•• NRC FORM 699 (03-2013)

U.S. NUCLEAR REGULATORY COMMISSION

CONVERSATION RECORD (continued) SUMMARY: (Continued from page 1)

Please note that certain sections of this NUREG have been modified since its last revision, as noted below:

A. We now require a total possession limit for each radionuclide requested, as well as providing the "per source" activity you need, which should match the Sealed Source and Device Registry certificate procured by the vendor.

RESPONSE: Please provide this information and it is acceptable to request more sealed sources than you may actually need immediately, to allow for some growth, so long as the request is reasonable and realistic.

B. You will not be able to change and name your RSO internally; NRC must do that for you via the amendment process.

RESPONSE: Please include the name and qualifications of your proposed RSO and a written, signed (by both senior management and the proposed RSO) and a currently dated statement that stipulates your proposed RSO accepts the RSO position and understands the duties and responsibilities associated with the position. Each proposed RSO must be qualified in accordance with the guidance in NUREG 1556, Vol I, Rev. I, Section 8.7, Item 7: Individual(s) Responsible for Radiation Safety Program and Their Training and Experience.

For guidance on preparing all licensing correspondence, please use NUREG 1556 Vol. I, Rev. 1, "Consolidated Guidance About Materials Licenses- Program-Specific Guidance About Portable Gauge Licenses." This document can be found at:

http://www .nrc.gov/reading-rm/doc-co llections/nuregs/staff/sr 15 5 6/v 1/r II

In accordance with I 0 CFR 2.390 of the NRC's "Rules of Practice," a copy ofthis letter and its enclosure will be available electronically for public inspection in the NRC Public Document Room or from the NRC's Agencywide Documents Access and Management System (ADAMS), accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html.

NRC FORM 699 (03-2013) Page 2 of 2

NRC FORM 313 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0120 EXPIRES: 05/31/2015 (03-2013)

Estimated burden per response to comply with this mandatory collection request: 4.3 hours. Submittal of the 10 CFR 30, 32, 33, 34, 35, 36, 39, and 40 application is necessary to detennine that the applicant is qualified and that adequate procedures exist to

~f'RIQU{ protect the public health and safety. Send comments regarding burden estimate to the lnfonnation Services .§' ·~ Branch (T-5 F53), U.S. Nudear Regulatory Commission, Washington, DC 20555-0001, or by internet e-mail to l¥\ APPLICATION FOR MATERIALS lnfocollects.Resource@nrc.gov, and to the Desk Officer, Office of lnfonnation and Regulatory Affairs, • 0

~ .. NEOB-10202, (3150-0120), Office of Management and Budget, Washington, DC 20503. ~a means used to ;. ~ LICENSE ;,;...... 0~ 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 infonnation collection . ......

INSTRUCTIONS: SEE THE APPROPRIATE LICENSE APPLICATION GUIDE FOR DETAILED INSTRUCTIONS FOR COMPLETING APPLICATION. SEND TWO COPIES OF THE ENTIRE COMPLETED APPLICATION TO THE NRC OFFICE SPECIFIED BELOW. *AMENDMENTS/RENEWALS THAT INCREASE THE SCOPE OF THE EXISTING LICENSE TO A NEW OR HIGHER FEE CATEGORY WILL REQUIRE A FEE.

APPLICATION FOR DISTRIBUTION OF EXEMPT PRODUCTS FILE APPLICATIONS WITH: IF YOU ARE LOCATED IN:

OFFICE OF FEDERAL & STATE MATERIALS AND ILLINOIS, INDIANA, IOWA, MICHIGAN, MINNESOTA, MISSOURI, OHIO, OR WISCONSIN, ENVIRONMENTAL MANAGEMENT PROGRAMS SEND APPLICATIONS TO: DIVISION OF MATERIALS SAFETY AND STATE AGREEMENTS U.S. NUCLEAR REGULATORY COMMISSION MATERIALS LICENSING BRANCH

WASHINGTON, DC 20555-0001 U.S. NUCLEAR REGULATORY COMMISSION, REGION Ill 2443 WARRENVILLE ROAD, SUITE 210

ALL OTHER PERSONS FILE APPLICATIONS AS FOLLOWS: LISLE, IL 60532-4352

IF YOU ARE LOCATED IN:

ALABAMA, CONNECTICUT, DELAWARE, DISTRICT OF COLUMBIA, FLORIDA, GEORGIA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, COLORADO, HAWAII, IDAHO, KANSAS, KENTUCKY, MAINE, MARYLAND, MASSACHUSETTS, NEW HAMPSHIRE, NEW JERSEY, LOUISIANA, MISSISSIPPI, MONTANA, NEBRASKA, NEVADA, NEW MEXICO, NORTH NEW YORK, NORTH CAROLINA, PENNSYLVANIA, PUERTO RICO, RHODE ISLAND, SOUTH DAKOTA, OKLAHOMA, OREGON, PACIFIC TRUST TERRITORIES, SOUTH DAKOTA, TEXAS, CAROLINA, TENNESSEE, VERMONT, VIRGINIA, VIRGIN ISLANDS, OR WEST VIRGINIA, UTAH, WASHINGTON, OR WYOMING,

SEND APPLICATIONS TO: SEND APPLICATIONS TO:

LICENSING ASSISTANCE TEAM NUCLEAR MATERIALS LICENSING BRANCH DIVISION OF NUCLEAR MATERIALS SAFETY U.S. NUCLEAR REGULATORY COMMISSION, REGION IV U.S. NUCLEAR REGULATORY COMMISSION, REGION I 1600 E. LAMAR BOULEVARD 2100 RENAISSANCE BOULEVARD, SUITE 100 . KING OF PRUSSIA, PA 19406-2713

ARLINGTON, TX 76011-4511

PERSONS LOCATED IN AGREEMENT STATES SEND APPLICATIONS TO THE U.S. NUCLEAR REGULATORY COMMISSION ONLY IF THEY WISH TO POSSESS AND USE LICENSED MATERIAL IN STATES SUBJECT TO U.S.NUCLEAR REGULATORY COMMISSION JURISDICTIONS.

1. THIS IS AN APPLICATION FOR (Check appropriate item) 2. NAME AND MAILING ADDRESS OF APPLICANT (Include ZIP code)

[] A. NEW LICENSE ..Je:.~,c"'ZIV!J Ul'v~vL.7 .&»N-r5 /.-7.1)_

D B. AMENDMENT TO LICENSE NUMBER ? o. .£SOx 13o5

;0 C. RENEWAL OF LICENSE NUMBER lf8- 2ol~z- o/ W4~.;/Ce.s-#-A/ wt:. s-3/8'7 3. ADDRESS WHERE LICENSED MATERIAL WILL BE USED OR POSSESSED 4. NAME OF PERSON TO BE CONTACTED ABOUT THIS APPLICATION

Z'"So'7 ,8A~B/<... .z:;k.. Lol/CS _V:IILM411l/lV BUSINESS TELEPHONE NUMBER I BUSINESS CELLULAR TELEPHONE NUMBER

tJII vI< 6~11-A. we. 5'"?1 g-g' 26:Z.. ~ ~1/q- O~tJZ- Z6 z. #~13- ~95"&' )

BUSINESS EMAIL ADDRESS

4vJri)/<'CLeN6. et:>~ SUBMIT ITEMS 5 THROUGH 11 ON 8-1/2 X 11" PAPER. THE TYPE AND SCOPE OF INFORMATION TO BE PROVIDED IS DESCRIBED IN THE LICENSE APPLICATION GUIDE.

5. RADIOACTIVE MATERIAL .l!~,.,,;u.lt!?1 - "),1/ I SEAl~ SfwN£ 6. PURPOSE(S) FOR WHICH LICENSED MATERIAL WILL BE USED. ~ H~~ a. Element and mass number; b. chemical and/or physical form; lnd c. maiximum amount

7. INDIVIDUAL(S) RESPONSIBLE FOR RADIATION SAFETY PROGRAM AND T~ which will be possessed at any one time. ;u.,o l'tdi~WZda$ TRAINING EXPERIENCE. £."v&,S' .:::JZ41tMifl~l.} ~ 0

8. TRAINING FOR INDIVIDUALS WORKING IN OR FREQUENTING RE~~Iji,T~_D AR,.S. 9. FACILITIES AND EQUIPMENT.

10. RADIATION SAFETY PROGRAM. ~65 . - 11. WASTE MANAGEMENT. ftV/A

12. LICENSE FEES (Fees required only for new applications, with few exceptions•) FEE CATEGORY I I AMOUNT

$1 I (See 10 CFR 170 and Section 170.31) ENCLOSED

13. CERTIFICATION. (Must be completed by applicant) THE APPLICANT UNDERSTANDS THAT ALL STATEMENTS AND REPRESENTATIONS MADE IN THIS APPLICATION ARE BINDING UPON THE APPLICANT.

THE APPLICANT AND ANY OFFICIAL EXECUTING THIS CERTIFICATION ON BEHALF OF THE APPLICANT, NAMED IN ITEM 2, CERTIFY THAT THIS APPLICATION IS PREPARED IN CONFORMITY WITH TITLE 10, CODE OF FEDERAL REGULATIONS, PARTS 30, 32, 33, 34, 35, 36, 39, AND 40, AND THAT ALL INFORMATION CONTANED HEREIN IS TRUE AND CORRECT TO THE BEST OF THEIR KNOWLEDGE AND BELIEF. WARNING: 18 U.S.C. SECTION 1001 ACT OF JUNE 25, 1948 62 STAT. 749 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.

CERTIFYING OFFICER-- TYPED/PRINTED NAME AND TITLE

"~j_ DATE

Levis. ::r:::;"a.....,4 "'"' tz.Jc:; 7;i~}1 t Pf'tt:-s:..ec-r+- '}.. 'A.IV

FOR NRC USE ONLY v TYPE OF FEE

rEELOG I FEE CATEGORY l:'OUNT RECEIVED CHECK NUMBER COMMENTS

APPROVED BY DATE

NRC FORM 313 (03-2013)

UNITED STATES NUCLEAR REGULATORY COMMISSION

REGION Ill 2443 WARRENVILLE ROAD, SUITE 210

LISLE, IL 60532-4352

April19, 2013

RO NG CONSULTANTS L TO. ATTN: is Juhlmann Radiation S t Officer P.O. Box 1305 Waukesha, WI 531

SUBJECT:

This is to acknowledge receipt of your a I" ation for renewal of the material(s) license identified below. Your application is deemed time d. Renewal actions are normally processed within 180 days. However, under timely filin (before pi ration) your license will not expire until final action has been taken by this office.

If you have any questions cone ning the processing of · renewal, you may contact the Materials Licensing Branch at -800-522-3025, extension 9 7 or 1-630-829-9887.

Any correspondence reg Cling the renewal application should ref specified below, and y r license number.

License No. 48- 0142-01

c7~o

Appendix B

Suggested Format for Providing Information Requested in Items 5

through 11

APPENDIXB

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

Yes No Radioisotope Manufacturer or Distributor Model No.

Cesium-137 Sealed source manufacturer or distributor and model number:

Device manufacturer or distributor and model number:

Americium- Sealed source manufacturer 241 or distributor and model

number: 11 5 &S .8Ei.cW ~

Device manufacturer or distributor and model number:

~· .Qe &t:v ~

~Jttf'8E (/ ~.t" ,t:'Zt! ;1td~JZ. /1oPd ~- )1~yt

Quantity

Not to exceed either the maximum activity per source or maximum activity per device as specified in Sealed Source and Device Registration Certificate

Not to exceed either the maximum activity per source or maximum activity per device as specified in Sealed Source and Device Registration Certificate

Use As Listed Specify Other on SSD Uses Not

Certificate Listed on SSD Certificate

Yes 0 ONot

Specific applicable

description of the gauge use: 0 Uses are:

(Submit safety analysis supporting safe use)

Yes)1 ~Not Specific

applicable

description of the gauge use:

;g.,t:_~6_fe 0 Uses are:

£6Nser~ (Submit safety /d_~v;z.E analysis

Mv~e supporting safe use)

-tJZt:>x L.eTZ­nolJI!t. N - 3Z/~

£tJAih St,v~e lf,"'~"~ert/11-4/Z. ... QS"A 6/.t:JBAL -t:Nc.. SQ~t& S"oufU.e Ht~NL If -X. z.o~lJ

s~~~ ~4::e #fi: - QSA ,~,J ~ ~vA.c:B lf41J6LIF _ ::rwc..

AXi. 1 x.:l /~ B-1 NUREG- 1556, Vol. I, Rev. I

APPENDIX B

Yes No Radioisotope Manufacturer or Quantity Use As Listed Specify Other Distributor Model No. on SSD Uses Not

Certificate Listed on SSD Certificate

Californium- Sealed source manufacturer Not to exceed YesO ONot 252 or distributor and model either the

Specific applicable

number: maximum activity per

description of the gauge use:

source or 0 Uses are: Device manufacturer or maximum distributor and model activity per number: device as (Submit safety

specified in analysis Sealed Source supporting safe and Device use) Registration Certificate

Other Isotope Sealed source manufacturer Not to exceed YesO ONot (Specify): or distributor and model either the

Specific applicable

number: maximum description of

activity per the gauge use:

source or 0 Uses are: Device manufacturer or maximum distributor and model activity per number: device as (Submit safety

specified in analysis Sealed Source supporting safe and Device use) Registration Certificate

Financial Assurance Required and Evidence of Financial Assurance Provided

NUREG- 1556, Vol. I, Rev. I B-2

APPENDIXB

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

Item No. And Title Suggested Response Yes Alternative Procedures Attached

7. INDIVIDUAL(S) Before obtaining licensed materials, the Pt 0 RESPONSIBLE FOR proposed RSO will have successfully RADIATION SAFETY completed one of the training courses PROGRAM AND THEIR described in Criteria in the section entitled TRAINING AND "Tndividual(s) Responsible for Radiation EXPERIENCE- Safety Program and Their Training and RADIATION SAFETY Experience - Radiation Safety Officer" in OFFICER NUREG-1556, Vol. I, Rev. I, dated

November 200 I.

Name:

8. TRAINING FOR Before using licensed materials, authorized )I 0 INDIVIDUALS WORKING users will have successfully completed one of IN OR FREQUENTING the training course described in Criteria in the RESTRICTED AREAS section entitled "Training for Individuals

Working In or Frequenting Restricted Areas" inNUREG-1556, Vol.l,Rev !,dated November 200 I.

9. FACILITIES AND No information needs to be submitted in Separate Item 9 EQUIPMENT response to this item; key issues are addressed Response

under "Radiation Safety Program- Public Need Not Be Submitted

Dose" and "Radiation Safety Program-With Application

Operating and Emergency Procedures."

10. RADIATION SAFETY The applicant is not required to, and should Need Not Be Submitted PROGRAM- AUDIT not, submit its audit program to NRC for With Application PROGRAM review during the licensing phase.

10. RADIATION SAFETY The applicant is not required to submit a Need Not Be Submitted PROGRAM- response to the termination of activities With Application TERMINATION OF section during the initial application. ACTIVITIES However, when the license expires when the

licensee ceases operation, NRC Form 314 must be submitted.

10. RADIATION SAFETY We will either possess and use, or have access )l{ 0 PROGRAM- SURVEY to and use, a radiation survey meter that meets INSTRUMENTS the Criteria in the section entitled "Radiation

Safety Program - Instruments" in NUREG-1556, Vol. I, Rev. I, dated November 2001.

8-3 NUREG- 1556, Vol. I, Rev. I

APPENDIXB

Item No. And Title Suggested Response Yes Alternative Procedures Attached

10. RADIATION SAFETY Physical inventories will be conducted at ~ 0 PROGRAM- MATERIAL intervals not to exceed 6 months, to account RECEIPT AND for all sealed sources and devices received ACCOUNTABILITY and possessed under the license.

10. RADIATION SAFETY Either we will maintain, for inspection by Jf 0 PROGRAM- NRC, documentation demonstrating that OCCUPATIONAL unmonitored individuals are not likely to DOSIMETRY receive a radiation dose in excess of

I 0 percent of the allowable limits in 10 CFR Part 20, or we will provide dosimetry processed and evaluated by an NVLAP-approved processor that is exchanged at a frequency recommended by the processor.

10. RADIATION SAFETY The applicant is not required to submit a Need Not Be Submitted PROGRAM- PUBLIC response to the public dose section during the With Application DOSE licensing phase. This matter will be examined'

during an inspection.

10. RADIATION SAFETY We will implement and maintain the operating )'. 0 PROGRAM- and emergency procedures in Appendix H of OPERATING AND NUREG-1556, Vol. I, Rev. I, dated EMERGENCY November 200 I, and provide copies of these PROCEDURES procedures to all gauge users and at each job

site.

OR

Operating and emergency procedures will be 0 developed, implemented, and maintained and will meet the criteria in the section entitled "Radiation Safety Program - Operating and Emergency Procedures" in NUREG-1556, Vol. I, Rev. I, dated November 200 I.

10. RADIATION SAFETY Leak tests will be performed at intervals )( 0 PROGRAM- LEAK TEST approved by NRC or an Agreement Sate and

The specified in the Sealed Source and Device

information in Registration Sheet. Leak tests will be

Appendix J performed by an organization authorized by NRC or an Agreement State to provide leak

supporting a

testing services for other licensees or using a request to perform leak

leak test kit supplied by an organization testing and

authorized by NRC or an Agreement State to sample

provide leak test kits to other licensees and analysis is

according to the kit supplier's instructions. attached.

NUREG- 1556, Vol. I, Rev. I B-4

APPENDIX B

Item No. And Title Suggested Response Yes Alternative Procedures Attached

10. RADIATION SAFETY Routine Cleaning and Lubrication PROGRAM-

We will implement and maintain procedures I 0 MAINTENANCE for routine maintenance of our gauges according to each manufacturer's recommendations and instructions.

Non-Routine Maintenance

We will send the gauge to the manufacturer or j 0 other person authorized by NRC or an

The Agreement State to perform non-routine

information maintenance or repair operations that require

listed in the removal of the source or source rod from

Appendix G the gauge.

supporting a request to perform non-routine maintenance in-house is attached.

lO.RADIATION SAFETY The applicant is not required to submit its Need Not Be Submitted PROGRAM- response to transportation during the licensing With Application

TRANSPORTATION process. However, this issue will be reviewed during inspection.

11. WASTE MANAGEMENT- The applicant is not required to submit a Need Not Be Submitted GAUGE DISPOSAL AND response to waste management during the With Application TRANSFER licensing process. However, the licensee

should develop, implement, and maintain gauge transfer and disposal procedures in its radiation protection program.

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

NRC FORM 313 I:J-~OOGi 1(1 ccrr< ~o. n. :n :14, :Jf> JIJ, :1ij_ ona 40

U.S, NUCLEAR Rt:GULATORY COMMISSION

APPLICATION FOR MATERIALS LICENSE

EXPIRES: 3/:11/2012

fi.3timotod OtJf ttn pilr t!i!~p.;m§!> to a~:~mply wl!h 1111• m~nd!i\oty eoll&ctioll l'<i!QU<itll. 4 ~ haur~ Suomlt1al ol thil cppliclltlotJ lfi 11t'!Ceti~ary w dt>!!lrmlntl thlilt tho; ll>IPitcant Is ejiJ~IIfled IIAei !hilt !ideq.Uiil\a prQGii>dUfifi IIKI~t to J'lfC;IIIIet trl~ pub/IQ hetillth IJnCI &ilfilty 6t<Jnd ~'lmmen!B rwflllt'dlng burdoh I)Gtlm81o to the. Reoorao lind F'OIA/Pr1V1i~~ &i!lrviWfi BriJMh (l·!l 1"~3), lJ.S. Nucllllili' Rfflgulotery Cotl11'1'lllitilon, W!l~hlngton, OC 2056!i·0001, or bY 1ntt1rnet e·mall to lnfoeolloct§ r~;~&ouroo@nre.aov. ond to tho Dt~l)k Offloor. Oll'la& of Information and RIIQUI!ltmy Afflllr~. NEOB·fll202, (3150.0120), OffiCii of Munilgoment and Budget, Wa~hln)lton. DC 20503. If a me!ln4 u•ed to 1mpo11e an Information collttctkm dt>iia not dlepl11y a curr~ntly valid OMB control numoor, tho NRC rroay not condu~t or eponeor, una 11 p!lr~on Ia not req~lrllld to reGpond to, lfl!!l ittfrmrutlton collection

INSTRUCTIONS: SEE THE APPROPRIATE LICENSE APPLICATION GUIDE FOR DETAILED INSTRLCTIONS FOR COMPLETING APPLICATION, SEND ·rwo COPIES OF THE ENTIRE COMPLETED APPLICATION TO THE NRC OFFICE SPECIFIEC BELOW.

APPLICATION FOR OIS'fRIBUTION 01' f::XI!MPT J>ltOOtJCT8 PIL~ APPLICATIONS WITH'

OffiCE OF Ff.DERAL & IliA if> MAnRIALil AN[;) t'NVIRONMI!fiTAL MMIAGt,Mii;N.I PROGRAMS OIVISION Of MAf!Of'liAl.S SAFETY AND STATit A0Rt'£M1:NiS U.ii. NUC~O:AR Rt-CIAATORY COMMISUION WIISriiNOror,, DC 20!HJ&-0001

A~L OTHER PI?.RVON& FILE APPWC:ATIONS AI'J F"OI..LOWS:

I~ YOIJ AR!l LOCArEfliN:

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IF YOU ARI.'! LOCATED IN'

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: ILLINOIS, INDIANA, IOWA, MICHI(;AN, MINNii!IIOTA, MllliiOURI, OHIO, OR WIIICQtJSIN, l!!tfl APPLICA TION!I tO:

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This form serves as a certification oid .'t:2. ... ~~ ~od ""'"'' de•rnooe. 5 C.F.R. 1320.3{1>)(1).

NRC FORM 526 r ~ U.S. NUCLEAR REGULATORY COMMISSIOO

~~~~~2f11 CERTIFICATION OF SMALL ENTITY STATUS FO E PURPOSES OF

ANNUAL FEES IMPOSED UNDER 10 C PART 171 (Effective August 22, 2012)

If you have QUESTIONS, e-mail them to: Sma11Entit¥.Resour~e@nrc.gov

SEE IMPORTANT INSTRUCTIONS FOR NRC FORM 526 --PLEASE READ CAREFULLY DO NOT COMPLETE OR RETURN THIS FORM IF YOU DO NOT QUALIFY AS A SMALL ENTITY

A Licensee that is a subsidiary of a large entity, including foreign entities, does NOT qualify as a small entity.

NAME AND ADDRESS OF LICENSEE (as it appears on the invoice): INVOICE NUMBER BUSINESS TELEPHONE NUMBER

F.o.~~ Co,.,s..,/~,"'J, L+J ,_ 1=" B 13-3o37 -u. 2..-r'-1 '-Dro "t P. o, ~ D.>c I :So..s- DOCKET NUMBER CONTACT NAME

\;v'4i"r"' "~-'"- ~ '-VI S3Jj'"'7 03oJgoJ3 L«>v ~~ ~L., '""orr..,.., EMAIL ADDRESS COMPANY WEBSITE ADDRESS CONTACT TELEPHONE NUMBER

Jo'fj@ 1<C L. ~~.co-w www.'f<CL c~. <.o.-, '"2-'2 -s~' .. c;J'o <. SIZE STANDARDS MAXIMUM ANNUAL FEE

(Check only 1 box below). PER LICENSED CATEGORY (See Items 2 and 3 on back)

1. SMALL BUSINESS

A for-profit concern that is not engaged in manufacturing ?(A. $450,000 TO $7,000,000 $2,300 with average GROSS receipts of $7.0 million or less over its last 3 completed fiscal years. For further information see

0 B. LESS THAN $450,000 $ 500 1 a and 1 b of attached instructions.

2. MANUFACTURING INDUSTRY

A manufacturing concern with an average number of 500 D A. 35 to 500 EMPLOYEES $2,300

or fewer employees based upon employment during each 0 B. LESS THAN 35 EMPLOYEES $ 500 pay period for the preceding 12 calendar months.

NAICS BUSINESS CODE (See 1 band 1e of attached instructions):

3. SMALL ORGANIZATION $2,300

A not-for-profit organization that is independently owned and DA $450,000 TO $7,000,000

operated and has annual GROSS receipts of $7.0 million or DB. LESS THAN $450,000 $ 500 less. For further information see 1 a and 1 b of attached instructions

4. SMALL GOVERNMENTAL JURISDICTION (INCLUDING D A. 20,000 TO 49,999 POPULATION PUBLICLY SUPPORTED EDUCATIONAL INSTITUTIONS) OF JURISDICTION

$2,300

A government of a city, county, town, township, village, school district, or special district with a population of less than D B. LESS THAN 20,000 POPULATION $ 500 50,000. For further information see 1 f of attached instructions. OF JURISDICTION

5. SMALL EDUCATIONAL INSTITUTION THAT IS NOT STATE OR PUBLICLY SUPPORTED 0 A. 35 to 500 EMPLOYEES $2,300

Only applicable to such small educational institutions if D B. LESS THAN 35 EMPLOYEES they have 500 or less employees. For further information $ 500

see 1 b and 1f of attached instructions.

CERTIFICATION

This certification MUST be signed by the owner of the entity named above or an official empowered to act on behalf of the entity.

1 certify that the above named NRC licensee qualifies as a small entity under the size standards established by the NRC for its licensees in 10 CFR 2.81 0. The licensee qualifies as a small entity under the specific size standard indicated above.

WARNING: 18 U.S.C. Section 1001, Act of June 25, 1948, 62 Stat. 749, 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. The submittal of willful false statements is punishable by fine or imprisonment, or both, and for purposes of this certification, may result in revocation or suspension ofthe license.

TYPED OR PRINTED NAME AND TITLE

':"'7:7/~ DATE

I CERTIFY UNDER PENALTY OF L-cui.S :::J:Ja,c~q.,, '-1/J z./13 PERJURY THAT THE FOREGOING vzk· -1] ... ., IS TRUE AND CORRECT. Pr <~a&Je'\7 "llo"' -/ ff/, ,

NRC FORM 526 (08-2012} See Attached Instructions

Roofing Consultants, Ltd. Engineers, Architects & Building Envelope Specialists P.O. Box 1305- Waukesha. WI - 53187-1305

Materials Licensing Branch U.S. Nuclear Regulatory Commission, Region Ill

2443 Warrenville Road, Suite 210 Lisle, IL 60532-4352

j~~ ~~~ • Liberty Freedom

FOREVER ~ FOREVER ~

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