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;tate of Collfornlo—Health"and Welfore Agency 13. Cont. 0 Department of Health Services Page 4 of 6 Pages RADIOACTIVE MATERIAL LICENSE License Number: 4097-39 Supplementary Sheet Amendment Number: 10 (e) A user may apply to the Departuent for authorization to operate up to an annual dose limit, for an individual member of the public, of 0.5 Rem (5 mSv), pursuant to provisions of Title 10, CFR, Part 20, Sec- tions 20.1301 and 20.1302, by submitting their request on Department Form PH 500. (ii) Except as specifically provided otherwise by this license, the licensee shall possess and use radioactive material described in this license in accordance with statements, representations, and procedures contained in the documents listed below: (a) The application with attachments dated August 24, 1989, signed by Anil K. Sain, M.D., Radiation Safety Officer. (b) The letter with attachments, dated November 13, 1991, signed by H. Walter Pepper, M.D. (relative to clearance survey of the old lab), and letter with attachments, dated December 20, 1991, signed by John Atherton and Anil Sain, M.D., relative to new nuclear medicine and cardiology laboratories and new quality assurance procedures on cameras. (c) The letter with attachments, dated February 26, 1992, signed by John R. Atherton and Anil Sain, .D., relative to storage location. (d) The letter dated July 13, 1992, with attached revised package receipt procedure, signed by H. Walter Pepper, M.D. 14. (a) 'Mie Radiation safety officer shall be H. Walter Pepper, M.D. (b) The Chairperson of the Radiation Safety Committee shall be H. Walter Pepper, M.D. (c) The Custodian of sealed sources shall be Anil K. Sain, M.D. (d) The Alternate Radiation Safety finer shall be Anilk Sain, M.D. 15. Sealed sources possessed under this license shall be tested for leakage and/or contamination as required by Section 30275(c) of the California Radiation Control Regulations. 16. Analytical tests for leakage and/or contamination of sealed sources shall be performed only by persons specifically authorized to perform that service. 17. The following individuals are authorized to collect wipe test samples of sealed sources possessed under this license using leak test kits acceptable to the California Department of Health Services. (a) The Radiation Safety Officer (b) Qualified Individuals designated by the Radiation Safety Officer For the State Department of Health Services Date: February 3, 1994 By. 3 Radiologic Health Branch P.O. Box 942732 Sacramento, CA 94234-7320 RH 2551 (Int.) (1/91)