NRC FORM 313 t3 2009)

U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 31SO~I2tl EXPIRES: 313112012

10 CFR:xl. 12 33 14)!;:!6J9_«l

APPLICATION FOR MATERIALS LICENSE

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ESilfIlaled burden per response 10 comply wlln lIus maocIalory coIlecllOIl request 4 J flOurs Sutlmltlal of the a pplicatIon IS necessa'Y to de termme lhallhe appllcanl '5 qualtfied and thai adequate p<OCedures e~lst 10 protect the public health and s.afely Send comments regard Ing buroon est,mate 10 the Records and FOlAlPnvacy ServlOOS Branch (T.$ F$3) . US Nuclear Regulatorv CommISSlOOl . Wastllr19tOll, DC 21)$$$-OOOt. 01 by onternet e m al l to Inlocollects resource@rucgov . and to the Desk OHicel, Office o f Informatton and Regulatory AHalls, NEO[)·I02{)2. (3150.017.0) . Office of Management a nd Budg el, Washm gton . DC 20$03 II a means used 10 Impose a n informa ti o n collection d oes no! d Isplay a c urre ntly va lId OMf! conlroi number. the NRC may nOI conduct o r s pon sor, and a person IS no t requ ired 10 respond \0 , I he III formah o n coIlectl()/"l

INSTRUCTIONS: SEe THE APPROPRIATE LICENSE APPLICATION GUIDE FOR DETAILED INSTRlCTIONS FOR COMPLETING APPLICA TlON . SEND TWO COPIES OF THE ENTIRE COMPLETED APPLICATION TO THE NRC OFFICE SPEC1F1E[ BELOW .

... Pf>UC ... TION FOR O1SlRl8UTIOH OF EXEMPT PROOUCTS FILE APPUCATJQNS Willi :

orn c£orrO)tllAl &SIAII MATUU"'LSAND ENVIRONMENT"'LMAW\GEMEN I I ,mGlIAMS UIV1SION 01 MATT"RIALS SAFETY AND STillE IIGKt:.t:.MI-N I S US NIICLENl fIH,UI AIOHY COMMISSION WA,SIIINCTON DC 20'/.>5 0001

ALL OTHER PERSONS FILE APPLICATIONS AS FOLLOWS:

IF YOU ARE LOCATED IN:

ALABAM ... . CONN£CTICUT. DELAWARE, DISTRICT OF COlUM8 IA. flORIDA. GEORGIA, IIENTUCKV. MAINE. MARYLAND. MASSACHUSETTS, N£W HAMPSHIRE. NEW JERSEY. NEW YORII , tWRTH C ... RDUN .... PENNSYLV ... NIA. PUERTO RICO. RHODE ISLAND. SOUT", CAROLlN .... TENNESSEE. VERMONT. VIRGINIA. VIRGIN ISLANDS. OR WEST VIRGINIA. SEND APPLICATIONS TO:

lICC",SINC ASSISTAHCE TfAM OMSION OF NUCLEAR MATERIALS SAl I-IY (J S NUCI I- Afl R(Gl)U\TORV COMMISSION REGION I .1511lLEN11AI1- Ii00n KING OF f'RUSSIA PA 14400--HI~

I fF YOU ARE LOCAll'D IN:

ILLINOIS. INOlANA. IOWA. MICHIGAN. MINNESO TA. MISSOURI. OHID. OR WISCONSI",. sero I ... PPLICATIONS TO:

MIIT£RIIII.S lIC~N SING HflA"'Ctf US NUCLEAR REGtJlII TORY COMMISSION III-(;ION III 2~~3 WARRENVILLE ROllO SUITF "0 LISLE IL 00532 ·~352

I ALASKA. ARIZONA. ARKA",SAS. CALIFORNI"', COLORADO. HAWAII. IDAHO. KANSAS. LOUISIANA. MISSISSIPPI. MONT ... NA. NEBRASII .... NEII ... DA. NEW MEXICO. NORTH 0"110' ... . C)l(lAt.O ...... OREGON. PACIfIC TRUS T TERRITORIES. SOUlli OAIIOTA, reus.

I UTA:~:::::::~:GS::~~UCAnoos TO:

US NUCl[AR RCGUlJITORY COMMISSION IIt:.GION IV

I (il2E lI\MAJI HOUI~IIAIlO 5UIT(400 ARLI NGTON TX 76011 4 1~~,

PERSONS LOCATED IN AGREEM ENT STATES SEND APPLIC ... TlONS TO THE U.S. NUCLEAR REGULA TORY COMMISSION ONLY IF lliEY WISH TO POSSESS AND USE LICENSED MATeRI"'L IN STA TES SU8JECT TO U.S.NUCLEAR REGUL ... TORV COMMISSION JURISDICTIONS.

1 THIS IS AN APPI iCAl lON FOR ( Cl>«~ "PiIIU,"''-m. 'l~mJ

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209 Nurlh Limeslone- Ave-nue­

Gillette-, WY 82717

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2 NAME AND MIIIIING AIlll111- SS or APPLIC"NT (I",/WI> liP""""!

Intermountain Construction and Materials

I P.O. UtlX 2469 Gillette, WV 827 17-2469

I. NAMl Ol' PERSON TO BE CONTACTfO AHOUI I I flS APVUC ... llON

I Michael Ne7.worski

I

TElEPHONE NUMBER

(J07) 682 ·8407

SUBMIT ITEMS 5 l Hf(OliGH 11 0 ", B_1I7 X 1 , - PAP[R TilE TYPE AND SCOf'~ Of INI 0I1MAt iUN 10 D[ PROVIDED IS OESCR IIl ~U I", I H ~ I ICt NSI APPlICA.TION GUID[

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" WA.STE MANII,,EMENI

PURPOS[ (S) FOR 'M-lICH UC~NS~U MAI I-Il ..... 1 IMI l (lC US[D

IIlAIN~C FOR INDIVIDUAlS v\()fiK1NG IN 011 I III QU[NTlN(> R[ STRICTED ... RE ... S

II"')IA liON SAfCTY PROGRfIM

I? I IC[NSC FEES Is"., 10 em ,m.>n(! Sect"", lro 3j)

I rrECATECORV JPOJI21 1 ~2~~:lEO s 1.500.00 13 CCRTIFIC"TION (1.1" ." t,,-, rompicfc<J by lWI»Calll) TilE IIppLlCIIN r I INIlH1S IANIlS TI IA, I ALL ST"TEMENTS flNU Ill-Plll-S~ N 1,0. l iONS MADE IN THISAPPLICIITION fI"~ IIINIl ING UPON THE IIprl ICAN I

THE APPLIC"NT lIND IINY 01 I lelAl l ·x rCUTINC nils CERTIFICflllON ON HI-HAl r 01" TII[ APPLICANT NfIM~U IN II I-M 1 CI Rl lry IIIAT Ti llS AP PLICATION IS f'Ht::I'I\I(~U IN CONFORMITY 1M1 ... If lf~ It} conr Of FEDCRAL REGOllllfONS PA!IIS:JO :Q :l3.3-I 35 3(;.39 IIN040 IINIl l HA I All INFORMI\TION CONTIINEO HEREIN IS IlllJ~ A,ND CORRECllO I H~ Ht SI Of' HICIR KNOWLEDC,E IINONt-111-f

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CEH";;IYV:::~[: ~=;~~O~~H::I~~;lSI:;";S AS TO mv MAneR IMfH~tI I :~~;;~~~ _/1 n.. DATE

Mil'hat'l Nt'zwnrsk i I Qualit:r Contrul Manager I r f...,LP 11 1.....v.· 02/ 13/2012

FOR NRC USE ONLY I ~OUNT RECEIVEU I CHrCK Nw nrR I COMMENTS

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i FC[ l OG TVPfOl II! fH CAli GORY

APPROVED IlY

NRC FORM 313 (3:1W!11 PRINTF IJ ON III CYCL[O P"PCR

5. Radioactive Material Manufacturers

( s- 137: Sea led sources (AEA Technology/Q5A, Inc., Model COCW556

Or Isotope Products Laboratories Model HEG-137)

30 millicuries total. No single source to exceed the maximum act ivity specified in the certi ficate of

registration issued by NRC or an Agreement State.

Manufacturers

Am-241: Sealed neutron sources (AEA Technology/QSA, Inc., Model AMNV.997 or Isotope Products

laboratories Models AMl.N02, 3021 or 3027)

150 millicuries total. No single source to exceed the maximum activ ity spec ified in the certificate of

registration issued by NRC or an Agreement State.

6. Purposes for which licensed

material will be used To be used in Troxler Model 3400 series

Purpose for equ ipment is to measure moisture and density of construction/ engineering materials.

7. Individuals responsible for

Radiation Safety Program and

their training experience. Purposed RSO; Michae l Nezworski

Before obtaining licensed materials, the proposed RSO will have successfully completed one of the

train ing courses described in Cr iteria in the section entitled " Ind ividual (s) Responsible for Rad iat ion

Safety Program and Their Training and Experience - Radiation Safety Officer" in NUREG-lSS6, Vol. 1,

Rev. 1, dated November 2001.

Michael Nezworski com pleted RSO tra ining offered by Troxler Electronic Laboratories on 2/2/12.

8. Training for individuals

working in or frequenting

restricted areas. Before using licensed materials, authorized users w ill have successfully completed one o f the t raining

course described in Criteria in the sect ion entitled "Training for Individuals Working In or Frequenting

Restricted Areas" in NUREG-1556, VoLl, Rev 1, dated November 2001.

10. Radiation Safety Program Survey Instruments: We w ill either possess and use, or have access to and use, a radiation survey meter

that meets the Cri teria in the section ent itled " Radiation Safety Program - Instruments" in NUREG~ 1556.

Vol. 1, Rev. 1, dated November 2001 .

Materia l Receipt and Accountabi lity: Physical inventories w ill be conducted at intervals not to exceed 6

month s, to account for all sea led sources and devices received and possessed under the l icense.

Occupational DOSimet ry: We will provide dosimet ry processed and evaluated by an NVLAP-approved

processor t hat is exchanged at a freq uency recommended by the processor.

Operati ng and Emergency Procedures: We w ill implement and mainta in the operating and emergency

procedures in Appendix H of NUREG-1556. Vol. 1. Rev. 1, dated November 2001, and provide copies of

these procedures to all gauge users and at each job si te.

leak Test ing: l eak tests wi ll be performed at intervals approved by NRC or an Agreement Sate and

specified in the Sea led Source and Device Regist ration Sheet. leak tests will be performed by an

organization authorized by NRC or an Ag reement State to provide leak testing services for other

licensees or using a leak test kit supplied by an organization authorized by NRC or an Agreement State to

provide leak test kit s to other licensees and according to the kit supplier's instructions.

Maintenance:

Routine Cleaninq and Lubrication

We w ill implement and maintain procedures for routine maintenance of our gauges according to each

manufacturer's recommendations and instructions.

Non-Routine M aintenance

We will send the gauge to the manufacturer or other person authorized by NRC or an Agreement State

to perform non-routine maintenance or repair operations that require the removal of the source or

source rod f rom the gauge.

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NRC FORM 532 U. S. NUCLEAR REGULATORY COMMISSION (1 -2012)

DATI::

02/2R120 12

NAME AND ADDRESS OF APPLICANT AND/OR LICENSEE LICENSE NUMBER

Intermountain Construction ilnd Materials A1TN: Michael Nezworski PO [lox 2469

49-27460-02

MAIL CONTROL NUM BER

577024

Gi llette, Wyomi ng &27 17·2469 LICENSING ANDIOR TECHNICAL REVIEI!\IER

ch

o o

This is to acknowledge the receipt of your:

o LETTER and/or [Z] APPLICATION DATED: __ ~02~/~13~/2~0~12~

The initial processing, which included an administrative review, has been performed.

o AMENDMENT 0 TERMINATION lZl NEW LICENSE D RENEWAL

There were no administrative omissions identified during our initial review.

This is to acknowledge receipt of your application for renewal of the material(s) license identified above. Your application is deemed timely filed , and accordingly , the license will not expire until final action has been taken by this office.

Your application for a new NRC license did not include your taxpayer identification number. Please fill out NRC Form 531 , located at the following link:

bttp:IltJ::J:iw . ru:c..gov/reading:Im/do~lectionsJformslnrc5.ll.pdf

Send the completed NRC Form 531, by facsimile , to the following number: (301) 415-5387

A copy of your action has been emailed toourlicenseFeeandAccountsReceivabieBranch. in our Headquarters office in Rockville , MD. You will be contacted separately if there is a fee issue involved.

Your application has been assigned the above listed MAIL CONTROL NUMBER. When calling to inquire about this action, please refer to this control number. Your application has been forwarded to a technical reviewer. Please note that the technical review, which is normally completed within 180 days for a renewal application (90 days for all other requests) , may identify additional omissions or require additional information. If you have any questions concerning the processing of your application, our contact information is listed below:

Region IV U. S. Nuclear Regulatory Commission DNMS/NMSB - B 1600 E. Lamar Boulevard Arlington, TX 760 11-4511 (817) 200-1103 or (817) 200-1140

NRC FORM 532 (1 ·2012)

BETWEEN:

Accounts ReceivablelPayable aod

Regional licensing Branches

[ FOR ARPB USE I INFORMATION FROM l TS

Program Code-Status Code. Pending New Fee Category: Exp_ Date: Fee Comments: Oecom Fin Assur Reqd"

License Fee Worksheet - License Fee Transmittal

A. REGION

1. APPLICATION ATTACHED

ApplicanUllcensee: Received Dale.

OocketNumber:

Mail Control Number:

license Number:

Action Type:

2. FEE ATTACHED

Inlermountain Consirudion and Maleri<lls

02121/2012 3038521

577024

49·27460-02

New license. existing licensee

Amount: $/~.O()

Ched< No.. W ,'9Vt!

3. COMMENTS

Signed:

Dale:

B. LICENSE FEE MANAGEMENT BRANCH (Check when milestOfle 03 [s entered

1. Fee Category and Amount

2. Correct Fee Paid. Application may be processed for:

Amendment"

Renewal:

license:

3. OTHER _ _ ________ ___ _

Signed:

Date:

-