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State of Califomia-Health and Welfare Agency <br />RADIOACTIVE MATERIAL LICENSE <br />Supplementary Sheet <br />Department of Health Services <br />Page 3 of 6 pages <br />License Number: 1294-39 <br />Amendment Number: 54 <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 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 March 31, 1989 signed by Michael N. Smith as <br />modified by letters with attachments dated June 29, 1990, July 12, 1990 and September 18, 1990, all <br />signed by Douglas McGirr, M.D. <br />(b) The letter with attachments dated October 7, 1994, signed by Michael N. Smith, Director, regarding <br />procedural changes and instruments calibration. <br />(c) The letter with attachments dated November 21, 1994 signed by Steve Ebert, Hospital Director, regarding <br />the new Radiation Training module. <br />(d) The letter dated December 13, 1994, signed by Douglas McGirr, M.D., regarding the use of Calicheck <br />device for the quarterly linearity test of the Dose calibrator. <br />(e) The letter with attachments dated September 16, 1995, signed by Douglas B. McGirr, M.D., Radiation <br />Safety Officer, regarding the purchase of new equipment (Picker Prism 1000 SPECT imaging system, <br />Atomlab 950 thyroid probe and Atomlab 100 Plus dose calibrator). <br />(f) The letter with attachments dated February 9, 1996 signed by Dennis Jacobsen, M.D., Radiation <br />Safety Officer, regarding the physical layout of the new facility, calculation for ventilation of xenon, <br />and applicable quality control tests for the Dose Calibrator. <br />14. (a) The Radiation Safety Officer in this program shall be Dennis D. Jacobson, M.D. <br />(b) The Chairperson of the Radiation Safety Committee shall be Douglas McGirr,M.D. <br />(c) The Custodian of sealed sources shall be Douglas McGirr, M.D. <br />15. Sealed sources possessed under this license shall be tested for leakage and/or contamination as required by <br />Section 30275 (c) of the California Radiation Control Regulations. <br />16. Quantitative analytical assays for the purpose of tests for leakage and/or contamination of sealed sources shall <br />be performed only by persons specifically authorized to perform that service. <br />17. The following individuals are authorized to collect wipe test samples of sealed sources possessed under this <br />license using leak test kits acceptable to the California Department of Health Services: <br />(a) The Radiation Safety Officer <br />(b) Qualified individuals designated in writing by the Radiation Safety Officer <br />