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U.S. NUCLEAM b.EIULATOdY COMMISSION*NRC FORaj' SIS *

APPROVED BY OM811441 .

ss .nd 40 APPLICATION FOR MATERIAL LICENSE OMO 31540120to CF2 30,32,33,34,E-Iree:63i.T

,

INSTRUCTIONS: SEE THE APPROPRIATE LICENSE APPLICATION GUIDE FOR DETAILED INSTRUCTIONS FOR COMPLETING APPLICATION. SEND TWO COPIESOF THE ENTIRE COMPLETED APPLICATION TO THE NRC OFFICE SPECIFIED BELOW,

FEDERAL AGENCIES FILE APPLICATIONS WITH: IF YOU ARE LOCATED IN:

U S. NUCLE AR REGULATORY COMMISSION ILLINOIS, INDI ANA, IOW A, MICHIG AN, MINN ESOT A, MISSOURI, OHIO, ORDivlSION OF FUEL CYCLE AND MATERIAL SAFETY,NMSS WISCONSIN,$END APPLICATIONS TO:CASHINGTON,DC 20655

U.S. NUCLE AR REGULATORY COMMISSION, REGION iilALLf7HER PERSONS FILE APPLICATIONS AS FOLLOWS,IF YOU ARE M ATERI ALS LICENSING SECTIONLOCATED IN: 799 ROOSEVELT ROAD

GLEN ELLYN,lL 60137CONNECTICUT, DELAWWARE, DISTRICT OF COLUMSIA, MAINE, MARYLAND,MASSACHUSETTS, NEW JERSEY, NEW YORK, PENNSYLVANI A RHODE ISLAND, A R K A NSAS, COLOR ADO, IDAHO, K ANSAS, LOUIS' 4N A, MONTAN A, N E B R ASK A,OR VERMONT, SENO APPLICATIONS TO: NEW MEXICO, NORTH DAKOTA, OKLAHOMA, SOUTH DAKOTA, TEXAS, UTAH,

OR WYOMING, SEND APPLICATIONS TOU.S. NUCLE AR REGULATORY COMMIS$10N, REGION 1NUCLEAR MATERIAL SECTION 5 U.S. NUCLE AR REGULATORY COMMIS$10N. REGION IVC31 PARK AVENUE MATERI AL R ADIATION PROTECTION SECTIONKING OF PRUSSIA,PA 19406 611 RYAN PLAZA DRIVE, SUITE 1000

ALASAMA, FLORlDA, CEORGIA, KENTUCK Y, MISS!$$1PPI, NORTH CAROLINA,PUE RTO RICO, SOUTH CAROLINA, TENNESSE E, VIRGINI A, VIRGIN ISLANDS, OR ALASK A. A RI2ONA, CALIFORNI A, HAWAll, NEVADA, OR EGON, WASHINGTON,WEST VIRQlNIA, SENO APPLICATIONS TO: AND U.S. TERRITORIES AND POSSESSIONS IN THE PACIFIC,SENO APPLICATIONS

70;U.S. NUCLE AR REGULATORY COMMIS$10N, REGION ilCATERI AL R ADIATION PROTECTION SECTION U.S. NUCLE AR REGULATORY COMMIS$10N, REGION V101 MARIETTA STREET, SUITE 2900 MATERIAL RADIATION PROTECTION SECTION

. ATLANTA,GA 30323 1450 MARIA LANE,$UITE 210WALNUT CHEEK,CA 94596

PERSONS LOCATED IN AGREEMENT STATES SEND APPLICATIONS TO THE U.S. NUCLE AR REGULATORY COMMIS$10N ONLY IF THEY WISH TO POSSESS ANO USE LICENSED MATERI ALIN STATES SUSJECT TO U.S. NUCLEAR REGULATORY COMMIS$10N JURISDICTION,

1.THl313 AN APPUCATION FOR (Orsch appropreveif**/ 2.NAME AND MAluNG ADDRESS OF APPUCANT(inefudele Code /

~E A. NEW uCENSE (Expired License No. 37-07474-01)Eastern Associated Coal Corp.-

s. AMENDMENT To uCENSE NUMBEROne PPG PlaceC, RENEWALOF UCENSE NUMBER

- Pittsburgh, Pa. 15222

3. ADDRESS (ES4 WHERE LICENSED MATERIAL WILL BE USED OR POSSESSED.

Federal No. 2 Mine

Route #1 (near Blacksville) 8506120457 850517Fairview, W. Va. 26570 REG 2 LIC30

47-23053-01 PDR4. NAME OF PERSON TO BE CONTACTED ABOUT THl3 APPLICATION TELEPHONE NUMBER

Floyd R. Anderson, Purchasing Agent 412-288-8126$U8MIT ITEMS S THROUGH 11 ON 84 s 11** PAPER. THE TYPE AND SCOPE OF INFORMATION TO SE PROVIDED l$ DESCRIBED IN THE LICENSE APPUCATION GUIDE.

s. RADIOACTIVE MATERIAL See Attached See Attacheda Element and mens number, tL chemical and/or physical form, and c. mesimum amount 6. PURPOSE!S) FOR WHICH UCENSED MATERIAL WILL SE USED.which win t e possessed at any one time.

7, INDIVIDUAUS) RESPONSIBLE FOR RADIATION SAFETY PROGRAM AND THEIR

8. TRAINISG FORANDIVIDtALStORKING IN OR FREQUENTING RESTRICTED AREAS.TRAINING AND EXPERIENCE. See Attached ee ttac e

None Required 10. RADIANON SAFSY PRO 1RAMequ red9. FACIUTIES AND EQUIPMENT.one

12. LECENSE E FEES (See 10 CFR 170andsact>on 110.31)

pO,Ug7 s 80.Mii, WASTE uANAGEuENT. gg gg mm,

13. CERTIFICATION. (Must Becomptemdby appficant) THE APPLICANT UNDERSTANDS THAT ALL STATEMENTS AND REPRESENTATIONS MADE IN THis APPUCATION ARESINDING UPON THE APPUCANT.THE APPLICANT AND ANY OFFICIAL EXECUTING THl3 CERTIFICATION ON BEHALF OF THE APPLICANT, NAMED IN ITEM 2, CERTIFY THAT THl3 APPLICATION 13PREPARED IN CONFORMITY WITH TITLE 10. CODE OF FEDERAL REGULATIONS. PARTS 30,32,33,34,35, AND 40 AND THAT ALL INFORMATION CONTAINED HEREIN,is TRUE AND CORRECT TO THE SEST OF THEIR KNOWLEDGE AND SELIEF.PARNING: 18 U S.C. SECTION 1001 ACT OF JUNE 25.1948,62 STAT. 749 MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT OR REPRESENTATIONTO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTE 85 WITHIN ITS JURISDICTION.

SIGNATURE-CERTIFYING OF FICER TYPED / PRINTED NAME TITLE DATE

14. YOLUNT A RY E CONOWC D AT Aa_ Awh o u_ m i cEiPT1 tt NUMBER OF EMPLOYEES (Foost for d. WOULD YOU 8E WILLING TO FURNISH COST INFORMATION Qonerand/orsurf fraurs)

'"'"' #8'A'F ''eivaint outside contracton/ ON THE ECONOMIC IMPACT OF CURAENT NRC REGULATIONS OR ANY FUTURE< $ 260K $1M-3.5M PROPOSED NRC REGULATIONS THAT MAY AFFECT YOUP (NRCmputationspermitit to protect conf 4 enter cornmercraf or financel-propretary-infornestion hernished to *

gggng_ggng g3,sy,yg

c' NUM8ER OF BEDS$600K-750K 87M-10M

8730K-1M >$10M YES NO

FOR NRC USE ONLY

LOG FEE CATEGORY COMMENTS 40 II APPROVED 8 YTYPE OF FEE '

d seen m .

p/f I,.\ /

,, ,DATEAMOUNT RECElvED CHECK NUMBER

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PRIVACY ACT STATEMENT ON THE REVERSE

T

' *. . . , . .

. . .,

.

PRIVACY ACT STATEMENT

Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by section 3 of the Privacy Act of 1974 (Public Law 93-579), the follow-ing statement is furnished to individuals who supply information to the Nuclear Regulatory Commission on NRC Form313. This information is maintained in a system of records designated as NRC-3 and described at 40 Federal Register 45334(October 1,1975).

1. AUTHORITY: Sections 81 and 161(b) of the Atomic Energy Act of 1954,as amended (42 U.S.C. 2111 and 2201(b)).

2. PRINCIPAL PURPOSE (S): The information is evaluated by the NRC staff pursuant to the criteria set forth in 10 CFRParts 30,32,33,34,35 and 40 to determine whether the application meets the requirements of the Atomic Energy Act of1954, as amended, and the Commission's regulations, for the issuance of a radioactive material license or amendmentthereof.

3. ROUTINE USES: The information may be (a) provided to State health departments for their information and use;and (b) provided to Federal, State, and local health officials and other persons in the event of incident or exposure,for their information, investigation, and protection of the public health and safety. The information may also be dis-closed to appropriate Federal, State, and local agencies in the event that the information indicates a violation or potentialviolation of law and in the course of an administrative or judicial proceeding, in addition, this information may be trans-ferred to an appropriate Federal, State, or local agency to the extent relevant and necessary for an NRC decision or to

'

an appropriate Federal agency to the extent relevant and necessary for that agency's decision about you.

4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVID-ING INFORMATION: Disclosure of the requested information is voluntary, if the requested information is not furn-ished, however, the app!! cation for radioactive material license, or amendment thereof, will not be processed. A requestthat information be held from public inspection must be in accordance with the provisions of 10 CFR 2.790. Withhold-ing from public inspection shall not affect the right,if any, of persons properly and directly concerned need to inspectthe document.

5. SYSTEM MANAGER (S) AND ADDRESS: U.S. Nuclear Regulatory CommissionDirector, Division of Fuel Cycle and Material SafetyOffice of Nuclear Material Safety and SafeguardsWashington, D.C. 20555

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NRC FORM 313j

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5.

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' Item 5.

(a) Element and Mass No. Cesium 137(b&c) 1 sealed source of 250 mil 11 curies each.

Source No. CS5541, Serial No. 7165360.

Item 6.

Used in Industrial Nucleonics Corp. Mbdel LS-102 source holder tomeasure material. levels in bin.

Iten 7.

Gary Shriver, Preparation Plant Superintendent.

Item 8.>

Mr. James Zabolotony has had approximately eleven (11) yearsexperience in cleaning plant maintenance and supervision. During.that time he has had instructions from Industrial Nucleonics Servicepeople on'the shut-off and lock-out of the source holders and has beentaught the cautions to maintain around the instruments. Theshutters for the Industrial Nucleonics devises are closed by leverand locked in the closed position. Mr. Zabolotony keeps the key and-is responsible for the closing and opening of shutters when required.to do so,- and to see that they are locked.*

i' Iten 11.

Waste disposal has been handled by Adco Services, Inc., P. O. Box35, Tinley Park, Illinois. Waste material has been shipped to

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State of. Washington, Department of Social and Health Service, PermitNo.- 2767.

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._

R s rm 782 U.U. LlRKV1J REGLRTOR U COMMISSEJa(1 87)

MATERIALS DATA INPUT-INDUSTRIAL, MEDICAL, SOURCE /SPECIAL NUCLEAR- -

A. TYPE L F ACTION AND IDENTIFICATION, CODES

AME NDMENT TO AMENDMENT DOCKET NUM8ER M AIL CONTROL CHANGEN VOIDRENEW LICE NSE TO TERMINATE % NUMBER NAME tADDR E SS

g I >r~e..,

1 o,,,,,,gD,,,, 1 030-2205 9 03096NEW LICENSE ANo CtE RiCAt CH ANGENEW LICENSE E NO AMENDMENT

B. INDICATIVE IN FORMATION

N AME lissf. Fest M4#e, NAME (Last. Fest. M4$e,

pOlVIOUAL N AME Itsst. Fest. M4ea, NAMai flest. Fase. M..f

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U S GOVE RNME NT AGE N kTYPE _.,_

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SECONDARY PROGR AM CODES (As requeredt

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ME DECAL CATEGORY: FOR HUMAN USE ONLY gONLY

POSSESSION OF THE MATERIAL IS AUTHORIJEO IN ONE OF THE FOLLOWING ARE AS

SAME AS ' ST AT E * IN ADDRESS ALL STATES ALL NON AGREEMENT STATESt.NDf0R

"IN THE 'AL ALABAYA GA GEORGE 4 MD MAHyLAND NJ NEW JEH$EY SC SOUTH CAROLINA WY . WVOYtNGSTATEIS).

TERRI AK ALASK A Hi HAWAis M A MASSACHUSETTS NY NEW ME AICO SD SOUTH DAK.OT A

Al AR elON A ID DAHO Mi MICHIGAN NY NEW YORK TN . TE NNESSE E AS AMERICAN SOMOA

CHECKED AR . AHK ANSAS 11. I L L INO'S MN MrNNE SOT A NC NOH TH C AROLIN A Tx TE M AS CZ . CANAL ZONE

N CA C ALIF OHNI A IN INDIANA MS Mi$$1SSIPPl NO . NOH TH D AKOY A UT-UTAH GU.GUAV

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CT CONNECT 6 CUT KS KANSAb MT MONTANA OK OK L AHOV A V A . VIRGINI A Vn . VIRGIN ISLANDS

DE DE L AW AHE KY KE NTUCKY N8 NF9HASKA OH OHEGON W A - WASHINGTON

DC W ASHINGTON DC LA LOU'SI AN A N% NEVADA PA PE NNSYLV ANIA WV AE ST vtRGiNI A CN CANADA

FL FLOHIDA ME M A INE NH NE W HAMPSHlHE Al - RHODF ISL AND WI WISCONSIN

D. POSSESSION LIMITS OF SOURCE AND SPECI AL NUCLE AR MATERI ALS AND TRITIUM

SOURCE MATF HI AL CE ILING G GHAMS SNM CL ILING G GRAMS 16 F OM POWEH RE ACTOR

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1-FILE COPY