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I State of California -Health and Human Sere Agency
<br />RADIOACTIVE MATERIAL LICENSE
<br />LICENSE CONDITIONS
<br />10. Radioactive material shall be used only at the following location:
<br />(a) 1420 North Tracy Boulevard, Tracy, CA.
<br />Department of Health Services
<br />Page 2 of 4 pages
<br />License Number: 4097-39
<br />Amendment Number. 19
<br />11. This license is subject to an annual fee for sources of radioactive material authorized to be possessed at any one time
<br />as specified in items 6, 7, 8 and 9 of this license. The annual fee for this license is required by and computed in
<br />accordance with Title 17, California Code of Regulations, Sections 30230-30232 and is also subject to an annual
<br />cost -of -living adjustment pursuant to Section 100425 of the California Health and Safety Code.
<br />12. The individuals named below are authorized the specific uses of radioactive material described in Items 6, 7, 8, and 9
<br />of this license as follows:
<br />(a)
<br />H. Walter Pepper, M.D.
<br />(b)
<br />Anil K. Sain, M.D.
<br />(c)
<br />Sam Kokoris, M.D.
<br />(d)
<br />Rajiv Punjya, M.D.
<br />(e)
<br />Chull Song M.D.
<br />(f)
<br />Barry Tepperman, M.D.
<br />(g)
<br />Vitune Vongtama, M.D.
<br />Groups 1, 2, 3 and 9
<br />Groups 1, 2, 3, 4 and 9
<br />Groups 1, 2, 3, 4 (I-131 only) and 9
<br />Groups (1, 2 and 3: cardiac studies only) and 9
<br />Groups 1, 2, 3 and 9
<br />Groups 6 and 9
<br />Groups 6 and 9
<br />13. Except as specifically provided otherwise by this license, the licensee shall possess and use radioactive material
<br />described in Items 6, 7, 8 and 9 of this license in accordance with the statements, representations, and procedures
<br />contained in the documents listed below. The Department's regulations shall govern unless the statements,
<br />representations, and procedures in the licensee's application and correspondence are more restrictive than the
<br />regulations.
<br />(a) The license renewal application, with attachments, dated December 5, 2001, and the letter, with attachments,
<br />dated December 17, 2001, both signed by David Bowlsby, Diagnostic Imaging Manager, and H. Walter Pepper,
<br />M.D., Medical Director, Radiation Safety Officer.
<br />(b) The letter, with attached Duties and Responsibilities of the Radiation Safety Officer and Delegation of
<br />Authority form, dated July 14, 2003, signed by Gary Rapaport, Chief Executive Officer, H. Walter
<br />Pepper, M.D., Radiation Safety Officer, and David Bowlsby, CNMT, regarding the change in the
<br />Radiation Safety Committee Membership and the new Radiation Safety Officer.
<br />14. (a) The Radiation Safety Officer in this program shall be Sam Kokoris, M.D.
<br />(b) The Chairperson of the Radiation Safety Committee shall be Sam Kokoris, M.D.
<br />(c) The Custodian of sealed sources shall be Anil K. Sain, M.D.
<br />(d) The Alternate Radiation Safety Officer in this program shall be Anil K. Sain, M.D.
<br />15. Sealed sources possessed under this license shall be tested for leakage and/or contamination as required by Title 17,
<br />California Code of Regulations, Section 30275 (c).
<br />16. In lieu of the leak test intervals required by California Code of Regulations, Title 17, Section 30275 (c), sealed
<br />sources can be tested for leakage and/or contamination at longer intervals when they are specified in a
<br />certificate of registration issued by the U.S. Nuclear Regulatory Commission, an Agreement State or a
<br />Licensing State. When a longer interval stipulated in a certificate of registration is used, the certificate must
<br />be maintained on file and available for inspection for as long as the associated leak test records are retained.
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