2014 April 29 06:38 PM ->630-515-1078 1/15

ROBERT A. SHARON, M.D. ROB~RT M. RUSS, M.D.

NINA NAYAK, M.D.

I..AI.IRA G. GRIMA. M.D.

RALPH W. RAPER. M.D.

MATTHEW A. GILL., M.D.

MAYAOA A·AZIZ, M.D.

RICHARD J. SHARON, M.D.

JE:SSICA L STAMATIS, PA·C

WYANDOTTE INTERNAL MEDICINE ASSOCIATES

April 22, 2014

Fax# (630) 5151078

To Whom It May Concern

Re: Termination of Llc:ense 21-32495-Gl

Please find attached NRC Form 314 to terminate above named Nuclear License.

The CardioMD Camera was removed from the building in 2012. The sealed sources were picked up

3/14/2013 and sent to ADCO in Tinley Park, Illinois. Unfortunately, ~DCO did not dispose of materials

{please see attached emails) and in February 2014 the State of Illinois appointment Bionomics to

permanently destroy sealed sources (documentation also attached)

There has been no radioactive material in the building since the sources were picked up by ADCO

3/14/2013. Former hot lab and stress area were surveyed using Ludlum Survey Meter Model14C­

Serial # 219345. All readings were negligible.

If you have any questions regarding this termination please do not hesitate to contact rne at (734) 284 2026.

Sincerely

1700 BIDDLE AVENUE'. • WYANDOTTE, MICHIGAN 48192 (734) 284-2026

2014 April29 06:38PM ->630-515-1 078 2/15

U.S. NUClEAR REGULATOR\' COMMISSION APPROVED BY Of,IB: NO. a150-00i1:8 exPIRE$: 10/3112013 NROFORM314 Es'mnd b~l!16n per ~nse 10 eoll'lllly wlltl 1111$ maldatory t;ellec1lon Jellu&B!; 30 mlnules. (05-201~) 10 CFR 3Q,:!G(I)~1l: 41l..C~0~1 ); This &lltlmi11BI Is usod by NRC <'$ pll1 Of 11\e basi& fOr hs delen'nl!llllicn lhallhe lacUIIY 1$ 1Mil(j}(1 ); And 2.5<1(~)(!i.X )(1) released. !or ull!lil&lrtcred uaa. send comment~ !l!gardll1!l burden estlma1e Ill tne lnfllrmauon

Servleos Branc!1 (M F53), u.s. NoolsarRI!!JUIII10!y Commission, WW1!ng1an, oc 20555-0001,

CERTIFICATE OF DISPOSITION OF MATERIALS or ~y lntamol e-mail to lnlocollaet&,Rfl!lOUrca@nre.gov, a~d to 1he Desk 0111091', Oftlce of 1ntcnnatl011 and Regut001ry Aff~s. NEOB-1 O'-Q2, (2150-0028), Ofllee ol Managoment and Budge~ Wl!!ihlngliln, oc :1.0503. 11 a meBII' uted 10 lm~ anln!Otm:.t!IOn colleeiiOn does nol di~3Y a cLmnUV v Bid OMB control nu!l'lber, me NFI¢ may not eoodud or $ponaor, !'lid a pomon Is not ~UI~ 1o mtj)Ond ID, 1hil hoormatloo couecdon.

LICENSE:E NAM!i AND ADDRESS LICENSE NUMB&fil DOCKET NUMiiEF!

Wyandotte Internal Medicine Associates 21-32495-01 030-36514

1700 Biddle Avenue LICiiNSE EXPIRATION CAiE

Wyandotte, MJ 48192 04/30/2014

A. LICENSE STATUS (Check the appropriate box)

D This license has expired. [{]This license has not yet expired; please terminate it.

B. DISPOSAL OF RADIOACTIVE MATERIAL (Chaek the appropriate bo~tes anL1 r;omplete 41S nec11~ry. If ,(lditional space Is needfMI, prvvlde att•chm~~nts}

The licensee, or any individual executing this certificate on behalf of the licensee, certifies that:

0 1. No radioactive materials have ever been procured or possessed by the licensee under this license.

D 2. All activities authori;~:ed by this license have ceased, and all radioactive materials procured andlor possessed by the licensee under this license number cited above have been disposed of in the following manner.

0 a. Transfer of radioactive materials to the licensee listed below:

[{)b. Disposal of radioactive materials:

0 1. Directly by the licensee:

0 2. By licensed dispOsal site:

Adco Services, 17660 DuviUl Drive, Tinley Park, lL. 60477 picked up on 3/14/2013 ·Manifest 13-00231... Bionomics, PO Box 817, Kingston, TN 37763 received material ti'om Adco 2/20/2014 (see att:at;hed documentation)

0 3. By waste contractor:

[ZJ c. All radioactive materials have been removed such that any remaining residual radioactivity is within the limits of 10 CFR Part 20, Subpart E, and is ALARA.

C. sURVEYS PERFORMED AND REPORTED

lZ] 1. A radiation survey was conducted by the licensee. The survey confirms:

0 a. the absence of licensed radioactive materials

D b. that any remaining residual radioactivity is within the limits of 10 CFR 20, Subpart E, and Is A LARA.

D 2. A copy of the radiation survey results:

0 a. is attached; or 0 b. is not attached (Provide explanation); or 0 c. was forwarded 10 NRC on:

0 3. A radiation survey is not required as only sealed sources were ever possessed under this license, and D9tl.>

[ll a. The results of the latest leak test are attached; and/or III b. No leaking sources have ever been identified.

The person to be contacted regarding the information provided on this form: t.~AME

rrrLE TELEPtiONE nndotl~ Al8& CQ<!oo} r-MAIL ADDRESS

1-layley Roth Office Manager (734) 284 2026 hay teyroth@gmait .com

M!lll All Mu"' COI'tHPCII~eo!ll<.t mgaodln~ thla lleen88 tv;

1700 Biddle Avenue, Wyandotte, Ml48192

C. CERTIFYING OFFICIAL

lpiiiNTEO NAME AND TITLE . I CERTIFY UNDER PI!!NAL lY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT . -. IG:~- ~~ T;IAU - --

Robert A. Sharon. M.D. -~G. 04/18/2014

WARNING: FALS~ STATEMENTS IN 1liiS CER'T1FICA~ MAY BE SUBJECT TO CIVIL ANDIOR C~!MINAL PENAL TlES, NRC REGUu;=QUIRE THAT SUBMIS$0HS TO THE NRC liiE COMPLETE AND P.C:CURATE IN ALL MATERIAL RESPECT, 18 U.S.C. SEC'nON 1001 MAKES IT A CRI FFENSi TO MAKE A WILLFULLY FALSE STA T£MENT OR REPI'U~SENTA TION TO ANY DEPAit'I'MENT OR AGENCY OF THE UNITIOD STAT'ES AS TO ANY MATTER WITHIN Its JURI!IDIC'110N.

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2014 April29 06:38PM ->630-515-1078

March 4, 2014

Haley Roth

Wyandotte Internal Medicine

1700 Biddle Ave. Wyandotte, Ml 43192

(734) 284-2026

Dear Ms. Roth,

P .0. :Box 817 -Kingston, TN 37763 - (865) 220-8501

6/15

As required by 10 CFR Part 20 (Appendix G), this letter is notification that Bionomics, Inc. has

received a shipment of sealed sources, recently picked up at the ADCO facility on February 20,

2014.

Please note this material had previously been shipped to ADCO. Bionomics, Inc. was contracted by the Illinois Emergency Management Agency (lEMA) to disposition this material and properly

dispose of the material.

This material was originally shipped from your facility on 3/14/13 and has been in storage at the ADCO facility. The material was originally consigned to TOXCO MMC and shipped in

container 12.0023-01 on manifest 13-Q023l

Please keep this letter with your original manifest for tracking purposes. We will send a disposal certification for this material when dispositioned.

Please find attached documentation we will need completed and returned to us so that we may

dispose of the material.

If you have any questions please feel free to contact me at (865) 220-8501.

Sincerely,

Paul Nipper OA Manager

Cc: Mike Klebe- lEMA

File BI0-02-14

2014 April29 06:38PM ->630-515-1078

Shipment Preparation and Waste Return Conditions

PREPERATION OF WASTE SHIPMENTS

Unless prior arrangements have been made, our agreements call for clients to provide us with

containerized wastes ready for shipml!nt. Broker functions (manifesting, labeling, loading, etc.) are typically not considered a licensed activity, however some jurisdictions view any assistance in placing wastes into containers1 no matter how minima It as a licensed actiVity.

Please review the following and check the bo)( that applies to the type of work Bionomics

performs at your facility.

N lPr 1"1 Work under Facility license; Bionomics rnay assist In shipment preparation and will work

under our facility license under direct supervision offacility personnel.

tJ I ~ [1 Reciprocity of Bionomics License; Reciprocity of the Bionomics Tennessee license is required for assisting in the preparation of wastes at this facility.

~ \ ~:1 Wastes are prepared by facility personnel, Bionomics provides Broker functions.

WASTE RETURN

Before wastes are shipped from client's lo.;ations, a disposal outlet for those wastes has bE!en established. While it is not anticipated that disposal of wastes will be a problem in the future, the State of Tennessee requires that each generator shipping waste to a Tennessee facility

indicate that they can and will accept return of their waste. Please indicate below that your

facility acknowledges this condition.

j. Our facility acknowledges that we are able and will accept back our wastes.

Facility

Radioactive Materials license#

Authorited Person

If you have any questions or need information please contact us at 865-220-8501.

Return requested: Fax;

Or Email: Or Mall:

865-220-8532

Laura@ Bionomlcs-lnc.com

Bionomics, Inc.

PO Box817

Kingston, TN 37763

Bionomics, Inc. Waste Shipment and Return Conditions page 1 of 1

7/15

2014 April 29 06:38 PM ->630-515-1 07 8

S•led Soun::• htwnfol)' Licensee: ~ndoj1e h'ltern.al Medici~ Assoc.f.JJ,& DEl~: 061?7111

Performed by: ~n Miller

Call bra~ en

Nuclide Type ActiVity Data Location MIN SIN

G&-1~7 Villi 20~.2uCi 05101104 Hat Lab 1047,44-20

Curmnl Ac!Nlly: t 72.23 uCI

sa-133 V1al 242.5 uCi 06/01/04 Hollsb 1047-63-7

Cum:~\ AciiYIIy: t53.{1auCI

cs-137 Rod 0.5~Ci 04101104 Hot Ulb 1 034-1 5-2.2

Currc:~l Activity; 0.4Z'ou0

Cs-137 Button 1 uCi 01/01104 Survey Mater 2802

Cunet1l Acllllily: 0.841 uCI

Cs-137 EMtO!\ 1 ~1Ci {l3f011Q4 SL1r~cy Meter 67'6

Current ActiYIIy: o.MotuCi co-57 Flood 10mCI 09114/07 Hot Lab BM07100028

Curmnl AcLIVIty: 0.291 mCi Sili!IIKl In bOx for di!IPO!I!II

Co-57 Flood 10 mCi 02111/10 Hot Lab BM07·10 BM071 000121 0

Cumlnl Aellvily: ~.nsmc;

SEALED SOURCE AMBIENT EXPOSURE SURVEY Meter;

Mal( Reading:

RAIJI.ATION SAFETY OFFICER: -----__,~x...~~r-J~·/--------~ I \1

$~ie!r.l Sc\1100 ll,.,.l!il\QI')' P* 1

8/15

2014 April 29 06:38PM ->630-515-1078

Chnail- Manifest #13-0023 L ; Wyandotte Internal Medicine

9/15

Page 1 of7

Hayley Roth <hayleyroth@gmail.com>

Manifest #13-0023 L ; Wyandotte Internal Medicine 6 messages

WAYNE JORDAN <weyne.adco@hotmail.com> Thu, Jun 20, 2013 at 1 :54 PM To: Hayley Roth <hayleyroth@gmail.com> Cc: James Bell Jr <jimp@adcoservices.com>, Jim Bell Sr <jbellsr@outlook.com>

Source waste containers from manifest #13.-0023 L (01; 02;03) are still in ADCO's possession and are located in ADCO's warehouse. lEMA and NRC are fully aware ofthis. lEMA plans to use financial surety posted by ADCO Services to dispose of these Source waste containers during the decommissioning of ADCO's facility as ADCO transitions over to a transportation only company vs. a storage facility. These drums are expected to be disposed of this summer.

W~ne

W~yne T. Jordan Ct~.rtomer .f enlice Manager ADCO SmJke.r, Inc. -.Phowe: (708) 429-1660 X-12 ra.:"': (708) 42.9-97.'19 Website: ack:o.rcnir:c.r. com

Hayley Roth <hayleyroth@gmail.com> To: rothh@oakwood.org

----~ Forwarded message -~-"~~ From: WAYNE JORDAN <wayne.adco@hotmail.com> Date: Thu, Jun 20, 2013 at 1:54PM Subject: Manifest #13-0023 L ; Wyandotte Internal Medicine To: Hayley Roth <hayleyroth@gmail.com>

Thu, Jun 20, 2013 at 2:52 PM

Cc: James Bell Jr <jimp@adcoservices.com>, Jim Bell Sr <jbellsr@outlook.com>

Source waste containers from manifest #13-0023 L (01; 02;03) are still in ADCO's possession and are located in ADCO's warehouse. lEMA and NRC are fully aware of this. lEMA plans to use financial surety posted by ADCO Services to dispose of these Source waste containers during the decommissioning of ADCO's facility as ADCO transitions over to a transportation only company vs. a storage facility. These drums are expected to be disposed oft his summer.

Wt!Yne

W f!)lt1C 1~ Jordan

httos://mail.Q:oog:le.com/maillu/O/?ui=2&ik=fc0le9545f&view=ot&search""'inbox&th""l3f ... 12/30i20l3

2014 April 29 06:38 PM ->630-515-1 078

Gmai1- Manifest #13-0023 L ; Wyandotte Inte:mal Medicine

Ctt.rtnmcr S mi6'e Mat1r:I.~C1" .. A.DCO Jemi~'tls, Im~ Ph011e: (70.Y) 42.9-1660 X-12 .Fa:)(:: (708} 42.9-97.;9 H'liduite: tJdi.'OJemia:.r. ''0111

10/15

Page 2 of7

Hayley Roth <hayleyroth@gmaU.com> Tue, Aug 13, 2013 at 7:06PM

To: WAYNE JORDAN <wayne.adco@hotmail.com> Co: James Bell Jr <jimp@adcoservices.com::., Jim Bell Sr <:jbellsr@ouUook.com>

Good evening,

Can I please get an update on the above manifest so I can update the NRC in regards to the status of the termination of our nuclear license.

Thank you Hayley Roth

On Jun 20,2013, at 1:54PM. WAYNE JORDAN <wayne.adco@hotmall.com> wrote:

Source waste containers from manifest #13~0023 L (01; 02;03) are still in ADCO's possession and are located in AOCO's warehouse. lEMA and NRC are fully aware of this. lEMA plans to use financial surety posted by ADCO Services to dispose of

these Source waste containers during the decommissioning of ADCO's facility as ADCO transitions over to a transportation only company vs. a storage facility. These

drums are expected to be disposed of this summer.

TVqyno T. ]ordm2 Ct~.rlfJI!IDr Sender. Mrmt~,~er /lDCO Jemices, l11C.

Phone.: (i08) 429-1660 X-12 1-'tt • .'~: (708) 429.9759 l.l:?eb.ritc: tldc:o,rr.n!lte.!~t'om

James Bell <jimp@adcoservices.com> Wed, Aug 14,2013 at 10:07 AM To: Hayley Roth <hayleyroth@gmail.com>, WAYNE JORDAN <wayne.adco@hotmail.com> Cc: Jim Bell Sr <jbellsr@outlook.com>

2014 April29 06:38PM ->630-515-1078

Gtnail - Manifest #13-0023 L ; Wyandotte Internal Medicine

The waste is still in ADCO's possession.

James P. Sell, Jr. Facility Manager

AOCO Services, Inc.

Phone: 708/429·1660 X-16

Fax: 708/429-9759

Website: adcoservices.com

"You must be the change you wish to see in the world.''"' Mohatma Gandhi

11/15

Page3 of7

·---··--·~-.. ··---~--------·-

From: Hayley Roth [mailto:hayleyroth@gmail.com] Sent: Tuesday, August 13, 2013 6:07 PM To: WAYNE JORDAN Cc: James Bell Jr; Jim Bell Sr Subject: Re: Manifest #13-Q023 L ; Wyandotte Intemal Medldne

Good evening,

Can I please get an update on the above manifest so I can update the NRC in regards to the status of the termination of our nuclear license.

Thank you

Hayley Roth

On Jun 20, 2013, at 1 :54 PM, WAYNE JORDAN <Wayne.adco@hotmail.com> wrote:

Source waste containers from manifest 1113..002.9 t (01; 02;03) are still in AOCO's possession and are located in ADCO's warehou$e. lEMA and NRC are fully aware of this. lEMA plans to use financial surety PO$ted by AOCO Services to disp0$e of these Source waste containers during the decommissioning of ADCO's facility ;:~s ADCO transitions over to a tr;:~nsportation only comp;:~ny vs. a storage facility. These drums are expected to be disposed of this summer.

IP"qyne I ] orr/an 01.rtqmer .rcn~''tl M~gcr

https:/ /mail.google.com/maiVu/O/?ui=2&ik=fcO 1 e9545f&view-o=pt&search""inhox&th= 1 ~f 1., I'MJ'1n11

2014 April 29 06:38PM ->630-515-1078

G:mail ~Manifest #13-0023 L; Wyandotte Internal Medicine

A.lJCO Sertli~..-. ,T, •.. Phom1: (70lJ) 429-1660 X-12 P,~~ (108) 429-.97S9 W'rb.fifc: (Jdtfl.•·crvit.-eJ:•YJf!?

12/15 Page4 of7

Hayley Roth <hayleyroth@gmail.com=- Thu, Dec 26, 2013 at 11 :38 AM To: James Belt <jimp@adcoservices.com> Cc: WAYNE JORDAN <wayne.adco@hotmail.com>, Jim Bell Sr <jbellsr@outlook.com>

Good Morning,

Checking to see if items removed from our facility in March are still in your possession for above manifest

number.

Kind regards Hayley Roth

Sent from my iPhone

On Aug 14, 2013, at 10:07 AM, "James BeliR <jimp@adooservices.com> wrote:

Hayley,

The waste is still in ADCO's possession.

James P. Bell, Jr. Facility Manager

ADCO Services, Inc.

Phone: 708/429-1660 X·l6

Fax: 708/429·9759

Website: adcoservices.com

"You must be the change you wish to see in the world.''"" Mahatma Gandhi

From: Hayley Roth [mailto:hayleyroth@gmail.com] Sent: Tuesday, August 131 2013 6:07 PM To: WAYNE JORDAN cc: James Bell Jr; Jim Bell Sr Subject: Re: Manifest #13-0023 L; Wyandotte Internal Medicine

·---·-----

httos://mail.goo.We.oom/maillu/O/?ui=2&ik""fc01e9545f&view=pt&search=inbox&th=13f ... 1.2/30/2013

2014 April 29 06:38 PM ->630-515-1 078

Gmail- Manifest #13-0023 L; Wyandotte Internal Medicine

Good evening,

13/15

PageS of7

Can I please get an update on the above manifest so I can update the NRC in regards to the status of the termination of our nudear license.

Thank you

Hayley Roth

On Jun 20,2013, at 1:54PM, WAYNE JORDAN <wayne.adco@hotrnail.com> wrote:

Sourr;e waste containers from manifest #13-0023 L (Ol; 02;Q3) are still in ADCO's possession and are lor;ated in ADCO's warehouse. lEMA and NRC are fully aware of this. lEMA plans to use financial surety posted by ADCO Services to dispose of these Source waste containers during the decommissioning of ADCO's facility as ADCO transitions over to a transportation only company vs. a storage facility. These drums are expected to be disposed of this summer.

TFt!J!IIC T. .Jmlrm Oatnmcr S cn.lic~ Mt111tt,gtr ADCO Jemkc.t. ln.~ P/.11m{!; (708) 42P-1660 X-12 Ftl:'(: (70.~) 429-975.9 U:'·"~b.rifC.' tld,'O.ICf'/.y'cu.t'OfiJ

James Bell <jimp@adcoservices.corn> Thu, Dec 26, 2013 at 1 :30 PM To: Hayley Roth <hayleyroth@gmail.com> Cc: WAYNE JORDAN <wayne.adco@hotmail.com>, Jim Bell Sr <jbellsr@outlook.com>

Hayley1

Yes1 this waste is still in our possession and is going to be shipped out as part of a dean·out project in the next month.

James P. Bell, Jr. Facility Manager

ADCO Services, Inc.

Phone: 708/429-1660 X-16

https://mail.google.com/maillu!O/?ui-2&ik=fc0 1 e9545 f&view=pt&search""'inbox&th""' l3f. .. 12/30/2013

2014 April 29 06:38 PM ->630-515-1078

Omail. Manifest #13-0023 L; Wyandotte Internal Medicine

Fax: 708/429·9759

Website; http://adcoservices.com

lf)'ou must be the change you wish to see in the wor{d." "'Mahatma Gondhi

14/15 Page6 of7

··-------~--~--~-~----~--------··--·--·---···~··-···-·~·

From~ Hayley Roth [mailto:hayleyroth@gmall.com] Sent: Thursday, DeCember 26, 2013 10:38 AM To: James Bell Cc: WAYNE .JORDAN; Jim Bell Sr Subject: Re: Manifest #13-Q02.3 L ; Wyandotte Internal Medicine

Good Morning,

Checking to see if items removed from our facility in March are still in your possession for above manifest number.

Kind regards

Hayley Roth

Sent from my iPhone

On Aug 14, 2013, at 10:07 AM, "James Belt" <jimp@adcoservioes.com> wrote:

Hayley,

The waste is still in ADCO's possession.

James P. Bell, Jr. Facility Manager

ADCO Services, Inc.

Phone: 708/429-1660 X-16

Fax: 708/429·9759

Website: adcoservice.s.com

ht.tns://mail.s;zoollle.com/maH/u/O/?ui=2&ik=fc01 e9545f&view=-pt&search=inbox&th=13 f... 12/30/2013

2014 April 29 06:38 PM ->630-515-1078

Gmail - Manifest #13~0023 L ; Wyandotte Internal Medjcine

"You must be the change you wish to see in the worfd.''"" Mahatma Gandhi

15/15

Page 7 of7

---·---- ~--~···-~·--------~-----------·---·-

From: Hayley Roth [mailto:hayteyroth@gmail.com] Sent: Tuesday, August 13, 2.013 6:07PM To: WAYNE JORDAN Cc: James Bell Jr; Jim Bell Sr Subject: Re: Manifest #13-o023L; Wyandotte Intemal Medicine

Good evening,

Can I please get an update on the above manifest so I can update the NRC in regards to the status of the termination of our nuclear I icense.

Thank you

Hayley Roth

On Jun 20,2013, at 1:54PM, WAYNE JORDAN <wayne.adco@hotmail.com> wrote:

Source wa$te containers from manifest #13-0023 L (01; 02;03) are still In ADCO's possession and are located in ADCO's warehouse. lEMA and NRC are fully aware of this. lEMA plans to use financial surety posted by ADCO Services to disp0$e of these Source waste containers during the decommissioning of ADCO's fadlity as ADCO transitions over to a transportation only company vs. a storage facility. These drums are exper;t!i!d to be disposed ofthis summer.

IWqJmr. T Jordan Clf.rf(lmtr Scn~ce M111111,gcr A.DCO Jcmicu, T11c. Pho11c: (701?) 429-1660 X 12 Fa.~: (108) 429-9759 [Jr.' cb.rite: tlttm,rr.rt.~'ccs, tYJ/11

i.H ... n •/1..,..,.;1 nr.nnl"' "n""' /TTO~iJ/nJn/?n.j=? k11,-;..fM)J P,Qi;j4 .r;;f&_vi AW=nt.&sea.rch=inbOX&th= 13 f... 12/30/2013