I No returned

to i manufacturer

Comments Ambient Exposure Rate Survey of Sealed Sources ( Ludlum 14C SN141804 001 mRhr)

Radiation Safety Officer

Provided by Advanced Medical Physics 16770 Cedar Creek Lane Inoblesville IN 46060 3172233022

1m Bathroom l

( -20 imaging

COLUMBUS DIAGNOSTIC IMAGING DAILY AREA SURVEYS

MONTH YEAR -

1 Dose Preparation

2 Dose Calibration l~ 3 Hot Trash Cttl(rhfJ ) 4 Sealed Source Storage(tm

5 Patient Injection Area 6 Gamma Camera 7 Computer Console

~ H~~~ OJIJI

G) Jm~j() 1raquo Door lO-IS ~~ lab t1Olt l-w ~t5~~

flt901f1 flDO (

Ll-- ~s~ J 1 H (~ (t1firl

Trigger Levels-mRhr Bkgd

Day mRhr 1 2 3 4 5 6 7 I

8 9

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

20 20 20 20 10 10 05 ~ HandsClothinq Initials Comments 1 2 3 4 5 6 7 8 111 (

t-) ft -gtY v r A U lLI_) l

J I U JI t I ~l1 OVV ~ I IJ 11 -

I

I

I

I c

i

I

I i

~~~~=~~-------- t----shy -shy----+-I----shyI I I I

I

I i I

I

~~~~~=~~C~~--- -1----------- ---Jshy

NUC-SJGAMMA

cORRIDOR cru

I I

SI 1 ltFe I I EQUIPI 11441

I

I

I I

t1tl~~-middot - middot--~~itmiddotl----~-middot-middot-I---middot-middot-middotmiddot--middot--- -------+-_----shy

6

~

r middot

~ shy ~fIr- _ _ -gt-- v~~

I existing shelf

10

g

8

7

6

-middot5

4

3

2

r l 2 3 4 5 6 7 8 9 10

OI~~__L--k__~~__~~__4-~~~

PRELIMINARY PCANtflNG ONLY PROJECT TITLE

COLUMBUS DIAGNOSTIC IMAGING NUCLEAR ROOM - MILLENIUM MG

COLUMBUS INDIANA SCHEME NO08INA080 DRAWN BY TlD DATE 07-22-0

t)~o

THIS LAYOUT MUST BE APPROVED BEFORE FINAL DRAWINGS CAN 8E STARTED THANK YOU

CUSTOMER DATE

Of ProjectManagerInitalfotion DATE

tlitwoukec bull - -- - - _ - - - WJScollSin

This eq~t loyouIlf(ftCO ue pin and inI_ndlon 0 Ill iMIl_ cqolpmcnt bullbullmporuonb 11gt I bo IlIltIctol 11101 dodor Iocol reqW_ Ihltgtt could Impltlo lite pnt f III ~I It tlllOlns tbo ClIIIom rupbltJly for uriog III oito and flgtOi eqipmnl pIoltomont pIl6gt Milgt 011 appKcble federal otQt ofldor Deal requiremDn15

1m Bathroom l

( -20 imaging

COLUMBUS DIAGNOSTIC IMAGING DAILY AREA SURVEYS

MONTH YEAR -

1 Dose Preparation

2 Dose Calibration l~ 3 Hot Trash Cttl(rhfJ ) 4 Sealed Source Storage(tm

5 Patient Injection Area 6 Gamma Camera 7 Computer Console

~ H~~~ OJIJI

G) Jm~j() 1raquo Door lO-IS ~~ lab t1Olt l-w ~t5~~

flt901f1 flDO (

Ll-- ~s~ J 1 H (~ (t1firl

Trigger Levels-mRhr Bkgd

Day mRhr 1 2 3 4 5 6 7 I

8 9

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

20 20 20 20 10 10 05 ~ HandsClothinq Initials Comments 1 2 3 4 5 6 7 8 111 (

t-) ft -gtY v r A U lLI_) l

J I U JI t I ~l1 OVV ~ I IJ 11 -

I

I

I

I c

i

I

I i

~~~~=~~-------- t----shy -shy----+-I----shyI I I I

I

I i I

I

~~~~~=~~C~~--- -1----------- ---Jshy

NUC-SJGAMMA

cORRIDOR cru

I I

SI 1 ltFe I I EQUIPI 11441

I

I

I I

t1tl~~-middot - middot--~~itmiddotl----~-middot-middot-I---middot-middot-middotmiddot--middot--- -------+-_----shy

6

~

r middot

~ shy ~fIr- _ _ -gt-- v~~

I existing shelf

10

g

8

7

6

-middot5

4

3

2

r l 2 3 4 5 6 7 8 9 10

OI~~__L--k__~~__~~__4-~~~

PRELIMINARY PCANtflNG ONLY PROJECT TITLE

COLUMBUS DIAGNOSTIC IMAGING NUCLEAR ROOM - MILLENIUM MG

COLUMBUS INDIANA SCHEME NO08INA080 DRAWN BY TlD DATE 07-22-0

t)~o

THIS LAYOUT MUST BE APPROVED BEFORE FINAL DRAWINGS CAN 8E STARTED THANK YOU

CUSTOMER DATE

Of ProjectManagerInitalfotion DATE

tlitwoukec bull - -- - - _ - - - WJScollSin

This eq~t loyouIlf(ftCO ue pin and inI_ndlon 0 Ill iMIl_ cqolpmcnt bullbullmporuonb 11gt I bo IlIltIctol 11101 dodor Iocol reqW_ Ihltgtt could Impltlo lite pnt f III ~I It tlllOlns tbo ClIIIom rupbltJly for uriog III oito and flgtOi eqipmnl pIoltomont pIl6gt Milgt 011 appKcble federal otQt ofldor Deal requiremDn15

I i

~~~~=~~-------- t----shy -shy----+-I----shyI I I I

I

I i I

I

~~~~~=~~C~~--- -1----------- ---Jshy

NUC-SJGAMMA

cORRIDOR cru

I I

SI 1 ltFe I I EQUIPI 11441

I

I

I I

t1tl~~-middot - middot--~~itmiddotl----~-middot-middot-I---middot-middot-middotmiddot--middot--- -------+-_----shy

6

~

r middot

~ shy ~fIr- _ _ -gt-- v~~

I existing shelf

10

g

8

7

6

-middot5

4

3

2

r l 2 3 4 5 6 7 8 9 10

OI~~__L--k__~~__~~__4-~~~

PRELIMINARY PCANtflNG ONLY PROJECT TITLE

COLUMBUS DIAGNOSTIC IMAGING NUCLEAR ROOM - MILLENIUM MG

COLUMBUS INDIANA SCHEME NO08INA080 DRAWN BY TlD DATE 07-22-0

t)~o

THIS LAYOUT MUST BE APPROVED BEFORE FINAL DRAWINGS CAN 8E STARTED THANK YOU

CUSTOMER DATE

Of ProjectManagerInitalfotion DATE

tlitwoukec bull - -- - - _ - - - WJScollSin

This eq~t loyouIlf(ftCO ue pin and inI_ndlon 0 Ill iMIl_ cqolpmcnt bullbullmporuonb 11gt I bo IlIltIctol 11101 dodor Iocol reqW_ Ihltgtt could Impltlo lite pnt f III ~I It tlllOlns tbo ClIIIom rupbltJly for uriog III oito and flgtOi eqipmnl pIoltomont pIl6gt Milgt 011 appKcble federal otQt ofldor Deal requiremDn15

6

~

r middot

~ shy ~fIr- _ _ -gt-- v~~

I existing shelf

10

g

8

7

6

-middot5

4

3

2

r l 2 3 4 5 6 7 8 9 10

OI~~__L--k__~~__~~__4-~~~

PRELIMINARY PCANtflNG ONLY PROJECT TITLE

COLUMBUS DIAGNOSTIC IMAGING NUCLEAR ROOM - MILLENIUM MG

COLUMBUS INDIANA SCHEME NO08INA080 DRAWN BY TlD DATE 07-22-0

t)~o

THIS LAYOUT MUST BE APPROVED BEFORE FINAL DRAWINGS CAN 8E STARTED THANK YOU

CUSTOMER DATE

Of ProjectManagerInitalfotion DATE

tlitwoukec bull - -- - - _ - - - WJScollSin

This eq~t loyouIlf(ftCO ue pin and inI_ndlon 0 Ill iMIl_ cqolpmcnt bullbullmporuonb 11gt I bo IlIltIctol 11101 dodor Iocol reqW_ Ihltgtt could Impltlo lite pnt f III ~I It tlllOlns tbo ClIIIom rupbltJly for uriog III oito and flgtOi eqipmnl pIoltomont pIl6gt Milgt 011 appKcble federal otQt ofldor Deal requiremDn15

Radioactive Wastt ~nd Disposal Record

Policy and Procedure 1 Seal and store radioactive waste containers behind adequate shielding 2 Indicate Container ID andor Contents (ie Hot TraSh Sharps etc) 3 Radioactive waste should be held for at least 10 half-lives of the longest-lived radioisotope to be disposed 4 Monitor background and surtace with a GM Survey Meter on its most sensitive scale without shielding prior to

disposal 5 Waste may be disposed of if activity is indistinguishable from background levels 6 All radioactive material labels will be removed andor obliterated before disposal as ordinary trash

0L] ~1YJ

Survey Meter Code

1

2

3

Model Serial Number

c_ r

ttIfn Last Assay 08te of

Waste to lie lJisposed of

r~tko~~middot~-middot~~ oh-ihi _gt Dt( -1

Container 10 JContents

r] tJG-~

Survey Meter

141 cl~fshy n1ht hr~~ch ~

frl-) ~~it1sectP1W~G 1--) I ~ r ~g C1Yl -f~~~llS IO~ ~J1j 84fi12sectt~ ~Jriilif~r)ltJamp --Q qCM Ah2 ~~11 ~ts-h shy I~m ~

~ ~-)7J I~71PZ~~jh 510~ - 1D I ~ I7rD-~ tL ~~1I=1 )jj I -gt J-poundiLill-~7iT-)ridil~~~ tC)V

f n ( - I I M--shy P ~- - v- -shy P -4 shy I ~ if I

f

1 Provided by Advanced Medical Physics 16770 c( ~reek Lane Noblesville IN 46060middot 3172233022 (

m

Radioactive Materials Shipment Rei (and Return Container Survey Record

Action Levels The Radiation Safety Omcer should be immediately notified when radiation or contamination level$ to whicb personnel may be exposed exceed tbe (ollowjng levels

Area Radiation Survey Contamination Surveys

Instruments Usedor Surveys

Meter No Make amp Model

Restricted 50 m81hr J 1OOODPMJIOOcm I 2 tr 0-- I I noV 1-----1

Unrestricted 20 m81hr I 1000 DPMllOO em 1] 3

Serial No Detector Efficiency

Note LQ indicates that the ack e does not exceed s ecified limits fur Limited QuantitidiJlhitm_ellts____---__---_--_________-- Receiot Sm-vey

Container ILabel I IT ITranspo-rt-middoty--=---------+---~c----JA-1t-c~-----+-L---------l----D-at-e lContact

No or III Index 3 mRlhr BKG Initials Retumed I mRlhr

--shy

Date

cm

BKG Cpm Initials

I

Report Date

Facility

State License Number USNRC License Number

Source Identification

Radionuclide Calibrated Activity Date Calibrated Activity Manufacturer Serial Number Model Number Source Description

Assay Results Counting Efficiency MDA Background time of assay cpm)

April 22 2012

Columbus Diagnostic Imaging Columbus IN Not Supplied 13-24706-01

Cobalt-57 090708 10mCi Not Supplied BM01-10 BMOll008220102 Flood Source

0762 cpmdp~ 1691543 cpmuCi 102 dp~ 78 cp~ 000005 uCi 351

Activity (uCi)Gross cpm Netcpm DPM Dry Wipe 000000347 0 0

Instrument used for Analysis Ludlum Well Counter MN2200 SIN 198663

Analysis Results Source is not leaking at this time

Removable contamination is lt0005 uCi

Next Leak Test Due

Leak Test Performed By

Analysis Performed By

Radiation Safety Officer (signature)

I

Report Date

Facility

State License Number USNRC License Number

Source Identification

Radionuclide Calibrated Activity Date Calibrated Activity Manufacturer Serial Number Model Number Source Description

Assay Results Counting Efficiency MDA Background time of assay ~cpm)

Apri122 2012

Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01

Cs-137

080197 2198uCi IPL 559-1627 RV-137-200V

Dose Calibrator Vial Source

02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm OOOQ13 uCi 351

Activity (uCi) Gross cpm Netcpm DPM Dry Wipe 0000000347 0 0

Instrument used for Analysis

Analysis Results

Next Leak Test Due

Leak Test Performed By

Analysis Performed By

Ludlum Well Counter MN2200 SIN PR 198663

Source is not leaking at this time Removable contamination is lt0005 uCi

I October-12 I t IrftL--WillWn K Btteden III MS D~~ April 62012 ~~ fz--v ( t- shy

Edward E WrolewDABSNM

April 22 2012

Officer (signature)

Clouse out survey for Columbus Imaging Associates dba Columbus Diagnostic Imaging

6182012 USNRC Materials License 13-26797-01

IL~ L~~~())~ Location Location Description Exposure Rate (mRhr) Wipe activity(dpml00cmJ2) ~~

1 Dose prep area

2 Dose calibrator

3 Rad waste bins (empty)

4 Seald Source box(empty)

5 patient injection area

6 gamma camera

7 computer console

8 hot lab door and handle

9 imaging room door and handle

10 hot la b floor

11 hot lab floor

12 hot lab floor

13 hot lab floor

14 hot lab floor

15 hot lab floor

16 imaging room floor

17 imaging room floor

18 imaging room floor

19 imaging room floor

20 imaging room floor

21 desk

22 hot lab counter

23 hot lab sink

24 sharps shielding box (empty)

002

002

002

002

002

001

002

002

002

002

002

001

002

002

002

002

002

001

002

002

002

002

002

001

421

421

421

421

403

403

403

18

15

27

29

44

44

32

33 275

279

32

47

31

20

4

14

9

Wipe tests measured with a Capintec CAPRAC SIN 00658 last calibrated 4612

Exposure rate surveyed with Ludlum 14C SIN 101782 last calibrated 33012

Perfomed by William K Breeden III MS DABR

fA-oJ Jl9~( 11 (IQ IJ J(f~ t6JVe

(e-AIl)) P llan Po tVlCft r~

~~~~ ~~ ~ j

-efTIrf 1h1r f~ h~ vr 6~1

~~~~

CERTIFICATE OF CALIBRATION

Customer Advanced Med Phys

Manufacturer BIODEX

Detector Type GM

Detector Model X End Window

D Side Window

X Pancake

High Voltage -y

Date Received March 20 2012

Calibration Date March 30 2012

NEXT Calibration Due March 30 2013

Calibration Data

Scale Distance

(cm)

Instrument MIN 14C

Probe MIN 44-9 Calibration Geometry X Probe II

Cap ON

Window Open Window Closed

Battery Test Acceptable

Reset Check Test Acceptable

Dedicated Check Source Reading (mRhr)

Dedicated Check Source Reading (mRhr)

Dedicated Check Source Activity and SIN

Calculated Measured

Reading mRhr

SIN 101782 SIN PR2424100

X Probe Perpendicular

X Cap Off

] NA

Correction Factor

100x 1000 1813 800800

200 100x 1000 1813 200

x 100 4053 160

x 100 4053 40

x 10 4053 16 160 100

x 10 4053 4 40 100

xl xl

I I

4053

4053 I I

16 160

OA OAO 100

100

x 1 12817 016 016 100

x 1 12817 004 004 100

Comments All instrument readings were within +1- 10 at the time of calibration for all scales used

Applicable correction factors are noted above

This instrument must be checke for proper operation with the dedicated check source prior to

use A reading as indicated above denotes proper operation

UNABLE TO CALIBRATE x 100 SCALE Calibration Source Cs-137 Calibration Date January 15 1985 (+- 3 NBS)

Calibrated Activity 0154 Ci Roentgenshr 1m 00493

MN 773 Source ID S-526

SIN 216 Manufacturer Tech-Ops

Calculated Activity 00821 Ci Roentgenshr 1m 002630 March 30 2012

Photon Measurements Plus Calibrated By _________________

1427 West 86th Street Suite 282 Edward E Wroblewski MA DABSNM

Indianapolis IN 46260

tele 317755-9688 USNRC Materials License Numbcr-13-32533-01

RETURN PACKING LIST All information must be provided to ensure proper

SENOTO

Eckert ampZiegler Isotope Products

1800 North Keystone Street Burbank CA 91504

~~nTjjlllhnmiddot661)309-1010 1-~__ILI~tt--L=-=I--_ampjICI~=----E_~ Fax (661) 257-8303

Email emaIl nucmedsalesezagcom

list must be affixed to the Q~12S and

RETURN RA- 2I fI ofthe package Each returned source EZlflmustb dina1)nHOOne exchange basis ~nly

please contact euroZIP customer service considerations

Reference Serial Capsule Source Wipe Nuclide Activity Date Number D~cription TestsSnCi- J amptQoosaao I ~ IRAbQ)~

(l4t OItli lJIH9f ~ lId) 8J2(gtaL cfgt-57 ~tJ--raquo~s DNo I i i

2) DYes 0 No

3) ___ DYeS 0 No

4) ___ DYes 0 No

If source is damaged broken or le~king describe under Capsule ~scription sectiOfl and submit a copy of the last leak test Keep a copy of this form for your recOrd~ It may be requested by your regulatory agency I acknowledge that the above information is true ~o the best of my knowledge

Contacts Signature

Shippers 24 Hour Emergency Response Number (Required) -- shy

FOR EZIP USE OfllY

EZIP has received ~he radioactive sources listed above e(cel)t as noted below

Receivers Name

Receipt Date -LO

Sources not received NA

Radioactive Materials Shipment Rei (and Return Container Survey Record

Action Levels The Radiation Safety Omcer should be immediately notified when radiation or contamination level$ to whicb personnel may be exposed exceed tbe (ollowjng levels

Area Radiation Survey Contamination Surveys

Instruments Usedor Surveys

Meter No Make amp Model

Restricted 50 m81hr J 1OOODPMJIOOcm I 2 tr 0-- I I noV 1-----1

Unrestricted 20 m81hr I 1000 DPMllOO em 1] 3

Serial No Detector Efficiency

Note LQ indicates that the ack e does not exceed s ecified limits fur Limited QuantitidiJlhitm_ellts____---__---_--_________-- Receiot Sm-vey

Container ILabel I IT ITranspo-rt-middoty--=---------+---~c----JA-1t-c~-----+-L---------l----D-at-e lContact

No or III Index 3 mRlhr BKG Initials Retumed I mRlhr

--shy

Date

cm

BKG Cpm Initials

I

Report Date

Facility

State License Number USNRC License Number

Source Identification

Radionuclide Calibrated Activity Date Calibrated Activity Manufacturer Serial Number Model Number Source Description

Assay Results Counting Efficiency MDA Background time of assay cpm)

April 22 2012

Columbus Diagnostic Imaging Columbus IN Not Supplied 13-24706-01

Cobalt-57 090708 10mCi Not Supplied BM01-10 BMOll008220102 Flood Source

0762 cpmdp~ 1691543 cpmuCi 102 dp~ 78 cp~ 000005 uCi 351

Activity (uCi)Gross cpm Netcpm DPM Dry Wipe 000000347 0 0

Instrument used for Analysis Ludlum Well Counter MN2200 SIN 198663

Analysis Results Source is not leaking at this time

Removable contamination is lt0005 uCi

Next Leak Test Due

Leak Test Performed By

Analysis Performed By

Radiation Safety Officer (signature)

I

Report Date

Facility

State License Number USNRC License Number

Source Identification

Radionuclide Calibrated Activity Date Calibrated Activity Manufacturer Serial Number Model Number Source Description

Assay Results Counting Efficiency MDA Background time of assay ~cpm)

Apri122 2012

Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01

Cs-137

080197 2198uCi IPL 559-1627 RV-137-200V

Dose Calibrator Vial Source

02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm OOOQ13 uCi 351

Activity (uCi) Gross cpm Netcpm DPM Dry Wipe 0000000347 0 0

Instrument used for Analysis

Analysis Results

Next Leak Test Due

Leak Test Performed By

Analysis Performed By

Ludlum Well Counter MN2200 SIN PR 198663

Source is not leaking at this time Removable contamination is lt0005 uCi

I October-12 I t IrftL--WillWn K Btteden III MS D~~ April 62012 ~~ fz--v ( t- shy

Edward E WrolewDABSNM

April 22 2012

Officer (signature)

Clouse out survey for Columbus Imaging Associates dba Columbus Diagnostic Imaging

6182012 USNRC Materials License 13-26797-01

IL~ L~~~())~ Location Location Description Exposure Rate (mRhr) Wipe activity(dpml00cmJ2) ~~

1 Dose prep area

2 Dose calibrator

3 Rad waste bins (empty)

4 Seald Source box(empty)

5 patient injection area

6 gamma camera

7 computer console

8 hot lab door and handle

9 imaging room door and handle

10 hot la b floor

11 hot lab floor

12 hot lab floor

13 hot lab floor

14 hot lab floor

15 hot lab floor

16 imaging room floor

17 imaging room floor

18 imaging room floor

19 imaging room floor

20 imaging room floor

21 desk

22 hot lab counter

23 hot lab sink

24 sharps shielding box (empty)

002

002

002

002

002

001

002

002

002

002

002

001

002

002

002

002

002

001

002

002

002

002

002

001

421

421

421

421

403

403

403

18

15

27

29

44

44

32

33 275

279

32

47

31

20

4

14

9

Wipe tests measured with a Capintec CAPRAC SIN 00658 last calibrated 4612

Exposure rate surveyed with Ludlum 14C SIN 101782 last calibrated 33012

Perfomed by William K Breeden III MS DABR

fA-oJ Jl9~( 11 (IQ IJ J(f~ t6JVe

(e-AIl)) P llan Po tVlCft r~

~~~~ ~~ ~ j

-efTIrf 1h1r f~ h~ vr 6~1

~~~~

CERTIFICATE OF CALIBRATION

Customer Advanced Med Phys

Manufacturer BIODEX

Detector Type GM

Detector Model X End Window

D Side Window

X Pancake

High Voltage -y

Date Received March 20 2012

Calibration Date March 30 2012

NEXT Calibration Due March 30 2013

Calibration Data

Scale Distance

(cm)

Instrument MIN 14C

Probe MIN 44-9 Calibration Geometry X Probe II

Cap ON

Window Open Window Closed

Battery Test Acceptable

Reset Check Test Acceptable

Dedicated Check Source Reading (mRhr)

Dedicated Check Source Reading (mRhr)

Dedicated Check Source Activity and SIN

Calculated Measured

Reading mRhr

SIN 101782 SIN PR2424100

X Probe Perpendicular

X Cap Off

] NA

Correction Factor

100x 1000 1813 800800

200 100x 1000 1813 200

x 100 4053 160

x 100 4053 40

x 10 4053 16 160 100

x 10 4053 4 40 100

xl xl

I I

4053

4053 I I

16 160

OA OAO 100

100

x 1 12817 016 016 100

x 1 12817 004 004 100

Comments All instrument readings were within +1- 10 at the time of calibration for all scales used

Applicable correction factors are noted above

This instrument must be checke for proper operation with the dedicated check source prior to

use A reading as indicated above denotes proper operation

UNABLE TO CALIBRATE x 100 SCALE Calibration Source Cs-137 Calibration Date January 15 1985 (+- 3 NBS)

Calibrated Activity 0154 Ci Roentgenshr 1m 00493

MN 773 Source ID S-526

SIN 216 Manufacturer Tech-Ops

Calculated Activity 00821 Ci Roentgenshr 1m 002630 March 30 2012

Photon Measurements Plus Calibrated By _________________

1427 West 86th Street Suite 282 Edward E Wroblewski MA DABSNM

Indianapolis IN 46260

tele 317755-9688 USNRC Materials License Numbcr-13-32533-01

RETURN PACKING LIST All information must be provided to ensure proper

SENOTO

Eckert ampZiegler Isotope Products

1800 North Keystone Street Burbank CA 91504

~~nTjjlllhnmiddot661)309-1010 1-~__ILI~tt--L=-=I--_ampjICI~=----E_~ Fax (661) 257-8303

Email emaIl nucmedsalesezagcom

list must be affixed to the Q~12S and

RETURN RA- 2I fI ofthe package Each returned source EZlflmustb dina1)nHOOne exchange basis ~nly

please contact euroZIP customer service considerations

Reference Serial Capsule Source Wipe Nuclide Activity Date Number D~cription TestsSnCi- J amptQoosaao I ~ IRAbQ)~

(l4t OItli lJIH9f ~ lId) 8J2(gtaL cfgt-57 ~tJ--raquo~s DNo I i i

2) DYes 0 No

3) ___ DYeS 0 No

4) ___ DYes 0 No

If source is damaged broken or le~king describe under Capsule ~scription sectiOfl and submit a copy of the last leak test Keep a copy of this form for your recOrd~ It may be requested by your regulatory agency I acknowledge that the above information is true ~o the best of my knowledge

Contacts Signature

Shippers 24 Hour Emergency Response Number (Required) -- shy

FOR EZIP USE OfllY

EZIP has received ~he radioactive sources listed above e(cel)t as noted below

Receivers Name

Receipt Date -LO

Sources not received NA

I

Report Date

Facility

State License Number USNRC License Number

Source Identification

Radionuclide Calibrated Activity Date Calibrated Activity Manufacturer Serial Number Model Number Source Description

Assay Results Counting Efficiency MDA Background time of assay cpm)

April 22 2012

Columbus Diagnostic Imaging Columbus IN Not Supplied 13-24706-01

Cobalt-57 090708 10mCi Not Supplied BM01-10 BMOll008220102 Flood Source

0762 cpmdp~ 1691543 cpmuCi 102 dp~ 78 cp~ 000005 uCi 351

Activity (uCi)Gross cpm Netcpm DPM Dry Wipe 000000347 0 0

Instrument used for Analysis Ludlum Well Counter MN2200 SIN 198663

Analysis Results Source is not leaking at this time

Removable contamination is lt0005 uCi

Next Leak Test Due

Leak Test Performed By

Analysis Performed By

Radiation Safety Officer (signature)

I

Report Date

Facility

State License Number USNRC License Number

Source Identification

Radionuclide Calibrated Activity Date Calibrated Activity Manufacturer Serial Number Model Number Source Description

Assay Results Counting Efficiency MDA Background time of assay ~cpm)

Apri122 2012

Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01

Cs-137

080197 2198uCi IPL 559-1627 RV-137-200V

Dose Calibrator Vial Source

02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm OOOQ13 uCi 351

Activity (uCi) Gross cpm Netcpm DPM Dry Wipe 0000000347 0 0

Instrument used for Analysis

Analysis Results

Next Leak Test Due

Leak Test Performed By

Analysis Performed By

Ludlum Well Counter MN2200 SIN PR 198663

Source is not leaking at this time Removable contamination is lt0005 uCi

I October-12 I t IrftL--WillWn K Btteden III MS D~~ April 62012 ~~ fz--v ( t- shy

Edward E WrolewDABSNM

April 22 2012

Officer (signature)

Clouse out survey for Columbus Imaging Associates dba Columbus Diagnostic Imaging

6182012 USNRC Materials License 13-26797-01

IL~ L~~~())~ Location Location Description Exposure Rate (mRhr) Wipe activity(dpml00cmJ2) ~~

1 Dose prep area

2 Dose calibrator

3 Rad waste bins (empty)

4 Seald Source box(empty)

5 patient injection area

6 gamma camera

7 computer console

8 hot lab door and handle

9 imaging room door and handle

10 hot la b floor

11 hot lab floor

12 hot lab floor

13 hot lab floor

14 hot lab floor

15 hot lab floor

16 imaging room floor

17 imaging room floor

18 imaging room floor

19 imaging room floor

20 imaging room floor

21 desk

22 hot lab counter

23 hot lab sink

24 sharps shielding box (empty)

002

002

002

002

002

001

002

002

002

002

002

001

002

002

002

002

002

001

002

002

002

002

002

001

421

421

421

421

403

403

403

18

15

27

29

44

44

32

33 275

279

32

47

31

20

4

14

9

Wipe tests measured with a Capintec CAPRAC SIN 00658 last calibrated 4612

Exposure rate surveyed with Ludlum 14C SIN 101782 last calibrated 33012

Perfomed by William K Breeden III MS DABR

fA-oJ Jl9~( 11 (IQ IJ J(f~ t6JVe

(e-AIl)) P llan Po tVlCft r~

~~~~ ~~ ~ j

-efTIrf 1h1r f~ h~ vr 6~1

~~~~

CERTIFICATE OF CALIBRATION

Customer Advanced Med Phys

Manufacturer BIODEX

Detector Type GM

Detector Model X End Window

D Side Window

X Pancake

High Voltage -y

Date Received March 20 2012

Calibration Date March 30 2012

NEXT Calibration Due March 30 2013

Calibration Data

Scale Distance

(cm)

Instrument MIN 14C

Probe MIN 44-9 Calibration Geometry X Probe II

Cap ON

Window Open Window Closed

Battery Test Acceptable

Reset Check Test Acceptable

Dedicated Check Source Reading (mRhr)

Dedicated Check Source Reading (mRhr)

Dedicated Check Source Activity and SIN

Calculated Measured

Reading mRhr

SIN 101782 SIN PR2424100

X Probe Perpendicular

X Cap Off

] NA

Correction Factor

100x 1000 1813 800800

200 100x 1000 1813 200

x 100 4053 160

x 100 4053 40

x 10 4053 16 160 100

x 10 4053 4 40 100

xl xl

I I

4053

4053 I I

16 160

OA OAO 100

100

x 1 12817 016 016 100

x 1 12817 004 004 100

Comments All instrument readings were within +1- 10 at the time of calibration for all scales used

Applicable correction factors are noted above

This instrument must be checke for proper operation with the dedicated check source prior to

use A reading as indicated above denotes proper operation

UNABLE TO CALIBRATE x 100 SCALE Calibration Source Cs-137 Calibration Date January 15 1985 (+- 3 NBS)

Calibrated Activity 0154 Ci Roentgenshr 1m 00493

MN 773 Source ID S-526

SIN 216 Manufacturer Tech-Ops

Calculated Activity 00821 Ci Roentgenshr 1m 002630 March 30 2012

Photon Measurements Plus Calibrated By _________________

1427 West 86th Street Suite 282 Edward E Wroblewski MA DABSNM

Indianapolis IN 46260

tele 317755-9688 USNRC Materials License Numbcr-13-32533-01

RETURN PACKING LIST All information must be provided to ensure proper

SENOTO

Eckert ampZiegler Isotope Products

1800 North Keystone Street Burbank CA 91504

~~nTjjlllhnmiddot661)309-1010 1-~__ILI~tt--L=-=I--_ampjICI~=----E_~ Fax (661) 257-8303

Email emaIl nucmedsalesezagcom

list must be affixed to the Q~12S and

RETURN RA- 2I fI ofthe package Each returned source EZlflmustb dina1)nHOOne exchange basis ~nly

please contact euroZIP customer service considerations

Reference Serial Capsule Source Wipe Nuclide Activity Date Number D~cription TestsSnCi- J amptQoosaao I ~ IRAbQ)~

(l4t OItli lJIH9f ~ lId) 8J2(gtaL cfgt-57 ~tJ--raquo~s DNo I i i

2) DYes 0 No

3) ___ DYeS 0 No

4) ___ DYes 0 No

If source is damaged broken or le~king describe under Capsule ~scription sectiOfl and submit a copy of the last leak test Keep a copy of this form for your recOrd~ It may be requested by your regulatory agency I acknowledge that the above information is true ~o the best of my knowledge

Contacts Signature

Shippers 24 Hour Emergency Response Number (Required) -- shy

FOR EZIP USE OfllY

EZIP has received ~he radioactive sources listed above e(cel)t as noted below

Receivers Name

Receipt Date -LO

Sources not received NA

I

Report Date

Facility

State License Number USNRC License Number

Source Identification

Radionuclide Calibrated Activity Date Calibrated Activity Manufacturer Serial Number Model Number Source Description

Assay Results Counting Efficiency MDA Background time of assay ~cpm)

Apri122 2012

Columbus Diagnostic Imaging Columbus IN Not Supplied 13-26797-01

Cs-137

080197 2198uCi IPL 559-1627 RV-137-200V

Dose Calibrator Vial Source

02639 cpmdpm 585946 cpmuCi 295 dpm 78 cpm OOOQ13 uCi 351

Activity (uCi) Gross cpm Netcpm DPM Dry Wipe 0000000347 0 0

Instrument used for Analysis

Analysis Results

Next Leak Test Due

Leak Test Performed By

Analysis Performed By

Ludlum Well Counter MN2200 SIN PR 198663

Source is not leaking at this time Removable contamination is lt0005 uCi

I October-12 I t IrftL--WillWn K Btteden III MS D~~ April 62012 ~~ fz--v ( t- shy

Edward E WrolewDABSNM

April 22 2012

Officer (signature)

Clouse out survey for Columbus Imaging Associates dba Columbus Diagnostic Imaging

6182012 USNRC Materials License 13-26797-01

IL~ L~~~())~ Location Location Description Exposure Rate (mRhr) Wipe activity(dpml00cmJ2) ~~

1 Dose prep area

2 Dose calibrator

3 Rad waste bins (empty)

4 Seald Source box(empty)

5 patient injection area

6 gamma camera

7 computer console

8 hot lab door and handle

9 imaging room door and handle

10 hot la b floor

11 hot lab floor

12 hot lab floor

13 hot lab floor

14 hot lab floor

15 hot lab floor

16 imaging room floor

17 imaging room floor

18 imaging room floor

19 imaging room floor

20 imaging room floor

21 desk

22 hot lab counter

23 hot lab sink

24 sharps shielding box (empty)

002

002

002

002

002

001

002

002

002

002

002

001

002

002

002

002

002

001

002

002

002

002

002

001

421

421

421

421

403

403

403

18

15

27

29

44

44

32

33 275

279

32

47

31

20

4

14

9

Wipe tests measured with a Capintec CAPRAC SIN 00658 last calibrated 4612

Exposure rate surveyed with Ludlum 14C SIN 101782 last calibrated 33012

Perfomed by William K Breeden III MS DABR

fA-oJ Jl9~( 11 (IQ IJ J(f~ t6JVe

(e-AIl)) P llan Po tVlCft r~

~~~~ ~~ ~ j

-efTIrf 1h1r f~ h~ vr 6~1

~~~~

CERTIFICATE OF CALIBRATION

Customer Advanced Med Phys

Manufacturer BIODEX

Detector Type GM

Detector Model X End Window

D Side Window

X Pancake

High Voltage -y

Date Received March 20 2012

Calibration Date March 30 2012

NEXT Calibration Due March 30 2013

Calibration Data

Scale Distance

(cm)

Instrument MIN 14C

Probe MIN 44-9 Calibration Geometry X Probe II

Cap ON

Window Open Window Closed

Battery Test Acceptable

Reset Check Test Acceptable

Dedicated Check Source Reading (mRhr)

Dedicated Check Source Reading (mRhr)

Dedicated Check Source Activity and SIN

Calculated Measured

Reading mRhr

SIN 101782 SIN PR2424100

X Probe Perpendicular

X Cap Off

] NA

Correction Factor

100x 1000 1813 800800

200 100x 1000 1813 200

x 100 4053 160

x 100 4053 40

x 10 4053 16 160 100

x 10 4053 4 40 100

xl xl

I I

4053

4053 I I

16 160

OA OAO 100

100

x 1 12817 016 016 100

x 1 12817 004 004 100

Comments All instrument readings were within +1- 10 at the time of calibration for all scales used

Applicable correction factors are noted above

This instrument must be checke for proper operation with the dedicated check source prior to

use A reading as indicated above denotes proper operation

UNABLE TO CALIBRATE x 100 SCALE Calibration Source Cs-137 Calibration Date January 15 1985 (+- 3 NBS)

Calibrated Activity 0154 Ci Roentgenshr 1m 00493

MN 773 Source ID S-526

SIN 216 Manufacturer Tech-Ops

Calculated Activity 00821 Ci Roentgenshr 1m 002630 March 30 2012

Photon Measurements Plus Calibrated By _________________

1427 West 86th Street Suite 282 Edward E Wroblewski MA DABSNM

Indianapolis IN 46260

tele 317755-9688 USNRC Materials License Numbcr-13-32533-01

RETURN PACKING LIST All information must be provided to ensure proper

SENOTO

Eckert ampZiegler Isotope Products

1800 North Keystone Street Burbank CA 91504

~~nTjjlllhnmiddot661)309-1010 1-~__ILI~tt--L=-=I--_ampjICI~=----E_~ Fax (661) 257-8303

Email emaIl nucmedsalesezagcom

list must be affixed to the Q~12S and

RETURN RA- 2I fI ofthe package Each returned source EZlflmustb dina1)nHOOne exchange basis ~nly

please contact euroZIP customer service considerations

Reference Serial Capsule Source Wipe Nuclide Activity Date Number D~cription TestsSnCi- J amptQoosaao I ~ IRAbQ)~

(l4t OItli lJIH9f ~ lId) 8J2(gtaL cfgt-57 ~tJ--raquo~s DNo I i i

2) DYes 0 No

3) ___ DYeS 0 No

4) ___ DYes 0 No

If source is damaged broken or le~king describe under Capsule ~scription sectiOfl and submit a copy of the last leak test Keep a copy of this form for your recOrd~ It may be requested by your regulatory agency I acknowledge that the above information is true ~o the best of my knowledge

Contacts Signature

Shippers 24 Hour Emergency Response Number (Required) -- shy

FOR EZIP USE OfllY

EZIP has received ~he radioactive sources listed above e(cel)t as noted below

Receivers Name

Receipt Date -LO

Sources not received NA

Clouse out survey for Columbus Imaging Associates dba Columbus Diagnostic Imaging

6182012 USNRC Materials License 13-26797-01

IL~ L~~~())~ Location Location Description Exposure Rate (mRhr) Wipe activity(dpml00cmJ2) ~~

1 Dose prep area

2 Dose calibrator

3 Rad waste bins (empty)

4 Seald Source box(empty)

5 patient injection area

6 gamma camera

7 computer console

8 hot lab door and handle

9 imaging room door and handle

10 hot la b floor

11 hot lab floor

12 hot lab floor

13 hot lab floor

14 hot lab floor

15 hot lab floor

16 imaging room floor

17 imaging room floor

18 imaging room floor

19 imaging room floor

20 imaging room floor

21 desk

22 hot lab counter

23 hot lab sink

24 sharps shielding box (empty)

002

002

002

002

002

001

002

002

002

002

002

001

002

002

002

002

002

001

002

002

002

002

002

001

421

421

421

421

403

403

403

18

15

27

29

44

44

32

33 275

279

32

47

31

20

4

14

9

Wipe tests measured with a Capintec CAPRAC SIN 00658 last calibrated 4612

Exposure rate surveyed with Ludlum 14C SIN 101782 last calibrated 33012

Perfomed by William K Breeden III MS DABR

fA-oJ Jl9~( 11 (IQ IJ J(f~ t6JVe

(e-AIl)) P llan Po tVlCft r~

~~~~ ~~ ~ j

-efTIrf 1h1r f~ h~ vr 6~1

~~~~

CERTIFICATE OF CALIBRATION

Customer Advanced Med Phys

Manufacturer BIODEX

Detector Type GM

Detector Model X End Window

D Side Window

X Pancake

High Voltage -y

Date Received March 20 2012

Calibration Date March 30 2012

NEXT Calibration Due March 30 2013

Calibration Data

Scale Distance

(cm)

Instrument MIN 14C

Probe MIN 44-9 Calibration Geometry X Probe II

Cap ON

Window Open Window Closed

Battery Test Acceptable

Reset Check Test Acceptable

Dedicated Check Source Reading (mRhr)

Dedicated Check Source Reading (mRhr)

Dedicated Check Source Activity and SIN

Calculated Measured

Reading mRhr

SIN 101782 SIN PR2424100

X Probe Perpendicular

X Cap Off

] NA

Correction Factor

100x 1000 1813 800800

200 100x 1000 1813 200

x 100 4053 160

x 100 4053 40

x 10 4053 16 160 100

x 10 4053 4 40 100

xl xl

I I

4053

4053 I I

16 160

OA OAO 100

100

x 1 12817 016 016 100

x 1 12817 004 004 100

Comments All instrument readings were within +1- 10 at the time of calibration for all scales used

Applicable correction factors are noted above

This instrument must be checke for proper operation with the dedicated check source prior to

use A reading as indicated above denotes proper operation

UNABLE TO CALIBRATE x 100 SCALE Calibration Source Cs-137 Calibration Date January 15 1985 (+- 3 NBS)

Calibrated Activity 0154 Ci Roentgenshr 1m 00493

MN 773 Source ID S-526

SIN 216 Manufacturer Tech-Ops

Calculated Activity 00821 Ci Roentgenshr 1m 002630 March 30 2012

Photon Measurements Plus Calibrated By _________________

1427 West 86th Street Suite 282 Edward E Wroblewski MA DABSNM

Indianapolis IN 46260

tele 317755-9688 USNRC Materials License Numbcr-13-32533-01

RETURN PACKING LIST All information must be provided to ensure proper

SENOTO

Eckert ampZiegler Isotope Products

1800 North Keystone Street Burbank CA 91504

~~nTjjlllhnmiddot661)309-1010 1-~__ILI~tt--L=-=I--_ampjICI~=----E_~ Fax (661) 257-8303

Email emaIl nucmedsalesezagcom

list must be affixed to the Q~12S and

RETURN RA- 2I fI ofthe package Each returned source EZlflmustb dina1)nHOOne exchange basis ~nly

please contact euroZIP customer service considerations

Reference Serial Capsule Source Wipe Nuclide Activity Date Number D~cription TestsSnCi- J amptQoosaao I ~ IRAbQ)~

(l4t OItli lJIH9f ~ lId) 8J2(gtaL cfgt-57 ~tJ--raquo~s DNo I i i

2) DYes 0 No

3) ___ DYeS 0 No

4) ___ DYes 0 No

If source is damaged broken or le~king describe under Capsule ~scription sectiOfl and submit a copy of the last leak test Keep a copy of this form for your recOrd~ It may be requested by your regulatory agency I acknowledge that the above information is true ~o the best of my knowledge

Contacts Signature

Shippers 24 Hour Emergency Response Number (Required) -- shy

FOR EZIP USE OfllY

EZIP has received ~he radioactive sources listed above e(cel)t as noted below

Receivers Name

Receipt Date -LO

Sources not received NA

CERTIFICATE OF CALIBRATION

Customer Advanced Med Phys

Manufacturer BIODEX

Detector Type GM

Detector Model X End Window

D Side Window

X Pancake

High Voltage -y

Date Received March 20 2012

Calibration Date March 30 2012

NEXT Calibration Due March 30 2013

Calibration Data

Scale Distance

(cm)

Instrument MIN 14C

Probe MIN 44-9 Calibration Geometry X Probe II

Cap ON

Window Open Window Closed

Battery Test Acceptable

Reset Check Test Acceptable

Dedicated Check Source Reading (mRhr)

Dedicated Check Source Reading (mRhr)

Dedicated Check Source Activity and SIN

Calculated Measured

Reading mRhr

SIN 101782 SIN PR2424100

X Probe Perpendicular

X Cap Off

] NA

Correction Factor

100x 1000 1813 800800

200 100x 1000 1813 200

x 100 4053 160

x 100 4053 40

x 10 4053 16 160 100

x 10 4053 4 40 100

xl xl

I I

4053

4053 I I

16 160

OA OAO 100

100

x 1 12817 016 016 100

x 1 12817 004 004 100

Comments All instrument readings were within +1- 10 at the time of calibration for all scales used

Applicable correction factors are noted above

This instrument must be checke for proper operation with the dedicated check source prior to

use A reading as indicated above denotes proper operation

UNABLE TO CALIBRATE x 100 SCALE Calibration Source Cs-137 Calibration Date January 15 1985 (+- 3 NBS)

Calibrated Activity 0154 Ci Roentgenshr 1m 00493

MN 773 Source ID S-526

SIN 216 Manufacturer Tech-Ops

Calculated Activity 00821 Ci Roentgenshr 1m 002630 March 30 2012

Photon Measurements Plus Calibrated By _________________

1427 West 86th Street Suite 282 Edward E Wroblewski MA DABSNM

Indianapolis IN 46260

tele 317755-9688 USNRC Materials License Numbcr-13-32533-01

RETURN PACKING LIST All information must be provided to ensure proper

SENOTO

Eckert ampZiegler Isotope Products

1800 North Keystone Street Burbank CA 91504

~~nTjjlllhnmiddot661)309-1010 1-~__ILI~tt--L=-=I--_ampjICI~=----E_~ Fax (661) 257-8303

Email emaIl nucmedsalesezagcom

list must be affixed to the Q~12S and

RETURN RA- 2I fI ofthe package Each returned source EZlflmustb dina1)nHOOne exchange basis ~nly

please contact euroZIP customer service considerations

Reference Serial Capsule Source Wipe Nuclide Activity Date Number D~cription TestsSnCi- J amptQoosaao I ~ IRAbQ)~

(l4t OItli lJIH9f ~ lId) 8J2(gtaL cfgt-57 ~tJ--raquo~s DNo I i i

2) DYes 0 No

3) ___ DYeS 0 No

4) ___ DYes 0 No

If source is damaged broken or le~king describe under Capsule ~scription sectiOfl and submit a copy of the last leak test Keep a copy of this form for your recOrd~ It may be requested by your regulatory agency I acknowledge that the above information is true ~o the best of my knowledge

Contacts Signature

Shippers 24 Hour Emergency Response Number (Required) -- shy

FOR EZIP USE OfllY

EZIP has received ~he radioactive sources listed above e(cel)t as noted below

Receivers Name

Receipt Date -LO

Sources not received NA

RETURN PACKING LIST All information must be provided to ensure proper

SENOTO

Eckert ampZiegler Isotope Products

1800 North Keystone Street Burbank CA 91504

~~nTjjlllhnmiddot661)309-1010 1-~__ILI~tt--L=-=I--_ampjICI~=----E_~ Fax (661) 257-8303

Email emaIl nucmedsalesezagcom

list must be affixed to the Q~12S and

RETURN RA- 2I fI ofthe package Each returned source EZlflmustb dina1)nHOOne exchange basis ~nly

please contact euroZIP customer service considerations

Reference Serial Capsule Source Wipe Nuclide Activity Date Number D~cription TestsSnCi- J amptQoosaao I ~ IRAbQ)~

(l4t OItli lJIH9f ~ lId) 8J2(gtaL cfgt-57 ~tJ--raquo~s DNo I i i

2) DYes 0 No

3) ___ DYeS 0 No

4) ___ DYes 0 No

If source is damaged broken or le~king describe under Capsule ~scription sectiOfl and submit a copy of the last leak test Keep a copy of this form for your recOrd~ It may be requested by your regulatory agency I acknowledge that the above information is true ~o the best of my knowledge

Contacts Signature

Shippers 24 Hour Emergency Response Number (Required) -- shy

FOR EZIP USE OfllY

EZIP has received ~he radioactive sources listed above e(cel)t as noted below

Receivers Name

Receipt Date -LO

Sources not received NA

RETURN PACKING LIST All information must be provided to ensure proper handling of your return

FROM SENDTO

Company Name

Address

City

i Eckert amp Ziegler Isotope Products

1800 North Keystone Street Burbank CA 91504 Telephone (661)309-1010 Fax (661)257-8303 Email nucmedsalesezagcom

RETURN RAshy 2( STOP This packing list must be affixed to the OllTSIOE and a copy placed inside of the package Each returned source to EZIP must be on a one-to-one exchange basisnnly For additional returns please contact poundZIP customer service for additional cost considerations

Nuclide Activity

1gtamp5-1312fj$ C

2) Csift t)middotlCfflAC

3) ___

4) ___

Reference Date

Serial Number SS shy ~t-

crt Itt lft6-3-L

Capsule Description

Source Wipe Tests SnCi

IN Gi(tIJ~- )I~) S~ e~ 0 No

amp) St1 rC f ~o DYes 0 No

CJ Yes 0 NCigt

If source is damaged broken or leaking describe under Capsule Description section and submit a copy of the last leak test Keep a copy of this form for your records It may be requested by your regulatory agency I acknowledge that the above information is true to the best of my knowledge

Contacts Signature

Shippers 24 Hour Emergency Response Num~er (Required)

FOR EZIP USE ONLY

EZIP has received the radioactive sources listed above except as noted below

Receivers Name~I~~ tgtltl~ ~No~Q1)s _Co -~bullbullbull - bullbullbull~-~~ -----shy ~ -- - -shy

Receipt Date ~ ~)- ) I

Sources not received riNA

1a902of2

Certificate of Instrument Detection Efficiency for

Columbus Diagnostic Imaging Columbus Indiana

April 6 2012

Instrument Capintec Caprac Well Counter

Instrument Net Conversion DetectionSource Activity Calibration Date

Settin CPM Factor Efficienc

Co-57 09967 uCi 4110 Well 302213 112dpmcpm 8929

MDA= 5x10-5

106 dpm

Results These results are within acceptable limits

-qA Radiation Safety Officer

Advanced Medical Physics LLC 9095 Doral CourtD bull Indianapolis IN 462503172233022 3178495058(fax) ~~~~

Certified in Medical Nuclear Physics by the American Board of Radiology

-~ C~lumbus II~USPOSTAGE Diagnostic ~ IUS POSTAGE $ 0 105 $ 0045 RRSTClASS

bull L l1li-shyImaging RRST ClASS

Mailed From 47201 bull 091042012 031A 0002309440

J ~ 031A 0002309440790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200

Fax (812) 376-6665

Certificate of Instrument Detection Efficiency for

Columbus Diagnostic Imaging Columbus Indiana

April 6 2012

Instrument Capintec Caprac Well Counter

Instrument Net Conversion DetectionSource Activity Calibration Date

Settin CPM Factor Efficienc

Co-57 09967 uCi 4110 Well 302213 112dpmcpm 8929

MDA= 5x10-5

106 dpm

Results These results are within acceptable limits

-qA Radiation Safety Officer

Advanced Medical Physics LLC 9095 Doral CourtD bull Indianapolis IN 462503172233022 3178495058(fax) ~~~~

Certified in Medical Nuclear Physics by the American Board of Radiology

-~ C~lumbus II~USPOSTAGE Diagnostic ~ IUS POSTAGE $ 0 105 $ 0045 RRSTClASS

bull L l1li-shyImaging RRST ClASS

Mailed From 47201 bull 091042012 031A 0002309440

J ~ 031A 0002309440790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200

Fax (812) 376-6665

-~ C~lumbus II~USPOSTAGE Diagnostic ~ IUS POSTAGE $ 0 105 $ 0045 RRSTClASS

bull L l1li-shyImaging RRST ClASS

Mailed From 47201 bull 091042012 031A 0002309440

J ~ 031A 0002309440790 Creekview Drivemiddot Columbus IN 47201 (812) 376-1000 bull (888) 689-4200

Fax (812) 376-6665