March 29, 2013

United States Nuclear Regulatory Commission Region IV License Amendment Section 1600 East Lamar Blvd Arlington, TX 76011-4511

Dear Sir or Madam,

RECE\VED

",~R - \ 'l.U13

DNMS

1401 West 5th Street Sheridan, WY 82801

(307) 672-1000

www.sheridanhospital .org

This communication is to inform you of our objective to add the following Physician as an Authorized User to Materials License #49-10982, currently held by the Licensee named as Memorial Hospital of Sheridan County, 1401 West 5th Street, Sheridan, WY 82801 (attached).

We (Memorial Hospital of Sheridan County) request the addition as an Authorized user Dr. Joseph Garcia for the medical use of isotopes under 10CFR 35.200. By way of supporting documentation, Dr. Garcia is currently listed as an Authorized User on License # L02689, Amendment #40. This License is held by Southwest General Hospital, LLP, DBA Southwest General Hospital, 7400 Barlite Boulevard, San Antonio, TX 78224. Specifically Dr. Garcia is named in Section 12 (Radioactive material may be used only by the individuals listed below for the uses specified) Subsection F (Diagnostic nuclear cardiology).

We thank you in advance for your timely attention to this request.

Please contact Thomas R. Nance (RT(R) ARRT at (307) 672-1051 should there be any questions regarding this communications or if I may be of any assistance.

Sincerely,

C: -~11~ Thomas R. Nance, RT(R) ARRT Memorial Hospital of Sheridan County 1401 West 5th Street Sheridan, WY 82801 (307) 672-1051 (office) (307) 672-1149 (fax) thomasnance@sheridanhospital .org

PUBLIC o Immediate Rele_

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Attachments: USNRC License #49-10982-02; Amendment 28. State of Texas-Radioactive Material License #L02689; Amendment #40.

1h 58 0 300

Taki Your1 Health

to Heart

NRC FORM 374 U.S. NUCLEAR REGULATORY COMMISSION

MATERIALS LICENSE

PAGE _1_ OF _4_ PAGES

Amendment No. 28

Pursuant to the Atomic Energy Act of 1954, as amended, the Energy Reorganization Act of 1974 (Public Law 93-438), and Title 10, Code of Federal Regulations, Chapter I, Parts 30, 31, 32, 33, 34, 35, 36, 39, 40, and 70, and in reliance on statements and representations heretofore made by the licensee, a license is hereby issued authorizing the licensee to receive, acquire, possess, and transfer byproduct, source, and special nuclear material designated below; to use such material for the purpose(s) and at the place(s) designated below; to deliver or transfer such material to persons authorized to receive it in accordance with the regulations of the applicable Part(s). This license shall be deemed to contain the conditions specified in Section 183 of the Atomic Energy Act of 1954, as amended, and is subject to aU applicable rules, regulations, and orders of the Nuclear Regulatory Commission now or hereafter in effect and to any conditions speCified below.

licensee In accordance with application dated

August 26, 2011

1. Memorial Hospital of Sheridan County 3. License number 49-1 0982-02 is renewed in

its entirety to read as follows:

2. 1401 West 5th Street f rtl:.XPG tio/::te December 31,2021

Sheridan, Wyoming 82801 5. Docket No.~~~13772

Reference N~.'" ;.. ~ ('>-

6. Byproduct, source, and/or special nllclear 7. Chemical and/or physical form ~"\ Maximum amount that licensee material 0 -.)-' may possess at anyone time

ltJ ...;:-........ , ........, ~nder this license

A. Any byproduct ma\e@I '- :' -"~\)Any 4 • A , As needed permitted by 10 CEB.35.100 \ .... .. -, t., .n·. ,..~/» ~ ~

"'I. ... ', ' '. , -;. "'" " -1 0 • ~ - '.: I , / ' ~ ".,,\ ~~ .-. .:1 B. Any byproduct ma"i'Srial ~.~, n~~~ Kf:i ,,:: .2 ~ As needed

permitted by 10 CERl 35.200 t\:', r _ . ,, -= ::.: '~ .; I ' 1_ ~' ··:~'''' ~-T - - I " • . . ~ ~ ,"/" ~

c. ~~~:~,mC~~300~~~ ~II 'itt" ! 1100 m;ll;"",, v' _ f ,,~ A~~ ... -'!l:,' ••

D. Any byproduct materiai ",/jff -... -[b. sa<1IA~~)!ceS"'{{j~ Healtt"(:i" D. 500 millicuries permitted by 10 CFR 35.4()9r':I Ph%~~rvice, a~d .... '-.

E. Any byproduct material permitted by 10 CFR 31.11

9. Authorized use:

• / Minnesota Mining and ,,~

~'... ,M~n~~ctU!i ng, M~a~ 1 Sene~q500(formerly Mode16D6C)

E. Prepackaged kits

A. Any uptake, dilution and excretion studies permitted by 10 CFR 35.100. B. Any imaging and localization studies permitted by 10 CFR 35.200. C. Any use permitted by 10 CFR 35.300. D. Any manual brachytherapy use permitted by 10 CFR 35.400. E. In vitro studies.

E. 50 millicuries

NRC FORM 374A U.S. NUCLEAR REGULATORY COMMISSION

MATERIALS LICENSE SUPPLEMENTARY SHEET

CONDITIONS

PAGE 2 of 4 PAGES

License Number 49-10982-02 Docket or Reference Number

030-13772

Amendment No. 28

10. Licensed material may be used or stored only at the licensee's facilities located at 1401 West 5th Street, Sheridan, Wyoming.

11. The Radiation Safety Officer for this license is John P. Stamato, M.D.

12. Licensed material is only authorized for use by, or under the supervision of:

A. Individuals permitted to work as an aH!h'9Qze~sjlt. fluJh,?rized nuclear pharmacist, andlor authorized medical physicist in accordance ~ll'tl 'CtR '35. 1'3 Ma&.j4. v"v <.

B. The following indiVidU!~e authorized users for the materia~~~dical uses indicated:

Authorized Users ..... Material and Use '-" ""'-''-''''''~'-'''''''''-'' r A -1) Robert L. Stears/b-D. or~ium iodide 1-131; 31.11

Jason M. White/-M.·D. of s~d~um iodide 1-131; 31.11

Daniel R. Alzhernfer, M.D. of sem iodide 1-131; 31.11

Michael W. Bre~an, M. :< H. _

John P. Stamato.'M.D. _~

o :::: 13. In addition to the poss.~ion restflgt the possession of licensed

material to quantities De~W 30 .3~) for establishing financial assurance for decommi'S~~ng . :\ 0"""

14. For sealed sources not assoc~ed with 10 35 use, the fo~owing conditions apply:

, -1 . ~! A. Sealed sources shall be tested'fo'r- l eakag~ '-and/or,contamination at intervals not to exceed the

intervals specified in the certificate 0'( regislration'lSsued by the U.S. Nuclear Regulatory Commission under 10 CFR 32.210 or under equivalent regulations of an Agreement State.

B. Notwithstanding Paragraph A of this Condition, sealed sources designed to primarily emit alpha particles shall be tested for leakage andlor contamination at intervals not to exceed 3 months.

C. In the absence of a certificate from a transferor indicating that a leak test has been made within the intervals specified in the certificate of registration issued by the U.S. Nuclear Regulatory Commission under 10 CFR 32.210 or under equivalent regulations of an Agreement State, prior to the transfer, a sealed source received from another person shall not be put into use until tested and the test results received.

D. Sealed sources need not be tested if they contain only hydrogen-3; or they contain only a radioactive gas; or the half-life of the isotope is 30 days or less; or they contain not more than 100 microcuries of beta- and/or gamma-emitting material or not more than 10 microcuries of alpha-emitting material.

NRC FORM 374A U.S. NUCLEAR REGULATORY COMMISSION PAGE 3 of 4 PAGES '

15.

16.

MATERIALS LICENSE SUPPLEMENTARY SHEET

license Number

49-10982-02 Docket or Reference Number

030-13772

Amendment No. 28

E. Sealed sources need not be tested if they are in storage and are not being used; however, when they are removed from storage for use or transferred to another person and have not been tested within the required leak test interval, they shall be tested before use or transfer. No sealed source shall be stored for a period of more than 10 years without being tested for leakage and/or contamination.

F. The leak test shall be capable of detecting the presence of 0.005 microcurie (185 becquerels) of radioactive material on the test sample. If the test reveals the presence of 0.005 microcurie (185 becquerels) or more of removable contamination, a report shall be filed with the U.S. Nuclear Regulatory Commission in a. ccord9ll.CC~ith~ .eF~-30.50(C)(2), and the source shall be removed immediately from service a~ ~'hia'mnat'ed, ~J1airE\.o/9f disposed of in accordance with Commission regulations. (ljie1'eport shall be filed within 5..d~f.: of the date the leak test result is known with the U.S. N~ear Regulatory Commission, Reg i.Th I~ 1600 East Lamar Boulevard, Arlington, Texas 7~Cf1F4511, A TIN: Director, Division of Nuclear'ty/aterials Safety. The report shall specify the source involved, the test results, and corrective ~ifuQP taken.

<%I -)J

G. Tests for including leak . cciection and analysis, shall be

H.

performed by ' , . by the U.S. Nuclear Regulatory Commission 0

tt~~t~~~:::o/r:rMicr1ictrries and sh~be maintained for 3 years. ..1 S

. ' other ~rvals approved by the a)I'~.Dl~rcl~lh~ilfr· ( )r de~s received and possessed

lJlf.1 the date of each inventory ~~St:~~me an~otJel numbers, and the date of

" ";',rnrrl,,,i\"~\"'with the provisions of

iJ 5 80 300

II

NRC FORM 374A u.s. NUCLEAR REGULATORY COMMISSION PAGE 4 of 4 PAGES

License Number 49-10982-02

MATERIALS LICENSE Docket or Reference Number

SUPPLEMENTARY SHEET 030-13772 ~A~m--en-d7m--en~t~N70-.~2~8~------------------

17. Except as specifically provided otherwise in this license, the licensee shall conduct its program in accordance with the statements, representations, and procedures contained in the documents, including any enclosures, listed below. This license condition applies only to those procedures that are required to be submitted in accordance with the regulations. Additionally, this license condition does not limit the licensee's ability to make changes to the radiation protection program as provided for in 10 CFR 35.26. The u.s. Nuclear Regulatory Commission's regulations shall govern unless the statements, representations, and procedures in the licensee's application and correspondence are more restrictive than the regulations.

A. Application dated August 26, 20~ I\. f\(M~1~4A03f) B. Letter dated December 8, 201\, '(:... I"' (ML 11~flQ"2~>{

-0° '4)-~ 0

V) -))..L !.t.t l-e::( I­(Jj

o \V V"/ 1~

Date December 22, 2011

()

o s

FOR THE u.s. NUCLEAR REGULATORY COMMISSION

By ~jf~ Roberto J . Torres, Senior Health PhysiCist Nuclear Materials Safety Branch B Region IV Arlington, Texas 76011-4511

'/29/2012 10: 41 2109213375 SWG RAD IOLOGY PAGE 02/04

rae Form 12·1 08/04

Page lof 3

Department of State Health Services

RADIOACTIVE MATERIAL LICENSE PlIrsullnt to the r e:tlls Rrl.dfatiQo Conrro1 Act 3nd Te~as Departmc:nt of Stale J.tt!!llth Servlce.iI: (Agency) regulation, on radiation. and in relitJl[;c on .!it9.rerhc~ arid representations hcmofore made by the li~mee. " license Is hereby usued authorizing the lIcclt!cc to receive. acquifCl, posse!!! tmd IIilnsf'er rsdioll<:tive materi",l ti"ed below; and to use such f!ldiollctive matenal tal" the ~fl!O!c(,,) ancl iU the pillct:(~) designated belt'lW. This license b subject to allllpplicable rules, rl:gt1latloJ1$.nd orders of the Agency now or hen:after in effect lind 10 any conditions sl)eciflcd below:.

I. Name

2. Address

LICENSEE

SOUTHWEST GENERAL HOSPITAL LLP DBA SOUTHWEST GENERAL HOSPITAL ATTN EZEQUIEL SILVA MD 7400 BARLITE BOULEVARD SAN ANTONIO TX 78224

This license is issued in response to a letter

pated! November 4, 2010

Signed by; Ezequiel Silva, M.D.

3. License Number Amendment Number

L0268? 40 PREVIOUS AMENDMENTS ARE VOID

- --...,.-:-::-::-:-,.....,,==-:-:--:-::=::-:-o-,-:-:=====----j 4. Expiration Date RADIOACTIVE MATERIAL AUTHORIZED May 31, 2017

5. Radioisotope A. Any radio­active material with a half-life < 120 days, except positron emitters

B. Xe-133

C. Sr-89

D. 1-131

E. Sm-I53

F. Pd-l03

G. 1-125

6. Form of Material 7. Maximum Activity A. AIIy radiopbanna- A. As needed for ceutica1 for diagnostic diagnostic purposes purposes

B. Any radiophanna-ceutica1

C. Strontium chloride

D. Sodium iodide (in capsules only)

E. EDTMP

F. Sealed source (seeds)

G. Sealed source (seeds)

E- 50 millicuries

C. 20 millicuries

D. 100 millicuries

E. 300 miUicuries

F. 1000 millicuries

G. 500 miUicuries

• Tex;u; Administrative Code (TAC)

8. Authori%ed Use A. Any diagnostic use indicated in Title 25 TACO §289.256(ff) and (bb), in unit dosage only.

B. Pulmonary function studies and lung imaging.

C. Treatment of pain secondary to bone metastases in accordance with 25 T AC §289.256(k.k).

D. Treatment of hyperthyroidism and thyroid cancer in accordance with 25 TAc §289. 256(kk).

E. Reference sQurce and treatment of pain secondary to metastatic bone cancer in accordance with 25 rAC §289.256(kk).

,F. lnterstitial treatment of cancer in accordance with 25 TAC §289.256(rr).

G. Interstitial treatment of cancer in accordance with 25 TAC §289.25§(rr) .

.1 29/201 2 1 0: 41

TRC Fonn 12·1 08/04

2189213375 SWG RADIOLOGY PAGE 03/84

P.~c 2 of 3

Department of State Health Services

RADIOACTIVE MATERIAL LICENSE

9. Radioactive material shall only be stored and used at:

Site NuIIiber 000

Location San Antonio - 7400 Barlite Blvd.

r7L~'C~~S.~N~UM~B~BR~~'M~'~N~DM~B~NT~N~U~M.~~~

L02689 40

10. Each site shall maintain documents and records pertinent to the operations at that site. Copies of all documents and records required by this license shall be maintained for Agency review at Site 000.

11. The licensee shall comply with the provisions (as amended) of Title 25 TAC §289.201, §289.202, §289.203, §289.204, §289.205, §289.251, §289.252, §289.256 and §289.257.

12. Radioactive material may be used only by the individuals listed below for the uses specified:

A. All diagnostic uses authorized by the license; therapy with 1-131 for hyperthyroidism and thyroid cancer; therapy with Sm-153; therapy with Sr-89.

Barry 1. Menick. M.D. Joseph P. Miller. M.D. Robert E. Vasquez, M.D.

B. All diagnostic uses authorized by the license; therapy with 1-131 for hyperthyroidism; therapy with Sr-89. .

David W. 'Bynum, M.D. G. Christopher Hammet, M.D. CadW. Hardin, M.D.

Mark E. HealY, M.D. Joseph R. McColley, M.D. Rosa E. Ramirez, M.D.

Veronica L. Rouse, M.D. John F. Stoll, M.D.

C . . All diagnostic uses authorized by the license; therapy with 1-131 for hyperthyroidism.

William G. Armington, M.D. Suzanne M. Marlar. M.D.

D. All diagnostic uses authorized by the license.

Andrea L. Allred-Crouch, M.D. Richard A. Benedikt, M.D. Gregory J. Boys, M.D. Richard A. Carnovale, M.D. John P. Clement IV. M.D. Robert O. Cone m, M.D. Keith A. Crow, M.D. James E. Dix. M.D. N. Carol Dombluth, M.D. Joel A. Dunlap, M.D. James S. Gilley, M.D.

D. A. Golden, M.D. H. M. Goldstein, M.D. Michael P. Granato, M.D. W. Lawrence Greif. M.D. John H. Gurian, M.D. Eric P. Hendrick, M.D. Robert V. KnapP. M.D. Michael J. Lane, M.D. Amit Mehta, M.D. Scott R. Partyka, M.D. Dipan L. Patel, M.D.

Ashwin K. Shetty. M.D.

Gladys Sepulveda, M.D. William J. Shea Jr., M.D. Ezequiel Silva m, M.D. Douglas K. Smith, M.D • . Cynthia A. Swann, M.D. Alvin Thaggard m, M.D. John W. Thomas, M.D. Martha K. Uhler, M.D. Alice B. Viroslav, M.D. Steven], Weger!, M.D . . Joseph B. Williams, M.D.

./ 29/ 2012 10: 41

me form 12-1 08/04

210921 3375 SWG RADIOLOGY

A ~

PAGE 04 / 04

Page 3 013

Department of State Health Services

RADIOACTIVE MATERIAL LICENSE ,....-;-LI""CE"'N""sa"N~uM::;;B;O;eR'""'~AM:;;.:;:;NO"'M ... e~NT;-:N;;';uM;;-;B;;;ER;;---.

L02689 40

12. (Continued)

E. Brachytherapy.

Rajiv S. Dahiya. M.D.

F. Diagi:lostic IRlclear cardiology.

George Boyd, D.O. David L. Briseno. M.D.

Jory D. Lange, M.D.

Joseph Garcia, M.D. Syed]. Umer, M.D. Dwarakraj Soundarraj, M.D.

13. The individual designated to perform the functions of Radiation Safety Officer (RSO) for activities covered by this license is Ezequiel Silva, M.D. Dr. Silva shall receive training concerning radiation safety aspects of therapy with radiopharmaceuticals from Physicians authorized on this license to use radiophannaceuticals in therapy. Records of this training shall be maintained by the licensee for Agency review.

14. The licensee shall not open sealed sources containing radioactive materiaL

15. All radiopharmaceuticals to be used in humans !DUSt be from suppliers approved for distribution by the United States Food and Drug Administration (FDA) or obtained from a licensed nuclear pharmacy.

16. The licensee shall maintain a current copy of the safety evaluation from ' "The Registry of Radioactive Sealed Sources and Devices" for each sealed source received under authority of this license, in excess of 100 microcuries of beta/gaIIlIIla-emitting material or 10 microcuries of alplla-emilting material.

17. Except as specifically provided otherwise by this license. the licensee shall possess and use the radioactive material authorized by this license in accordance with statements, representations, and procedures contained in the following;

application dated May 24, 2007, facsimile received October 16. 2007.

Title 25 TAC §289 shall prevail over statements contained in the above documents unless such statements are more restrictive than the regulations.

KEM:1un FOR THE DEPARTMENT OF STATE HEALTH SERVICES

Date December 17. 2010 ~ J. seottee: PTOgram Coordin

Medical and Academic Licensing Program 11 580300

USPS TRACK ING NUMBER

['11'11 "" 11 II III 9505 5106 2475 3088 4 140 54

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UNI TED ST~TES POST~LSERVICE

Visit us at usps. com

Label 107R, January 2008

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Sheridan Memorial Hospital 1401 West Fifth Street Sheridan, Wyoming 8280i

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RECFiVED

APR - 1 2013

DNMS

U.S. POSTAGE PA lO

SHER~g~~iWY MAR 29. ' 13

AMOUNT

$6.00 00 062475-05

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

DATE

04/0112013

NAME AND ADDRESS OF APPLICANT ANDIOR LICENSEE LICENSE NUMBER

Memorial Hospital of Sheridan County ATIN: Thomas R. Nance, RT(R), ARRT

Medical Imaging Supervisor 1401 West 5th Street Sheridan, Wyoming 8280 I

This is to acknowledge the receipt of your:

IZl LEITER and/or IZl APPLICATION

49-10982-02

MAIL CONTROL NUMBER

580300

LICENSING ANDIOR TECHNICAL REVIEWER

ch

DATED: 03129/2013

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

[{] AMENDMENT 0 TERMINATION 0 NEW LICENSE 0 RENEWAL

[{] There were no administrative omissions identified during our initial review.

o 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.

o 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:

hIlQ:llwww.nrc.gov/reading-rmldoc-coliections/forms/nrc531 .pdf

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

A copy of your action has been emailedtoourLicenseFeeandAccountsReceivableBranch.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:

NRC FORM 532 II I (1-2012) VI/II II.!:>

Region IV U. S. Nuclear Regulatory Commission DNMS/NMSB - B 1600 E. Lamar Boulevard Arlington, TX 76011-4511 (817) 200-1103 or (817) 200-1140

BETWEEN :

Accounts Receivable/Payable and

Regional Licensing Branches

[ FOR ARPB USE J INFORMATION FROM WBL

Program Code: 02120 Status Code: Pending Amendment Fee Category: 7C

Exp. Date: 09/3012011 Fee Comments: CODE 13 Decem Fin Assur Reqd: N

License Fee Worksheet - License Fee Transmittal

A. REGION

1. APPLICATION ATTACHED ApplicanULicensee: MEMORIAL HOSPITAL OF SHERIDAN COUNTY

Received Date: 04/01 /2013 Docket Number: 3013772

Mail Control Number: 580300 License Number: 49-10982-02

Action Type: Amendment

2. FEE ATTACHED

Amount:

Check No.:

3. COMMENTS

Signed:

Dale:

e, LICENSE FEE MANAGEMENT BRANCH (Check when milestone 03 is entered I I

1. Fee Category and Amount

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

Amendment

Renewal:

License:

3. OTHER ______________ _

Signed:

Date: