May 28.2013

Marian Medical Services. LLC 906 Kingsridge Court

Wildwood, Missouri 63021

Material Radiation Protection Section United States Nuclear Regulatory Commission, Region IV 1600 E. Lamar Boulevard Arlington. TX 76011-451 1

Re: Form 314 for RAML #24-29248-01

U.S. Nuclear Regulatory Commission:

This letter is to inform you that we will be terminating our licensed activities at one of our 3 licensed facilities. This facility is located at: 75-170 Hualalai Road, Unit #C 11 0, Kailua-Kona, HI. 96740. All locations are listed on RAML #24-29248-01. Please note that we do not want to terminate the entire license, just licensed activities at this one location. The remaining two locations will continue with licensed activities.

Included with this letter are NRC FORM 314 and all necessary documentation to complete this form.

If you have any additional questions or concerns please contact me at (808) 487-0814.

Sincerely,

~~ Blaine Ikeda, Pharm D Radiation Safetv Officer

Enclosures

cc w/enclosures: Jere and Mark Palazzolo

PUBUC o /j)Imed1.1e R., .... ~ormal Rele ...

NON·PUBUC o A.3 S.nsllive-S.curlty ReIUld o A.7 Sensltiv. Inlem.' o Other:,_ .-__ _

RevIewer: h D.Ie:~

RECEIVED

JUN 0 3 2013

DNMS '.I.., ~ .....

U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0028 EXPIRES: 1013112013 NRC FORM 314 (Q5.2012) 10 CFR JO.36(j)(1); 40.420)(1); 70.380)(1); and 72.54(k)(5)(1)(1}

CERTIFICATE OF DISPOSITION OF MATERIALS

Estimated burden per re5p:K1Se 10 comply with this mandatory ooIIecOOn request 30 minutes. This submittal is used by NRC as part of the basis for its determi'lation that the facility is released for unrestricted use. Send comments regarding burden estimate 10 the Information Services Bra1ch er-5 F53), U.S. NLdear Regulatory Commission, Washilglon, DC 20555-0001 , or by internet e-mail to Infocollects.Resource@f1It.gov, and 10 the Desk Officer, Office of Infoonation and RegulatOfy Affairs, NEQB-10202, (3150-0(28), Office of Managemeflt aod Budget, Washington, DC 20503. If a means used 10 impose an information coIIedion does nol display a WITerlHy valid OMS control number, the NRC may not conduct or sponsor, and a person is 001 required to respond to, the informatm ooIIectioo.

LICENSEE NAME AND ADDRESS LICENSE NUMBER DOCKET NUMBER

I"A/<.IM Aalc.Al... ~cf?.i/;<-£S 75-/"70 HrJALA'-A1 ,;<!OAb. (/~rT c./IO

J

;:A.t<-v.<l - K.O,..JA./ j-f.I '767<f-O LICENSE EXPIRATION DATE

~ -31· }-o(7

D This license has expired.

A. LICENSE STATUS (Check the appropriate box)

IZl This license has not yet expired; please terminate it. (C)/JC; l..OC..A TIt:N O,..h..y\

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

The licensee, or any individual executing this certificate on behalf of the licensee, certifies thaI:

D 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 and/or possessed by the licensee under this license number cited above have been disposed of in the following manner.

gj a. Transfer of radioactive materials to the licensee listed below: S€AUih SDV~ T~r<eI'. 70 : f!/<l\fPJo-AI1X f:t./".-JA II "l"is - 0 >-1 /<AN ~ "X:-.E.HA f.I '" y -* .6i<)'

rv'i A Ie.A J H:L. ;.~ ·.>o, IC::j b. Disposal of radioactive materials:

'g) 1 Directly by the licensee:

'-Ie "''""' s;;: -:it 53·)"<J ,.1" .. 01 PI.!;. -h;:..,~: ~--f- I:> C.o;JT",CT ; &..ApJ£ ~ (S?ft)~>-t'W-f

Vll'iS7C! /;o!'tS Het..!. A?A ~y ,-", S.700'1~&e. 7Ntf.,.J 7~~~~ flAwJIIl 1 6/0- ,~~·rt~ S>'s-r6<--1s./..-Z/V<:...--/0"''-'' jOe/v NA I sr.t<!e6.--r

. ;-Io-Jo ,-v<-v . H:r Q6""'/9 (g<D\ f!;'fl ··1 ~<+i) By licensed disposal site: ~

o 3. By wasle contractor:

o c. All radioactive materials have been removed such Ihat 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 radialion survey was conducted by the licensee. The survey confirms:

~ a. the absence of licensed radioactive materials

o b. Ihat any remaining residual radioactivity is within Ihe Ii mils of 10 CFR 20, Subpart E, and is ALARA.

~ 2. A copy of the radiation survey results:

~ a. is attached; or 0 b. is not attached (Provide explanation); or 0 c. was forwarded 10 NRC on:

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

o a. The results of the lateslleak test are attached; and/or 0 b. No leaking sources have ever been identified.

The person to be contacted regarding the information provided on this form: TITLE TELEPHONE (Inclucle Area Code)

/!.ScJ t~ 'f'6)-c-~/-+ Man all future rorrespondenoe regarding this Iioense to:

tf'iJ. 0 ;;'1 j::A;-1 G.fll4Po~.HJ4. HW!' =P 3>/"7 "' AIt£A / HI C. CERTIFYING OFFICIAL

E-MAIL ADORESS

6L.A1"'';:' Z,tl<~AI!:J<+<AwAt/, CC-M

I CERTIFY UNDER PENAL TV OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT PRINTED NAME ANO TITLe T'G".6/~- ~-t.J -- --- IOA~_;l~_/;---WARNING: FALSE STATEMENTS IN THIS CERTIFICATE MAY BE SUBJECT TO CIVIL ANDIOR CRIMINAL PENALTIES. NRC REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRC BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECT. 18 U.S.C. 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 MATTER WITHIN ITS JURISDICTION.

NRC FORM 31 4 (05-2012)

================================================================================================

Date : 04/30/2013 »> Sealed Source Leak Test «< =========== ======================================================= ==============================

Report for Customer : Test Date: 04 / 30 / 2013 @18:30 PHARMARX MMS - KONA HI1013 98-021 KAMEHAMEHA HY 319 75-170 HUALALAI RD #C110 AIEA, HI (808)-487 -0814 KAILUA-KONA, HI (808)-329-9211

***************************» STANDARD SOURCE «***************************

Isotope - Cs- 137 Type - ROD SOURCE

Serial # - BM0837-013-7 Manufact . - RADQUAL

Currnt Act - 0.09861 uCi Activity - 0.11660 uCi on 01/13/2006 ************************* » COUNTING INSTRUMENT « *************************

Instrument Name - MCA Manufacturer - SPECTECH

Last Calibration - 02 / 12 / 2013

Model Number - UCS-20 Serial Number - 447 Instrument ID - II 1 II

************************* » SEALED SOURCE TESTED « *************************

Isotope - Cs-137 Serial # - BM06E37 - 2211 Type - VIAL REFERENCE SOURCE Manufact. - RADQUAL

Activity - 212 . 0000 uCi on 03/26/2008 Currnt Act - 188.5849 uCi onTest Date ****************************» COUNTING DATA «****************************

Gross Std Srce Counts (Gstd) 22474 Standard Source Time. (Tstd) 1.0 Min Standard Source Bkg. (Bstd) 30 Std Source Bkg Time .. (Xstd) 1.0 Min Net Std Count Rate .. (Rstd) 22444 Cpm Gross Samp l e Counts. (Gsam) 28 Sample Count Time .... (Tsam) 1. 0 Min Sample Bkg Counts . .. (Bsam) 30 Sample Bkg Count Time. (Xsam) 1.0 Min Sample Bkg Count Rate. (Rbkg) 30 Cpm Net Sample Count Rate. (Rsam) 0 Cpm

************************** » CALCULATION FORMAT « **************************

Net Std Count Rate (Rs td ) _ Gstd/Tstd Bstd/xstd Net Sample Coun t Rate (Rsam) z Gsam/Tsam - Bsam/Xsam

22444 Cpm Instrument Net Std Cpm (Rstdj

Efficiency . ----------------- ­

Standard Dpm

------------- - ------ -- ------ - 0.10345 cpm/Dpm or 10.35 '

0 . 09861 uCi x 2200000 Dpm/uCi

(Note : Z R 1.65, Factor From Standard Normal Distribution z scale f or 951 Confidence Interval)

Detection

Limit

wipe

Sample

Activity

2

z +22

Tsam

Sample Net

RDkg

1_ Xs am 1_

Xsam 1 1 1+- -- - -11

Tsam _1_1

o Cpm

Std Cpm/uCi 227595 cpm/uCi

1/2

28 Cpm Net Sample Cpm! !

0.00012427 uCi

Activity <_ Detection Limit of 0.000124 uCi

****************************** » Comments and Recommendations «********** *******************

The Removable contamination on this sealed source is within the maximum limit of 0.005 uCi Removable activity is <= Dectection limit!

Marian Medical Services - Kona PASSED Source transfered to PharmaRx Hawaii

Sealed Source Leak testing must be performed periodically in accordance with Applicable Facility License Conditions-Consult Facility License This source is due for its next Leak test by: Monday October 28, 2013

====================== = =========================================================================

Date: 04 / 30 / 2013 »> Sealed Source Leak Test « <

============================================================================== ==================

Test Date: 04/30/2013 @18:30 PHARMARX

Report for Customer : MMS - KONA 75-170 HUALALAI RD #C110

HIl013 98 - 021 KAMEHAMEHA HY 319 AIEA, HI (808)-487-0814

***************************» KAILUA- KONA, HI (808)-329-9211

STANDARD SOURCE «***************************

Isotope - Co -57 Type - ROD SOURCE

Activity - 0 . 15960 uCi on 01 / 31 / 2011 ************************* » COUNTING

Instrument Name - MeA Manufacturer - SPECTECH

Last Calibration - 02 / 12 / 2013

Serial # - BM08 057 Manufact. - RAD QUAL

Currnt Act - 0 . 01960 uCi INSTRUMENT « *************************

Model Number - UCS-20 Serial Number - 447 Instrument ID - II 1 II

************************* » SEALED SOURCE TESTED « *************************

Isotope - Co-57 Serial # - BM06E57-6222 Type - VIAL REFERENCE SOURCE Manufact. - RADQUAL

Activity - 5 . 6100 mCi on 04 / 04 / 2008 Currnt Act - 49. 22 39 uCi onTest Date ****************************» COUNTING DATA «****************************

Gross Std Srce Counts (Gstd) 39511 150

Standard Source Time .. (Tstd) Std Source Bkg Time .. (Xstd)

1. 0 Min 1. 0 Min Standard Source Bkg . .. (Bstd)

Net Std Count Rate .... (Rstd) Gross Sample Counts ... (Gsam) Sample Bkg Counts ..... (Bsam) Sample Bkg Count Rate. (Rbkg)

393 61 Cpm 169 150 150 Cpm

Sample Count Time . . . . (Tsam) Sample Bkg Count Time. (Xsam) Net Sample Count Rate. (Rsam)

1. 0 Min 1. 0 Min

19 Cpm **************************» CALCULATION FORMAT « **************************

Net Std Count Rate (Rstd) ~ Gstd/Ts td Bstd/xstd Net Sample Count Ra te (Rsam) • Gsam/Tsam - Bs am/Xsam

Instrumen t Net Std Cpm (Rstd )

Ef f iciency ---- - ------------­

Standard Dpm

39361 Cpm

-------------------------- - - m 0.9 1260 Cpm/Dpm

0 . 01960 uCi x 2200000 Dpm/uCi

or 91. 26 \

(Note: Z • 1.65, Factor From Standa rd Normal Distr ibution z scale for 95\ Confidence I nterval)

Detection

Limit

Wipe

Sample

Ac t ivity

2

2

• 22

Ts a m

Sample Net

Rbkg

1_ Xsam 1_

Xsam 1 1 , ·--- -- 11

Tsam _1_1

1 9 Cpm

1 /2

60 Cpm Net Sample Cpm!!

0.00002982 uCi

----------------- - - . Activity <_ Detection Limit of 0.000030 uCi

Std Cpm/uCi 200 773 1 cpm/uCi

******************************» Comments and Recommendations « *****************************

The Re movable contamination on this sealed source is within the maximum limit of 0.0 0 5 uCi Removable activity is < = Dectection limi t 1 Marian Medical Services - Kona

PASSED

Source transfered to PharrnaRx Hawaii

Sealed Source Leak testing must be performed periodically in accordance With Applicable Facility License Conditions - Consult Facility License This source is due for its next Leak test by: Monday October 28, 2013

1h5 81 1 5 1

======= = ============ = ====== = ==== = ====== = ==== = = = =================================== ======= = ======

Date: 04 / 30 /20 13 »> Sealed Source Leak Test «<

= ======= = == = ============= = ======= = =========== = =========== = = == ======== = ================= = ========

Report for Customer : Test Date: 04/30/2013 @18:30 PHARMARX MMS - KONA Hl1013

75-170 HUALALAI RD #C110 98-021 KAMEHAMEHA HY 319 AIEA, HI (808) - 487 - 0814

***************************» KAI LUA-KONA, HI ( 808)-329-9211

STANDARD SOURCE « *************************** Isotope - Co-57

Type - ROD SOURCE Serial # - BM08057

Manufact. - RAD QUAL Currnt Act - 0.01960 uCi Activity - 0.15960 uCi on 01 / 31 /20 11

************************* » COUNTING INSTRUMENT « *************************

Instrument Name - MCA Manufacturer - SPECTECH

Last Calibration - 02/12/2013

Model Number - UCS-20 Serial Number - 44 7 Instrument ID - III 11

************************* » SEALED SOURCE TESTED « *************************

Isotope - Co -57 Seri al # - BM0710 Type - FLOOD FIELD SOURCE Manuf act. - RADQUAL

Activity - 10 .0000 mCi on 10 /0 3 / 2009 Currnt Act - 355 . 3844 uCi onTest Date ******************** * ******* » COUNTI NG DATA «********** * ****** * **********

Gross Std Srce Counts (Gstd) 39511 Standard Source Time . . (Tstd ) 1. 0 Min Standard Source Bkg .. . (Bstd) 150 std Source Bkg Time. (Xstd) 1.0 Min Net Std Count Rate .. . (Rstd ) 39361 Cpm Gross Sample Counts ... (Gsam) 170 Sample Count Time . . . (Tsam ) 1.0 Min Sample Bkg Counts . . . . . (Bsam) 150 Sample Bkg Count Ti me . (Xsam) 1.0 Min Sample Bkg Count Rate. (Rbkg) 150 Cpm Net Sampl e Count Rate. (Rsa m) 20 Cpm

**************************» CALCULATION FORMAT « **************************

Net Std Count Rate (Rstd) • Gstd/Tstd Bstd/xstd Net Sample Count Rate (Rsam) _ Gsam/Tsam - Bsam/Xsam

Instrument N@t Std Cpm (Rstd) 39361 Cpm

Efficiency z ---- --- - -- -------- • ------------- --- ---------- - • 0.91260 Cpm/Dpm or 91. 26 t

Standard Dpm 0 . 01960 uCi x 2200000 Dpm/uCi

(Note: Z • 1.65, Factor From Standard Normal Distribution z scale for 95\ Confidence Interval)

2

Detection Z Rbkg 1 Xsam 1 1 Limit + 2Z 1 1 + ----- 1 1

Tsam 1_ Xsam 1_ Tsam _1_1

Sample Net 20 Cpm

1/2

60 Cpm Net sample Cpm! !

0.00002982 uCi

wipe

sample

Activity -- - --- ---- ---- -----. Activity <: Detection Limi t of 0.000030 uCi

Std Cpm/uCi 2007731 Cpm/uCi

******************************» Comments and Recommendations « *****************************

The Removable contami nation on this s ealed source is within the maximum limit of 0 . 00 5 uCi Removable activity is < = Dectection limit!

Marian Medical Services - Kona PASSED Source transfered to PharmaRx Hawaii

Sealed Source Leak testing must be performed periodically in accordance With Applicabl e Facility License Conditions-Consult Facility License This source is due for its next Leak test by : Monday October 28, 2013

Marian Medical Services - Kana Final Exit Survey and Wipe Test Results

April 4, 2013

Hot Lab

Area Survey Resutts (mRlhr)' Net cpm Net dpm'

Cabinets (lower) Background 0 0 Cabinets (upper) Background 23 25 Sink (1 & 2) Background 19 21 Injection Chair Background 0 0 Lead Lined Sharps (1 & 2) Background 3 Z Lead Lined Trash Container Background 2 2 Generator Shields (4 totaQ Background 0 0 Floor Background 28 30 Dose Calibrator Background 0 0 L-Block Background 4 4 Heat Block Background 0 0 Generator Elution Shields Background 0 0 Kit Prep Shields Background 0 0 Syringe Shields Background 21 23 Syringe Carry Case Background 20 22 Plastic Sharps Container Background 18 20

Treadmill Room

Treadmill Background 0 0 Computer Background 26 28 Exam Table Background 12 13 Cart Background 15 16 Floor Background 0 0

Camera Room

Camera Background 36 39 Camera Table Background 0 0 Computer #1 Background 25 27 Computer #2 Background 17 1e Closet Background 25 27 Floor Background 9 10

1 Calibration Certificate is attached

2 Efficiency of Wipe Counter is attached

D II ----.... -~ --------M EDICAL PHYSICS

Survey Meter Calibration Certificate

Facility: PharmaRx Hawaii Frequency : Annual

98-021 Kamehameha H~ Unit319 Date of Test: 10/30/2012

Aiea, HI 96701 Unit # 1

Dept Due Next: I 10/30/2013 I

Meter Data Pro be Data Additio na l T est s

Manuf: Lud lum Manuf: Ludlum Efficiency Co-57: N/A

Model : 14C Model : 44-9 Efficiency 8a-1 33: N/A

Serial No: 221650 Serial No: 235817 Chi-Square Cs-1 37: N/A

Type: Ratemeter Type: Pancake

Action Level : +1- 10% Variance

Calibration Equipment: J.L. Shepard Model 28-6Awith 3-M Type 4F6S Source, SN# 72518

950 mCi Cs-137 294 mR/hr at 100cm on Jan 20th, 1995 (+1-5%)

Calibration Geometry; _ ...:Fc:ix:;;e::d,-_ Instrumentation Check:

Physical Inspection: I NOTE Batteries: LI _...:O~k::..........J

Geometry Perpendicular

Check Source: IL--,-Y.::E",S_ .J

Attenuation Distance Attenuation Pre-Cal calibrated Post-Cal Correction

Scale Factor (em) Multiplier (mRlhr) (mRlhr) (mRlhr) % Error Factor

1000 1 40 294.000 Do not use 1219.7 Do not use

1000 1 70 294.00 Do not use 398.3 Do not use

100 1 130 294.00 116 115.48 116 0.5 1.00

100 3 105 66.97 40.36 40.32 40.36 0.1 1.00

10 5 40 2.882 11.99 11 .96 11.99 0.3 1.00

10 5 70 2.882 3.91 3.90 3.91 0.1 1.00

1 5 125 2.882 1.23 1.2244 1.23 0.5 1.00

1 5 215 2.882 0.413 0.4139 0.413 -0.2 1.00

0.01 5 395 2.882 0.1228 0.1226 0.1228 0.2 1.00

0_01 5 480 2.882 0.0832 0.0830 0.0832 0.2 1.00

Attenuation Factor: 1=1. 2:1 ,99. 3"",616, "211 .54. 500120.43

Test Results: I Passed

Comments: NOTE: Internal probe broken before ca libration 10-30-2012 NOTE: Aud io speaker workS.bad at C.Board

Test Performed By: _ ____ "'D.::av.:.;e:..:.,:N:.... Y.:.o::rk"-,tJt,,,,,,,~'Sf) __ Date: 10/30/2012

Test Reviewed By: _ _ _ ______ -::-:-:------

Facility RSO

Dato: _ _ _ _ _

Survey Meter Calibratlon shouJd be performed on a annual basis

or foilowWlg repair. unless othelWise specifoed in your R.A.M,L.

$ ALARA Review • Radiology Tube Cal ibration • Survey Meter Ca libration

23810 Via Del Rio, Unit B • Yorba Linda, CA 92887 • R.A.M.L. No. 5535-30 • (714) 692-9675 • FAX (714) 692-5348

== === ==== == = == == = == = == == ===== == = == == === ==== = = == == ===== = ===== === == ==== = == = ====== == ======= ===== = == Date , 04/04/2013 »> MULTI CHANNEL ANALYZER AND SCALER CALIBRATION «<

= == = = ====== = === = = = == = ====== ===== = === ======== = === = = = = == === == ========= = ====== === == ===== = ==== = ===== Test Date, 04 /0 4 / 2013 PHARMARX

Report for Customer : MMS - KONA HIl 013

98-021 KAMEHAMEHA HY 319 AIEA, HI (808)-487-08 14

75-170 HUALALAI RD #C110 KAILUA-KONA, HI (808)-329-9211

***************************» STANDARD SOURCE « ***************************

Std Source - Co-5 7 ROD SOURCE 0 . 0210 uCi on 04/0 4 /2013 - HI1HI1 Manufacturer - RAD QUAL Ser# - BM080 57

********************» COUNTI NG I NSTRUMENT CALIBRATED « ********************

Instrument Name - Ludlum 2200 Scale r Manufacturer - LUDLUM

Last Calibratio n - 02/14/2012

Model Number - 2200 Serial Number - 2 48565 Instrument ID - "13 11

****************************» COUNTING DATA «****************************

Instrument Sett ings. Source counts .... . Source Background . . .

. ... 50-200 KEV (Cstd) (Cbkg )

4272 0 16 2

Geometry . . SOURCE IN I,ELL Cpm Source Count Time . .... (Tstd) Cpm Background Count Time. (Tbkg)

1. 0 Min 1. 0 Min

***************************** » CALCULATIONS «* ********* * ******************

Standard Theoretical Dpm = Std Activity (uCi) x 2 20 000 0 Dpm/ uCi =46095 Dpm Std Net Cp m = Std Counts/Count Time - Std Bkg Counts/Count Time=42 55 8 Cpm

D~tection Limit (Ld ) - Th~ Ld is defined as the smallest quant ity of radioact ive oaterial which can be de tected

with some specif ied degr~e of conf i de nce . This test uses a 99 % conf i den ce interva l . The value obta ined

represents the l owe r lim i t or obs~rved NET counting rate that is statistically different f rom background

99 \ of the time. Another way of stating the result is:

Gi ven a s amp le . Its NET count per minute ra t e must be a t l east the detection limit to be abl e to state

that ac tivity was actually detected with 99% confidence o f be ing correct.

2 1 /2 Z 1 Rbkg 1 Tbkg 1

Ld + 2Z 1 1 1 + 1 1 89 Cpm Ts td 1- Tbkg 1- Tstd _I _I

Z ", 99\" con f idence interval factor 2. 3 3 (assum ing appr ox no roa t distribut ion large sample size )

Effi ciency of the instrument i s def ined as a ratio of the number of counts pe r minute observed pe r theoretica l

cou nt s possible for a gi ven act i vity of an iso t ope. It i s specif i c to each i nstrumen t and i s otope count ~d.

The var i ance in this numbe r i s introduced by ins t rument sett i ngs and ac tivity counted (due t o dead time considerations)

Standard Cpm Ef ficiency % - --- -- - -- -- - -- - x 100

Standard Dpm

It can also be expressed as Cpm/uCi Standard Cpm

0.9233 Cpm 92.33% = -- ----- - -

Actual Dpm

Efficiency = 2031167 Cpm/uCi Standar d Ac t uCi

Performed by: Title:

Radiation Safety Officer:

HAWAII BIO-WASTE SYSTEMS, INC.

Regulated Medical Waste, n.o.s. 1084 Puuwal Sireel. Honolulu. HI 96819 Tel. 808·841·1240 Fax. 808-845·3035 6.2; UN3291; PG II

Invoicc;Munifc>i No. Generator: ,

0

I

I I Ha'Aaii Department of Ikalth S(llid Wihle \1ana,l!cm cllt Pcm lit '\'(1 "lW-Hn~ l ~lX

I Ha\\aii Dcpartmcnll)! Hc.lhh " nn ('1I\1,.'n..-d Slmn.:c P..:rmit ! II (14'q..f) , DATE jTIME AM PM r P\ If) ' no IIlDtJX..w 7on9h

Service Description AUTOCLAVE AUTOCLAVE

DESCRIPTION PROD OTY DESCRIPTION PROD OTY

HIGH HEAT I OTHER

.

DESCRIPTION - OTHER ITEMS CODE OTY

Photo Fixer 9701

Comments: Office Closed 1099

No Waste 1{)()()

D GENERATOR REPRESENTATIVE

0 hi .. dll,: uml'll1 h.I ' bee st;!reg t -d. pal,.K dun he cod Jfl an:nnbnct" \\ all llx:11. ~Ul1l' rol • I u\m

o I II ~nn,",lcj c c P )1 11 prodU I ann. Latcd OI l til I lin'll.: 1

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). ~ -,; D..;.!t,

HAWAII SIO·WASTE SYSTEMS, INC. REPRESENTATIVE ,de n n (' h;!'> nt't' n tr~·:tl l·d ..... 1 ~ ~ .

CJ ,1\ II; Ix ()lilo.!r - -

0 X - 0 X - - 0 X IR \. 'SI~)RII'R TRr: \T\11'~T I \CII In 'f RI \T\1 F~T f· \CII ITY 1 (hh 1 II \\aI Ru \\, [ S~ It'l11 hit II \\ til H n \\a .. t "i} 1 m .. II"k:

Ib 0 :J r

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11.1.5 811 5 1

NRC FORM 532 U. S. NUCLEAR REGULATORY COMMISSION (1 -2012)

DATE

06126/2013

NAME AND ADDRESS OF APPLICANT AND/OR LICENSEE LICENSE NUMBER

Marian Medical Services, LLC A1TN: Jere Pala2zolo

President

24-29248-0 I

MAIL CONTROL NUMBER

581151 906 Kingsridge Court Wildwood, MS 63021 LICENSING AND/OR TECHNICAL REVIEWER

ch

o D

D

This is to acknowledge the receipt of your:

[Z] LEDER and/or [Z] APPLICATION DATED: 05/28/2013

The initial processing, which included an administrative review, has been performed.

iZ!"~MENDMENT [J TERMINATION D NEW LICENSE D RENEWAL

There were no administrative omissions identified during our initial review.

This is to acknowledge receipt of your application for renewal of the material(s) license identified above. Your application is deemed timely filed, and accordingly, the license will not expire until final action has been taken by this office.

Your application for a new NRC license did not include your taxpayer identification number. Please fill out NRC Form 531, located at the following link:

http://www . nrc. gov Ireading-rm/doc-collections/forms/n rc531 . pdf

Send the completed NRC Form 531, by facsimile, to the following number: (301) 415-5387

A copy of your action has been emailed to our License Fee and Accounts ReceivableBranch,in our Headquarters office in Rockville, MD. You will be contacted separately if there is a fee issue involved.

Your application has been assigned the above listed MAIL CONTROL NUMBER. When calling to inquire about this action, please refer to this control number. Your application has been forwarded to a technical reviewer. Please note that the technical review, which is normally completed within 180 days for a renewal application (90 days for all other requests), may identify additional omissions or require additional information. If you have any questions concerning the processing of your application, our contact information is listed below:

Region IV U. S. Nuclear Regulatory Commission DNMS/NMSB - B 1600 E. Lamar Boulevard Arlington, TX 76011 -4511 (817) 200-1103 or (817) 200-1140

NRCFORM5~ (1-2012) t/~/J ~

BETWEEN:

Accounts Receivable/Payable and

Regional Licensing Branches

[ FOR ARPB USE I INFORMATION FROM WBL

Program Code: 02201 Status Code: Pending Termination Fee Category: 7C Exp. Date:

Fee Comments: Decom Fin Assur Reqd : N

License Fee Worksheet - License Fee Transmittal

A. REGION

1. APPLICATION ATIACHED ApplicanULicensee: MARIAN MEDICAL SERVICES, LLC

Received Date: 05128/2013 Docket Number: 3037399 Mail Control Number: 581151 License Number: 24-29246-01

Action Type: Termination

2 FEEATIACH~D Amount-

Check No '

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