Oct 29 2010 854 CT Oncolog~ amp Hematolog~ 489-2551 p2 Mar n 2010 125BPM No 0892 P 3

STATE OF CONNECTICUT DEPARTMENT Of ENVRONMENTAL PROTECTION Bureau of Air Management Division of Radiation 860-424-3029

Ionizing Radiation Registration

Please complete Ihis rorm in accardalce wilh the instructions (DEP-RAD-INST-100) 10 ensure the proper handling of your reglslration Prinl or type unless otherwise noted You must 8ubmitlhe invoice regislration fee and all suppoMing documentation including a completed AppJJcant Compliance Informtlon Form (OEPmiddotAPpmiddot002) along with 1his form

Part I Registration Type Check the appropriate box identifying the registration type

This registration is for

o AMW ionizing radia1ion registration (If thi5 a new registratfon you must call B60-424-3535 before you rel1i5fer to obtaIn an InvoIce)

8l ~ re~~a~Of an eXj~~~ n iZQ radiation registration

tJ Anamendmentto anexlstnmiddotg Ionizing radiatiQrl regist~~IOIlmiddot

bull YI1~n ~u~rri~inQ iH~neX~Iot or an amel1dment to an exsting radiation registration please indicale any changes ttllNe existing registration informalion by IJsing red ink

Part It Fee Information

An annual registration fee of ~200 00 is to be submitted with earh registration and applies for Ihe period covertng 1he calendar year The registration will not be processed without the fee

Part III Facility Information

1 Comanv Natne CONNECTICUT ONCOLOGY amp HEMATOLOGY

FacililY Nama(ir different

Ad~ress 220 KENNEDY DRIVE

~i1ylTown TORFUNGTON

Business Phone 860-482-5384

Slale CT

ext 22~

I bull l

Zip Code 06790

Fax 860-4892551

I

CitylTown Slate lip Code

CEP-RACFtEG-10D 1cf5 Rev 05t6l(lS

57 gtto~RECIO IN LAT NOV - 4 2DiO NMS~GN1MA~

p3 Oct 29 2010 854 CT Oncolo~~ ~ Hematolo~~ 489-2551

Mar 29 2010 1258PM No 0892 p 4

Part IV NRC LIGene

For new IIcfmsN attach a copy 0 each license for renewals or modifications alfach any amendampei pages of each ficanampe

Part V Radiation Safety Personnel

Lisl contact people In the radiation safely sectiltm

1 Name K PAUL STEINMEYER

Title RSO

Direct Phone 860228middot0487

EmiddotMail Address KPSTEINRADPROCOM

24middotHour Emergency Phone

ex Fax

2 Name CATHY COLEMAN

Title PET

Oirect Phone 860middot482middot5384

EmiddotMaIl Addres~ ccolemanconnonccom

24middotHour Emergency Phone

ext tit

r14 Fa)(

3 Name

Title

Direct Phone

EmiddotMail Address

2middotHoUf Emergency Phone

ext Fax

Part VI Personnel DOSimetry

1 Imicale whether personnel dosimetry is performed at your facility [8j Yes DNo

2 If yes indicate the name ot vendor Ihat provitfes this service

LANDAUER

2 of e Rev O~f25IC9

Part VII Industrial XRay Equipment

Part VIII Analytic Equipment for Examination of Material (Including but not limited to X-ray diffraction units electron microscopes gauging devices spectrosoopic equipment gas chromatographs and fluoroscopjc units do not include X-ray tubes used for diagnosis or therapy)

Part IX lndusvial Radiographic Equipment (For examination of struclllre With a sealed source)

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aPart XI Special Nuclear Materia J

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p7 Oct 29 2010 855 CT Oncolog~ amp Hematolog~ 489-2551

Mar 29 2010 12 S9PM No 0892 p 8

Part XV Waste Disposal

Does your facility generate LLRW which Ntll require disposal by burial DYes 181 No

Does your facility generate shorr half-lire radioacdve wasle 181 Yes o No

Does your facility dispose of radklaclive wasle to a sanitary sewer [8JYes o No

Remarks or Comments

Part XVI Registration Certlfictlon

The company executive with overall responsibility for tne facilit~ and the iMlvidual(fraquo responsible or actually preparing the registration must sgn this part Please nole a registrafion will be returned unprocessed unless aM ampignatures are provided

I have persoMlty examined and am familiar with the informalion SlJbmitted in this doolJrnenl and all attachments thereto and certiry that based on reasonable investigation Including my inquiry of the individuals responiible for obtaining the illformation the submllted Information is true acclJrate and complete to the best or my knowledge and belief

I certify Ihatthis application is on complete and acc~rate forms 85 prescribed by the commissioner wit~out alteration of the text

I understand that a false statemeht In the submilted infonnation may be punishable as a criminal offense In accordance w_h sectIOn 22amiddot6 of tne General Slatutes pursuant to section 53amiddot157b of the General Sialulas and accordance with any other applicable stalule

- ( 0

Dale

Ivan Lowenthal MD Name of Company ElCGcJlive (print or Iype) Title (if applicable)

= ~~

Caih COleman CNMT Name of Preparer (prinf or type) Title (if appliCable)

o Check here if 3adifional sigllatures are required 1f so please reproduce this sheet and attach signed copies to Ihls sheet

No16 Please submil Inc ollowing 181 a compleled fegi61ralicm form

~ Ivolce is] fee

o copy of each NRC license or amended pages 01 NRC licenses I8l a (ompleted Applnt Compne Information form (OEPAPP-002)

to CENTRAl PERMIT PROCESSING UNIT CT DEPARTMENT OF ENVIRONMENTAL PROTECTION 79 ELM S1 HARTFORD cr 06106-5127

DEP-RAD-REGmiddot100 6016 Rell 0512609

p8 Oct 29 2010 855 CT Oncolog~ amp Hematolog~ 489-2551

Mar 29 2010 lCOPM No 0892 P 9

APP__ ______~

Applicant Compliance Informt=--Omiddot_-=shy _-=t

Appltant Name CONNECTICUT ONCOLOGY ampHEMATOLOGY (aamp indicaled on the Permit AppJicfltion Transmittal Form)

If you anWef 1s to any of the questIons below you must complele lhe Table of Enforcement Actions on the reverse side or this sheet as direcled in the insrucliOns ror )lour permit application

A During the five years Immediately preceding submission oithis application has the applicant been conVICIeO In any jurlsdlcliofl of a criminal violalion of any enllironmentallaw

DYes 18I No

B Ouringlhe five years immediately preceding submission or this application has a civil penally been impO$ed upon th~ applieant in any slate ineluding Connecticut or rederal Judicial proceeding tor any violalll)n 01 an wironmental law

DYes ~ No

C Durilg Ihe five years immediately preQeding submission of this applicalron has a civil penalty elltceedlng five thousand dollars been imposed on the applicant in any state including C(JnneCtiClIt or federal administrative proceeding for any violation of an erlronmentallaw

DYes o No

p DUring the five years immediately preceding submission of this applicalton has any state ilCIUding Connecticul or federal couri issued any order Of enlered any judgement to the applicant concerning a violation of any environmental law

DYes [8] No

E During the five yean immediately preceding submission of this application has any state including Connecticut or federal administmlive agency issued any order to the applicant concerning a violation 0 any environmentallaw7

DYes CJ No

OEpmiddotAPP-002 I of 2 Rev 0510704

act 29 2010 911 CT Oncolog~ amp Hematolog~ 489-2551 p2

STATE OF CONNECTICUT DEPARTMENT OF ENVIRONMENTAL PROTECTION Bureau of Air Management Division of Radiation 880-424-3029

Ionizing Radiation Registration

Please complelJ this form In accordance with the instructions (0EP-RAO-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation Including a completed Applicant Compliance Information Form (DEP-A~P-002) along w~h this form

Part I Registltion Type

Check the appropriate oox identifyng the registration type

This registration is for

o A new ionizing radiation registration

I8l A renewal of an existing ionizing radiation registration

o An amendment to an existing ionizing radiation registration

Part II Fee Infonnation

An annual registration fee of $20000 is to be submitted with each registration and applies for the period covering the calendar year The registration will not be processed without the fee

Part III Facility Information

1 Company Name CONNECTICUT ONCOLOGY amp HEMATOLOGY

Facility Name (if different)

Address 200 KENNEDY DRIVE

CityITown TORRINGTON

Business Phone 860482-5384

State CT

e)(t 229

Zip Code 06790

Fax 880-489-2551

24-Hour Emergency Phone

2 Location of Material (If different) 220 KENNEDY DRIVE

CitylTown TORRINGTON State CT Zip COde 06790

oEPmiddotRAD-REG-1 00 106

p3489-2551CT Oncolog~ L Hematolog~

Oct 29 2010 911

~

fla ~RC CamptM ~

For new licenses attach a copy of each license for renewsls ()fmcxJi~tioriS attach any amendedpa~es of~ each license

Part V Radiation Safety Personnel

l1st~~~~~~~~gt 1 Name K PAUL S~INMeYER

Title RSO

Direct Phone 860-228-0487 ext Fax

E-Mail AddressKPSTEINRAOPROCOM

24-Hour Emergency Phone

2 Name CATHY COLEMAN CNMT

Title PET

Direct Phone 860-4825384 ext 229 Fax E-Mail Addresscatherinecolemanusoncologycom

24-Hour Emergency Phone

3 Name

Title

Direct Phone ext Fax E-Mail Address

24dioUf me(gllncyPtl9ne ~ -

Part VI Personnel Dosimetry

1 Indicate whether personnel dosimetry is pelfofTl1ed at your facility IlJ Yes o No

2 If yes indicate the name of vendor that provides this service LANDAUER

OIPRAO-REG100

Part VII Industrial XRay Equipment

Part VIII Analytic Equipment for Examination of Material (Including but not limited to X-ray diffraction units electron microscopes gauging devices spectrosoopic equipment gas chromatographs and fluoroscopjc units do not include X-ray tubes used for diagnosis or therapy)

Part IX lndusvial Radiographic Equipment (For examination of struclllre With a sealed source)

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aPart XI Special Nuclear Materia J

Cl (Special nuclear material rSNMl refers to plutonium Z33U uranium enriched in the isotope 23301 in the Isotope 235 greater tka its natural abundance and 0 any other material which the US NRC pursuant to the provisions of Section 5lof the Atomic Energy Act of 1954 delermfnes 10 be speciall1Uclellf material 0 SNM does not include source material) (Ij

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(Source materialiSM) refers to uranium or thorium or any combination thereof in any physical or chemica form or ores which contaill at least 005 by fgt weight uranium thorium 01 any combination thereof except whln the materiel is deSignated as special nlJCJear materia) CD

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DEPfVU)REG-1oo Sal6 Rev 05012609 ll

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p7 Oct 29 2010 855 CT Oncolog~ amp Hematolog~ 489-2551

Mar 29 2010 12 S9PM No 0892 p 8

Part XV Waste Disposal

Does your facility generate LLRW which Ntll require disposal by burial DYes 181 No

Does your facility generate shorr half-lire radioacdve wasle 181 Yes o No

Does your facility dispose of radklaclive wasle to a sanitary sewer [8JYes o No

Remarks or Comments

Part XVI Registration Certlfictlon

The company executive with overall responsibility for tne facilit~ and the iMlvidual(fraquo responsible or actually preparing the registration must sgn this part Please nole a registrafion will be returned unprocessed unless aM ampignatures are provided

I have persoMlty examined and am familiar with the informalion SlJbmitted in this doolJrnenl and all attachments thereto and certiry that based on reasonable investigation Including my inquiry of the individuals responiible for obtaining the illformation the submllted Information is true acclJrate and complete to the best or my knowledge and belief

I certify Ihatthis application is on complete and acc~rate forms 85 prescribed by the commissioner wit~out alteration of the text

I understand that a false statemeht In the submilted infonnation may be punishable as a criminal offense In accordance w_h sectIOn 22amiddot6 of tne General Slatutes pursuant to section 53amiddot157b of the General Sialulas and accordance with any other applicable stalule

- ( 0

Dale

Ivan Lowenthal MD Name of Company ElCGcJlive (print or Iype) Title (if applicable)

= ~~

Caih COleman CNMT Name of Preparer (prinf or type) Title (if appliCable)

o Check here if 3adifional sigllatures are required 1f so please reproduce this sheet and attach signed copies to Ihls sheet

No16 Please submil Inc ollowing 181 a compleled fegi61ralicm form

~ Ivolce is] fee

o copy of each NRC license or amended pages 01 NRC licenses I8l a (ompleted Applnt Compne Information form (OEPAPP-002)

to CENTRAl PERMIT PROCESSING UNIT CT DEPARTMENT OF ENVIRONMENTAL PROTECTION 79 ELM S1 HARTFORD cr 06106-5127

DEP-RAD-REGmiddot100 6016 Rell 0512609

p8 Oct 29 2010 855 CT Oncolog~ amp Hematolog~ 489-2551

Mar 29 2010 lCOPM No 0892 P 9

APP__ ______~

Applicant Compliance Informt=--Omiddot_-=shy _-=t

Appltant Name CONNECTICUT ONCOLOGY ampHEMATOLOGY (aamp indicaled on the Permit AppJicfltion Transmittal Form)

If you anWef 1s to any of the questIons below you must complele lhe Table of Enforcement Actions on the reverse side or this sheet as direcled in the insrucliOns ror )lour permit application

A During the five years Immediately preceding submission oithis application has the applicant been conVICIeO In any jurlsdlcliofl of a criminal violalion of any enllironmentallaw

DYes 18I No

B Ouringlhe five years immediately preceding submission or this application has a civil penally been impO$ed upon th~ applieant in any slate ineluding Connecticut or rederal Judicial proceeding tor any violalll)n 01 an wironmental law

DYes ~ No

C Durilg Ihe five years immediately preQeding submission of this applicalron has a civil penalty elltceedlng five thousand dollars been imposed on the applicant in any state including C(JnneCtiClIt or federal administrative proceeding for any violation of an erlronmentallaw

DYes o No

p DUring the five years immediately preceding submission of this applicalton has any state ilCIUding Connecticul or federal couri issued any order Of enlered any judgement to the applicant concerning a violation of any environmental law

DYes [8] No

E During the five yean immediately preceding submission of this application has any state including Connecticut or federal administmlive agency issued any order to the applicant concerning a violation 0 any environmentallaw7

DYes CJ No

OEpmiddotAPP-002 I of 2 Rev 0510704

act 29 2010 911 CT Oncolog~ amp Hematolog~ 489-2551 p2

STATE OF CONNECTICUT DEPARTMENT OF ENVIRONMENTAL PROTECTION Bureau of Air Management Division of Radiation 880-424-3029

Ionizing Radiation Registration

Please complelJ this form In accordance with the instructions (0EP-RAO-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation Including a completed Applicant Compliance Information Form (DEP-A~P-002) along w~h this form

Part I Registltion Type

Check the appropriate oox identifyng the registration type

This registration is for

o A new ionizing radiation registration

I8l A renewal of an existing ionizing radiation registration

o An amendment to an existing ionizing radiation registration

Part II Fee Infonnation

An annual registration fee of $20000 is to be submitted with each registration and applies for the period covering the calendar year The registration will not be processed without the fee

Part III Facility Information

1 Company Name CONNECTICUT ONCOLOGY amp HEMATOLOGY

Facility Name (if different)

Address 200 KENNEDY DRIVE

CityITown TORRINGTON

Business Phone 860482-5384

State CT

e)(t 229

Zip Code 06790

Fax 880-489-2551

24-Hour Emergency Phone

2 Location of Material (If different) 220 KENNEDY DRIVE

CitylTown TORRINGTON State CT Zip COde 06790

oEPmiddotRAD-REG-1 00 106

p3489-2551CT Oncolog~ L Hematolog~

Oct 29 2010 911

~

fla ~RC CamptM ~

For new licenses attach a copy of each license for renewsls ()fmcxJi~tioriS attach any amendedpa~es of~ each license

Part V Radiation Safety Personnel

l1st~~~~~~~~gt 1 Name K PAUL S~INMeYER

Title RSO

Direct Phone 860-228-0487 ext Fax

E-Mail AddressKPSTEINRAOPROCOM

24-Hour Emergency Phone

2 Name CATHY COLEMAN CNMT

Title PET

Direct Phone 860-4825384 ext 229 Fax E-Mail Addresscatherinecolemanusoncologycom

24-Hour Emergency Phone

3 Name

Title

Direct Phone ext Fax E-Mail Address

24dioUf me(gllncyPtl9ne ~ -

Part VI Personnel Dosimetry

1 Indicate whether personnel dosimetry is pelfofTl1ed at your facility IlJ Yes o No

2 If yes indicate the name of vendor that provides this service LANDAUER

OIPRAO-REG100

a Cl ct

Part X Particle Accelerators I)

-0(Including but nQt limited to Van de Grafb Linacs Cyclolrons Electronic Beam Welders) -gt co

I) gt ltgt a cgt a -gt CD

- (1-= ~gt fgt3

n -1

aPart XI Special Nuclear Materia J

Cl (Special nuclear material rSNMl refers to plutonium Z33U uranium enriched in the isotope 23301 in the Isotope 235 greater tka its natural abundance and 0 any other material which the US NRC pursuant to the provisions of Section 5lof the Atomic Energy Act of 1954 delermfnes 10 be speciall1Uclellf material 0 SNM does not include source material) (Ij

u

P

J (J)

3 III ct 0 0

(Ij

u Part Xii Source Material

(Source materialiSM) refers to uranium or thorium or any combination thereof in any physical or chemica form or ores which contaill at least 005 by fgt weight uranium thorium 01 any combination thereof except whln the materiel is deSignated as special nlJCJear materia) CD

co I

I)

=(1(1ltgt

= CD -D -

-0

0shy

O~P-RA[)REt1QO 40f6 Rev 0SJ26109

(1

Part XIII Sealed Sources bull

~

- ~

0 0 ct

I) CD

I)

~o

0

- CD VcCJI i

n -1

0 l 0 0 0 n u p

Part XIV other Radioactive Materials 4including medical isotopes) t II)

3 llI ct 0 0 n u

CD CD I

I)

CJI =CJ1 ltgt

=gt CD

0 -gt

-0

-J

DEPfVU)REG-1oo Sal6 Rev 05012609 ll

en

p7 Oct 29 2010 855 CT Oncolog~ amp Hematolog~ 489-2551

Mar 29 2010 12 S9PM No 0892 p 8

Part XV Waste Disposal

Does your facility generate LLRW which Ntll require disposal by burial DYes 181 No

Does your facility generate shorr half-lire radioacdve wasle 181 Yes o No

Does your facility dispose of radklaclive wasle to a sanitary sewer [8JYes o No

Remarks or Comments

Part XVI Registration Certlfictlon

The company executive with overall responsibility for tne facilit~ and the iMlvidual(fraquo responsible or actually preparing the registration must sgn this part Please nole a registrafion will be returned unprocessed unless aM ampignatures are provided

I have persoMlty examined and am familiar with the informalion SlJbmitted in this doolJrnenl and all attachments thereto and certiry that based on reasonable investigation Including my inquiry of the individuals responiible for obtaining the illformation the submllted Information is true acclJrate and complete to the best or my knowledge and belief

I certify Ihatthis application is on complete and acc~rate forms 85 prescribed by the commissioner wit~out alteration of the text

I understand that a false statemeht In the submilted infonnation may be punishable as a criminal offense In accordance w_h sectIOn 22amiddot6 of tne General Slatutes pursuant to section 53amiddot157b of the General Sialulas and accordance with any other applicable stalule

- ( 0

Dale

Ivan Lowenthal MD Name of Company ElCGcJlive (print or Iype) Title (if applicable)

= ~~

Caih COleman CNMT Name of Preparer (prinf or type) Title (if appliCable)

o Check here if 3adifional sigllatures are required 1f so please reproduce this sheet and attach signed copies to Ihls sheet

No16 Please submil Inc ollowing 181 a compleled fegi61ralicm form

~ Ivolce is] fee

o copy of each NRC license or amended pages 01 NRC licenses I8l a (ompleted Applnt Compne Information form (OEPAPP-002)

to CENTRAl PERMIT PROCESSING UNIT CT DEPARTMENT OF ENVIRONMENTAL PROTECTION 79 ELM S1 HARTFORD cr 06106-5127

DEP-RAD-REGmiddot100 6016 Rell 0512609

p8 Oct 29 2010 855 CT Oncolog~ amp Hematolog~ 489-2551

Mar 29 2010 lCOPM No 0892 P 9

APP__ ______~

Applicant Compliance Informt=--Omiddot_-=shy _-=t

Appltant Name CONNECTICUT ONCOLOGY ampHEMATOLOGY (aamp indicaled on the Permit AppJicfltion Transmittal Form)

If you anWef 1s to any of the questIons below you must complele lhe Table of Enforcement Actions on the reverse side or this sheet as direcled in the insrucliOns ror )lour permit application

A During the five years Immediately preceding submission oithis application has the applicant been conVICIeO In any jurlsdlcliofl of a criminal violalion of any enllironmentallaw

DYes 18I No

B Ouringlhe five years immediately preceding submission or this application has a civil penally been impO$ed upon th~ applieant in any slate ineluding Connecticut or rederal Judicial proceeding tor any violalll)n 01 an wironmental law

DYes ~ No

C Durilg Ihe five years immediately preQeding submission of this applicalron has a civil penalty elltceedlng five thousand dollars been imposed on the applicant in any state including C(JnneCtiClIt or federal administrative proceeding for any violation of an erlronmentallaw

DYes o No

p DUring the five years immediately preceding submission of this applicalton has any state ilCIUding Connecticul or federal couri issued any order Of enlered any judgement to the applicant concerning a violation of any environmental law

DYes [8] No

E During the five yean immediately preceding submission of this application has any state including Connecticut or federal administmlive agency issued any order to the applicant concerning a violation 0 any environmentallaw7

DYes CJ No

OEpmiddotAPP-002 I of 2 Rev 0510704

act 29 2010 911 CT Oncolog~ amp Hematolog~ 489-2551 p2

STATE OF CONNECTICUT DEPARTMENT OF ENVIRONMENTAL PROTECTION Bureau of Air Management Division of Radiation 880-424-3029

Ionizing Radiation Registration

Please complelJ this form In accordance with the instructions (0EP-RAO-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation Including a completed Applicant Compliance Information Form (DEP-A~P-002) along w~h this form

Part I Registltion Type

Check the appropriate oox identifyng the registration type

This registration is for

o A new ionizing radiation registration

I8l A renewal of an existing ionizing radiation registration

o An amendment to an existing ionizing radiation registration

Part II Fee Infonnation

An annual registration fee of $20000 is to be submitted with each registration and applies for the period covering the calendar year The registration will not be processed without the fee

Part III Facility Information

1 Company Name CONNECTICUT ONCOLOGY amp HEMATOLOGY

Facility Name (if different)

Address 200 KENNEDY DRIVE

CityITown TORRINGTON

Business Phone 860482-5384

State CT

e)(t 229

Zip Code 06790

Fax 880-489-2551

24-Hour Emergency Phone

2 Location of Material (If different) 220 KENNEDY DRIVE

CitylTown TORRINGTON State CT Zip COde 06790

oEPmiddotRAD-REG-1 00 106

p3489-2551CT Oncolog~ L Hematolog~

Oct 29 2010 911

~

fla ~RC CamptM ~

For new licenses attach a copy of each license for renewsls ()fmcxJi~tioriS attach any amendedpa~es of~ each license

Part V Radiation Safety Personnel

l1st~~~~~~~~gt 1 Name K PAUL S~INMeYER

Title RSO

Direct Phone 860-228-0487 ext Fax

E-Mail AddressKPSTEINRAOPROCOM

24-Hour Emergency Phone

2 Name CATHY COLEMAN CNMT

Title PET

Direct Phone 860-4825384 ext 229 Fax E-Mail Addresscatherinecolemanusoncologycom

24-Hour Emergency Phone

3 Name

Title

Direct Phone ext Fax E-Mail Address

24dioUf me(gllncyPtl9ne ~ -

Part VI Personnel Dosimetry

1 Indicate whether personnel dosimetry is pelfofTl1ed at your facility IlJ Yes o No

2 If yes indicate the name of vendor that provides this service LANDAUER

OIPRAO-REG100

Part XIII Sealed Sources bull

~

- ~

0 0 ct

I) CD

I)

~o

0

- CD VcCJI i

n -1

0 l 0 0 0 n u p

Part XIV other Radioactive Materials 4including medical isotopes) t II)

3 llI ct 0 0 n u

CD CD I

I)

CJI =CJ1 ltgt

=gt CD

0 -gt

-0

-J

DEPfVU)REG-1oo Sal6 Rev 05012609 ll

en

p7 Oct 29 2010 855 CT Oncolog~ amp Hematolog~ 489-2551

Mar 29 2010 12 S9PM No 0892 p 8

Part XV Waste Disposal

Does your facility generate LLRW which Ntll require disposal by burial DYes 181 No

Does your facility generate shorr half-lire radioacdve wasle 181 Yes o No

Does your facility dispose of radklaclive wasle to a sanitary sewer [8JYes o No

Remarks or Comments

Part XVI Registration Certlfictlon

The company executive with overall responsibility for tne facilit~ and the iMlvidual(fraquo responsible or actually preparing the registration must sgn this part Please nole a registrafion will be returned unprocessed unless aM ampignatures are provided

I have persoMlty examined and am familiar with the informalion SlJbmitted in this doolJrnenl and all attachments thereto and certiry that based on reasonable investigation Including my inquiry of the individuals responiible for obtaining the illformation the submllted Information is true acclJrate and complete to the best or my knowledge and belief

I certify Ihatthis application is on complete and acc~rate forms 85 prescribed by the commissioner wit~out alteration of the text

I understand that a false statemeht In the submilted infonnation may be punishable as a criminal offense In accordance w_h sectIOn 22amiddot6 of tne General Slatutes pursuant to section 53amiddot157b of the General Sialulas and accordance with any other applicable stalule

- ( 0

Dale

Ivan Lowenthal MD Name of Company ElCGcJlive (print or Iype) Title (if applicable)

= ~~

Caih COleman CNMT Name of Preparer (prinf or type) Title (if appliCable)

o Check here if 3adifional sigllatures are required 1f so please reproduce this sheet and attach signed copies to Ihls sheet

No16 Please submil Inc ollowing 181 a compleled fegi61ralicm form

~ Ivolce is] fee

o copy of each NRC license or amended pages 01 NRC licenses I8l a (ompleted Applnt Compne Information form (OEPAPP-002)

to CENTRAl PERMIT PROCESSING UNIT CT DEPARTMENT OF ENVIRONMENTAL PROTECTION 79 ELM S1 HARTFORD cr 06106-5127

DEP-RAD-REGmiddot100 6016 Rell 0512609

p8 Oct 29 2010 855 CT Oncolog~ amp Hematolog~ 489-2551

Mar 29 2010 lCOPM No 0892 P 9

APP__ ______~

Applicant Compliance Informt=--Omiddot_-=shy _-=t

Appltant Name CONNECTICUT ONCOLOGY ampHEMATOLOGY (aamp indicaled on the Permit AppJicfltion Transmittal Form)

If you anWef 1s to any of the questIons below you must complele lhe Table of Enforcement Actions on the reverse side or this sheet as direcled in the insrucliOns ror )lour permit application

A During the five years Immediately preceding submission oithis application has the applicant been conVICIeO In any jurlsdlcliofl of a criminal violalion of any enllironmentallaw

DYes 18I No

B Ouringlhe five years immediately preceding submission or this application has a civil penally been impO$ed upon th~ applieant in any slate ineluding Connecticut or rederal Judicial proceeding tor any violalll)n 01 an wironmental law

DYes ~ No

C Durilg Ihe five years immediately preQeding submission of this applicalron has a civil penalty elltceedlng five thousand dollars been imposed on the applicant in any state including C(JnneCtiClIt or federal administrative proceeding for any violation of an erlronmentallaw

DYes o No

p DUring the five years immediately preceding submission of this applicalton has any state ilCIUding Connecticul or federal couri issued any order Of enlered any judgement to the applicant concerning a violation of any environmental law

DYes [8] No

E During the five yean immediately preceding submission of this application has any state including Connecticut or federal administmlive agency issued any order to the applicant concerning a violation 0 any environmentallaw7

DYes CJ No

OEpmiddotAPP-002 I of 2 Rev 0510704

act 29 2010 911 CT Oncolog~ amp Hematolog~ 489-2551 p2

STATE OF CONNECTICUT DEPARTMENT OF ENVIRONMENTAL PROTECTION Bureau of Air Management Division of Radiation 880-424-3029

Ionizing Radiation Registration

Please complelJ this form In accordance with the instructions (0EP-RAO-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation Including a completed Applicant Compliance Information Form (DEP-A~P-002) along w~h this form

Part I Registltion Type

Check the appropriate oox identifyng the registration type

This registration is for

o A new ionizing radiation registration

I8l A renewal of an existing ionizing radiation registration

o An amendment to an existing ionizing radiation registration

Part II Fee Infonnation

An annual registration fee of $20000 is to be submitted with each registration and applies for the period covering the calendar year The registration will not be processed without the fee

Part III Facility Information

1 Company Name CONNECTICUT ONCOLOGY amp HEMATOLOGY

Facility Name (if different)

Address 200 KENNEDY DRIVE

CityITown TORRINGTON

Business Phone 860482-5384

State CT

e)(t 229

Zip Code 06790

Fax 880-489-2551

24-Hour Emergency Phone

2 Location of Material (If different) 220 KENNEDY DRIVE

CitylTown TORRINGTON State CT Zip COde 06790

oEPmiddotRAD-REG-1 00 106

p3489-2551CT Oncolog~ L Hematolog~

Oct 29 2010 911

~

fla ~RC CamptM ~

For new licenses attach a copy of each license for renewsls ()fmcxJi~tioriS attach any amendedpa~es of~ each license

Part V Radiation Safety Personnel

l1st~~~~~~~~gt 1 Name K PAUL S~INMeYER

Title RSO

Direct Phone 860-228-0487 ext Fax

E-Mail AddressKPSTEINRAOPROCOM

24-Hour Emergency Phone

2 Name CATHY COLEMAN CNMT

Title PET

Direct Phone 860-4825384 ext 229 Fax E-Mail Addresscatherinecolemanusoncologycom

24-Hour Emergency Phone

3 Name

Title

Direct Phone ext Fax E-Mail Address

24dioUf me(gllncyPtl9ne ~ -

Part VI Personnel Dosimetry

1 Indicate whether personnel dosimetry is pelfofTl1ed at your facility IlJ Yes o No

2 If yes indicate the name of vendor that provides this service LANDAUER

OIPRAO-REG100

p7 Oct 29 2010 855 CT Oncolog~ amp Hematolog~ 489-2551

Mar 29 2010 12 S9PM No 0892 p 8

Part XV Waste Disposal

Does your facility generate LLRW which Ntll require disposal by burial DYes 181 No

Does your facility generate shorr half-lire radioacdve wasle 181 Yes o No

Does your facility dispose of radklaclive wasle to a sanitary sewer [8JYes o No

Remarks or Comments

Part XVI Registration Certlfictlon

The company executive with overall responsibility for tne facilit~ and the iMlvidual(fraquo responsible or actually preparing the registration must sgn this part Please nole a registrafion will be returned unprocessed unless aM ampignatures are provided

I have persoMlty examined and am familiar with the informalion SlJbmitted in this doolJrnenl and all attachments thereto and certiry that based on reasonable investigation Including my inquiry of the individuals responiible for obtaining the illformation the submllted Information is true acclJrate and complete to the best or my knowledge and belief

I certify Ihatthis application is on complete and acc~rate forms 85 prescribed by the commissioner wit~out alteration of the text

I understand that a false statemeht In the submilted infonnation may be punishable as a criminal offense In accordance w_h sectIOn 22amiddot6 of tne General Slatutes pursuant to section 53amiddot157b of the General Sialulas and accordance with any other applicable stalule

- ( 0

Dale

Ivan Lowenthal MD Name of Company ElCGcJlive (print or Iype) Title (if applicable)

= ~~

Caih COleman CNMT Name of Preparer (prinf or type) Title (if appliCable)

o Check here if 3adifional sigllatures are required 1f so please reproduce this sheet and attach signed copies to Ihls sheet

No16 Please submil Inc ollowing 181 a compleled fegi61ralicm form

~ Ivolce is] fee

o copy of each NRC license or amended pages 01 NRC licenses I8l a (ompleted Applnt Compne Information form (OEPAPP-002)

to CENTRAl PERMIT PROCESSING UNIT CT DEPARTMENT OF ENVIRONMENTAL PROTECTION 79 ELM S1 HARTFORD cr 06106-5127

DEP-RAD-REGmiddot100 6016 Rell 0512609

p8 Oct 29 2010 855 CT Oncolog~ amp Hematolog~ 489-2551

Mar 29 2010 lCOPM No 0892 P 9

APP__ ______~

Applicant Compliance Informt=--Omiddot_-=shy _-=t

Appltant Name CONNECTICUT ONCOLOGY ampHEMATOLOGY (aamp indicaled on the Permit AppJicfltion Transmittal Form)

If you anWef 1s to any of the questIons below you must complele lhe Table of Enforcement Actions on the reverse side or this sheet as direcled in the insrucliOns ror )lour permit application

A During the five years Immediately preceding submission oithis application has the applicant been conVICIeO In any jurlsdlcliofl of a criminal violalion of any enllironmentallaw

DYes 18I No

B Ouringlhe five years immediately preceding submission or this application has a civil penally been impO$ed upon th~ applieant in any slate ineluding Connecticut or rederal Judicial proceeding tor any violalll)n 01 an wironmental law

DYes ~ No

C Durilg Ihe five years immediately preQeding submission of this applicalron has a civil penalty elltceedlng five thousand dollars been imposed on the applicant in any state including C(JnneCtiClIt or federal administrative proceeding for any violation of an erlronmentallaw

DYes o No

p DUring the five years immediately preceding submission of this applicalton has any state ilCIUding Connecticul or federal couri issued any order Of enlered any judgement to the applicant concerning a violation of any environmental law

DYes [8] No

E During the five yean immediately preceding submission of this application has any state including Connecticut or federal administmlive agency issued any order to the applicant concerning a violation 0 any environmentallaw7

DYes CJ No

OEpmiddotAPP-002 I of 2 Rev 0510704

act 29 2010 911 CT Oncolog~ amp Hematolog~ 489-2551 p2

STATE OF CONNECTICUT DEPARTMENT OF ENVIRONMENTAL PROTECTION Bureau of Air Management Division of Radiation 880-424-3029

Ionizing Radiation Registration

Please complelJ this form In accordance with the instructions (0EP-RAO-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation Including a completed Applicant Compliance Information Form (DEP-A~P-002) along w~h this form

Part I Registltion Type

Check the appropriate oox identifyng the registration type

This registration is for

o A new ionizing radiation registration

I8l A renewal of an existing ionizing radiation registration

o An amendment to an existing ionizing radiation registration

Part II Fee Infonnation

An annual registration fee of $20000 is to be submitted with each registration and applies for the period covering the calendar year The registration will not be processed without the fee

Part III Facility Information

1 Company Name CONNECTICUT ONCOLOGY amp HEMATOLOGY

Facility Name (if different)

Address 200 KENNEDY DRIVE

CityITown TORRINGTON

Business Phone 860482-5384

State CT

e)(t 229

Zip Code 06790

Fax 880-489-2551

24-Hour Emergency Phone

2 Location of Material (If different) 220 KENNEDY DRIVE

CitylTown TORRINGTON State CT Zip COde 06790

oEPmiddotRAD-REG-1 00 106

p3489-2551CT Oncolog~ L Hematolog~

Oct 29 2010 911

~

fla ~RC CamptM ~

For new licenses attach a copy of each license for renewsls ()fmcxJi~tioriS attach any amendedpa~es of~ each license

Part V Radiation Safety Personnel

l1st~~~~~~~~gt 1 Name K PAUL S~INMeYER

Title RSO

Direct Phone 860-228-0487 ext Fax

E-Mail AddressKPSTEINRAOPROCOM

24-Hour Emergency Phone

2 Name CATHY COLEMAN CNMT

Title PET

Direct Phone 860-4825384 ext 229 Fax E-Mail Addresscatherinecolemanusoncologycom

24-Hour Emergency Phone

3 Name

Title

Direct Phone ext Fax E-Mail Address

24dioUf me(gllncyPtl9ne ~ -

Part VI Personnel Dosimetry

1 Indicate whether personnel dosimetry is pelfofTl1ed at your facility IlJ Yes o No

2 If yes indicate the name of vendor that provides this service LANDAUER

OIPRAO-REG100

p8 Oct 29 2010 855 CT Oncolog~ amp Hematolog~ 489-2551

Mar 29 2010 lCOPM No 0892 P 9

APP__ ______~

Applicant Compliance Informt=--Omiddot_-=shy _-=t

Appltant Name CONNECTICUT ONCOLOGY ampHEMATOLOGY (aamp indicaled on the Permit AppJicfltion Transmittal Form)

If you anWef 1s to any of the questIons below you must complele lhe Table of Enforcement Actions on the reverse side or this sheet as direcled in the insrucliOns ror )lour permit application

A During the five years Immediately preceding submission oithis application has the applicant been conVICIeO In any jurlsdlcliofl of a criminal violalion of any enllironmentallaw

DYes 18I No

B Ouringlhe five years immediately preceding submission or this application has a civil penally been impO$ed upon th~ applieant in any slate ineluding Connecticut or rederal Judicial proceeding tor any violalll)n 01 an wironmental law

DYes ~ No

C Durilg Ihe five years immediately preQeding submission of this applicalron has a civil penalty elltceedlng five thousand dollars been imposed on the applicant in any state including C(JnneCtiClIt or federal administrative proceeding for any violation of an erlronmentallaw

DYes o No

p DUring the five years immediately preceding submission of this applicalton has any state ilCIUding Connecticul or federal couri issued any order Of enlered any judgement to the applicant concerning a violation of any environmental law

DYes [8] No

E During the five yean immediately preceding submission of this application has any state including Connecticut or federal administmlive agency issued any order to the applicant concerning a violation 0 any environmentallaw7

DYes CJ No

OEpmiddotAPP-002 I of 2 Rev 0510704

act 29 2010 911 CT Oncolog~ amp Hematolog~ 489-2551 p2

STATE OF CONNECTICUT DEPARTMENT OF ENVIRONMENTAL PROTECTION Bureau of Air Management Division of Radiation 880-424-3029

Ionizing Radiation Registration

Please complelJ this form In accordance with the instructions (0EP-RAO-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation Including a completed Applicant Compliance Information Form (DEP-A~P-002) along w~h this form

Part I Registltion Type

Check the appropriate oox identifyng the registration type

This registration is for

o A new ionizing radiation registration

I8l A renewal of an existing ionizing radiation registration

o An amendment to an existing ionizing radiation registration

Part II Fee Infonnation

An annual registration fee of $20000 is to be submitted with each registration and applies for the period covering the calendar year The registration will not be processed without the fee

Part III Facility Information

1 Company Name CONNECTICUT ONCOLOGY amp HEMATOLOGY

Facility Name (if different)

Address 200 KENNEDY DRIVE

CityITown TORRINGTON

Business Phone 860482-5384

State CT

e)(t 229

Zip Code 06790

Fax 880-489-2551

24-Hour Emergency Phone

2 Location of Material (If different) 220 KENNEDY DRIVE

CitylTown TORRINGTON State CT Zip COde 06790

oEPmiddotRAD-REG-1 00 106

p3489-2551CT Oncolog~ L Hematolog~

Oct 29 2010 911

~

fla ~RC CamptM ~

For new licenses attach a copy of each license for renewsls ()fmcxJi~tioriS attach any amendedpa~es of~ each license

Part V Radiation Safety Personnel

l1st~~~~~~~~gt 1 Name K PAUL S~INMeYER

Title RSO

Direct Phone 860-228-0487 ext Fax

E-Mail AddressKPSTEINRAOPROCOM

24-Hour Emergency Phone

2 Name CATHY COLEMAN CNMT

Title PET

Direct Phone 860-4825384 ext 229 Fax E-Mail Addresscatherinecolemanusoncologycom

24-Hour Emergency Phone

3 Name

Title

Direct Phone ext Fax E-Mail Address

24dioUf me(gllncyPtl9ne ~ -

Part VI Personnel Dosimetry

1 Indicate whether personnel dosimetry is pelfofTl1ed at your facility IlJ Yes o No

2 If yes indicate the name of vendor that provides this service LANDAUER

OIPRAO-REG100

act 29 2010 911 CT Oncolog~ amp Hematolog~ 489-2551 p2

STATE OF CONNECTICUT DEPARTMENT OF ENVIRONMENTAL PROTECTION Bureau of Air Management Division of Radiation 880-424-3029

Ionizing Radiation Registration

Please complelJ this form In accordance with the instructions (0EP-RAO-INST-100) to ensure the proper handling of your registration Print or type unless otherwise noted You must submit the registration fee and all supporting documentation Including a completed Applicant Compliance Information Form (DEP-A~P-002) along w~h this form

Part I Registltion Type

Check the appropriate oox identifyng the registration type

This registration is for

o A new ionizing radiation registration

I8l A renewal of an existing ionizing radiation registration

o An amendment to an existing ionizing radiation registration

Part II Fee Infonnation

An annual registration fee of $20000 is to be submitted with each registration and applies for the period covering the calendar year The registration will not be processed without the fee

Part III Facility Information

1 Company Name CONNECTICUT ONCOLOGY amp HEMATOLOGY

Facility Name (if different)

Address 200 KENNEDY DRIVE

CityITown TORRINGTON

Business Phone 860482-5384

State CT

e)(t 229

Zip Code 06790

Fax 880-489-2551

24-Hour Emergency Phone

2 Location of Material (If different) 220 KENNEDY DRIVE

CitylTown TORRINGTON State CT Zip COde 06790

oEPmiddotRAD-REG-1 00 106

p3489-2551CT Oncolog~ L Hematolog~

Oct 29 2010 911

~

fla ~RC CamptM ~

For new licenses attach a copy of each license for renewsls ()fmcxJi~tioriS attach any amendedpa~es of~ each license

Part V Radiation Safety Personnel

l1st~~~~~~~~gt 1 Name K PAUL S~INMeYER

Title RSO

Direct Phone 860-228-0487 ext Fax

E-Mail AddressKPSTEINRAOPROCOM

24-Hour Emergency Phone

2 Name CATHY COLEMAN CNMT

Title PET

Direct Phone 860-4825384 ext 229 Fax E-Mail Addresscatherinecolemanusoncologycom

24-Hour Emergency Phone

3 Name

Title

Direct Phone ext Fax E-Mail Address

24dioUf me(gllncyPtl9ne ~ -

Part VI Personnel Dosimetry

1 Indicate whether personnel dosimetry is pelfofTl1ed at your facility IlJ Yes o No

2 If yes indicate the name of vendor that provides this service LANDAUER

OIPRAO-REG100

p3489-2551CT Oncolog~ L Hematolog~

Oct 29 2010 911

~

fla ~RC CamptM ~

For new licenses attach a copy of each license for renewsls ()fmcxJi~tioriS attach any amendedpa~es of~ each license

Part V Radiation Safety Personnel

l1st~~~~~~~~gt 1 Name K PAUL S~INMeYER

Title RSO

Direct Phone 860-228-0487 ext Fax

E-Mail AddressKPSTEINRAOPROCOM

24-Hour Emergency Phone

2 Name CATHY COLEMAN CNMT

Title PET

Direct Phone 860-4825384 ext 229 Fax E-Mail Addresscatherinecolemanusoncologycom

24-Hour Emergency Phone

3 Name

Title

Direct Phone ext Fax E-Mail Address

24dioUf me(gllncyPtl9ne ~ -

Part VI Personnel Dosimetry

1 Indicate whether personnel dosimetry is pelfofTl1ed at your facility IlJ Yes o No

2 If yes indicate the name of vendor that provides this service LANDAUER

OIPRAO-REG100

p4 CT Oncolog~ L Hematolog~ 489-2551Oct 29 2010 911

Part XVI Wa$te Disposal

Ooes your facility generate LlRW whlctt wilt require disposal by burial DYes 181 No

Does your facility generate short halflife radioactive waste 181 Yes o No

Does your facility dispose of radioactive waste to a sanitary sewer 181 Yes o No

Remarks or Comments

Part XVII Registration Certification The company executive with overall responsibility for the facility and the individual(s) responsible for actually preparing the registration must sign this part Please note a registration will be returned unprocessed unless all oIA bullt Ii signaturea Qr8 VI~ (ji~

-t1 ~f ~

have personally examined and am familiar with the infonnation submitted In this document and all attachments thereto and I certify that based on reasonable investigation including my inquiry of the individualS respasible for obtaining the information the submitted information is true accurate angcomplete to the best of myknQwledge ~~

I certify that this application is on complete and accurate forms as prescribed by the commissioner withQut alteration of the text

I understand that a false statement in the submitted infonnation may be punishable as a criminal offense in sccordance with section 22a-e of the General Statutes pursuant to ~eotion 53a-157b of the General Statutes and in accordance with any other applicable statute

I

416107 Date

MD IVAN LOWENTHAL Name of Company Executive (print or type) Title (if applicable)

CA1lfY COLEMAN CNMT Name of Preparer (print or type) Title (if applicable)

o Check here if additional signatures are required If so please reprodUce this sheet and attach signed copies fa this sheet

Nate Pleas submit 1he following o a completed registration form

o fee o copy of each NRC license or amended pages of NRC licenses

o a complliJted Appllcllnt Compillineenfonnallon form (DEP-APP-002)

to CENTRAL PERMIT PROCESSING UNIT CT DEPARTMENT OF ENVIRONMENTAL PROTECTION 79 ELM 8T HARTFORD CT 06106-5127

nsnOAnDC14ftf ~ bull

If) Part VII Industrial X-Ray Equipment

Q

~

If) If) (J

I en CD Part VIII Analytic Equipment for M~r9$copic Examination of Material V

(Including but not11mited to X-ray diffraction Wits electron microscopes moisture density gauging devices spectroscopic equipment gas qromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or lherapy) n

-D o ~ o

laquoJ e III I

ail

n -D o ~

o o Part IX Indu8trial Radiographic Sources c o (For examination of structure with a sealed source) I shyU

(J ~

en o ~

a (J

en (J

o a OEP-RAD-REG-100 30fS Rev02M101

Part XIII Radium Sources (D

0 (Including but not limited to slatic eliminators)

~

11) 11)

Cl Part XlV Sealed Sources I

~ Part XV Other Radioactive Materials

en ltII v

I _ __~ 1 ~~~vw~V __ J~~v VA~~~V u~_____~n 11

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~ OEP-RAD-REG-100 Sof6 Rev02lO8J07

If) Part VII Industrial X-Ray Equipment

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I en CD Part VIII Analytic Equipment for M~r9$copic Examination of Material V

(Including but not11mited to X-ray diffraction Wits electron microscopes moisture density gauging devices spectroscopic equipment gas qromatographs and fluoroscopic units do not include X-ray tubes used for diagnosis or lherapy) n

-D o ~ o

laquoJ e III I

ail

n -D o ~

o o Part IX Indu8trial Radiographic Sources c o (For examination of structure with a sealed source) I shyU

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o a OEP-RAD-REG-100 30fS Rev02M101

Part XIII Radium Sources (D

0 (Including but not limited to slatic eliminators)

~

11) 11)

Cl Part XlV Sealed Sources I

~ Part XV Other Radioactive Materials

en ltII v

I _ __~ 1 ~~~vw~V __ J~~v VA~~~V u~_____~n 11

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Part XIII Radium Sources (D

0 (Including but not limited to slatic eliminators)

~

11) 11)

Cl Part XlV Sealed Sources I

~ Part XV Other Radioactive Materials

en ltII v

I _ __~ 1 ~~~vw~V __ J~~v VA~~~V u~_____~n 11

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