A A INA A 0s106/2020 SECTION 1 wae ronusss <1 04 PAGE 1 of 2 e219 Us. NUCLEAR REGULATORY coHMSSION ‘born GENERAL LICENSEE REGISTRATION APPROVED BY OMB: NO. 2150-0198 (OMB EXPIRATION DATE: 09/30/2022 Estimated curr pe response camo} wi tis mandaioy collection request 20 miules_NAC wil se his WfaWalen fo cx genera Icensees and hl devios to Jensize angher vel of doce accounts. Send comments regarding bulden eabmete ote lflomaton Services Grane’ 7-6 ATON), U.S. Meer Regulate [Common Vashington, OC 20865.000, oy to oles Resouron@nc gov. aoe Onsk fea. Oca o information ana Regulatory Aas NEOB-10202, (31508188), Offco of Meragorart and Budget Weshnglon, OC 20803. Ife means used to moose an incrmation colecton does nt sepa &curenty vate ONS convo number, tne NRC may nt condi or spore, anda Person I nol request resp ote lomatoncalecion Complete all six sections of this registration form. If any of the preprinted information is incorrect, provide the changes in the applicable boxes. USE CAPITAL LETTERS. General License SECTION 1 - GENERAL LICENSEE INFORMATION Registration Number GL-1918-25 Enter the company name and the street address for the physical location of use for your device(s). For portable devices, specify the primary storage location. Do not use P.O. Boxes. Company Name: DECORATIVE PANELS INTNL T | i|_| | | Department’ MAINTENANCE | ] 1] | | | | | | | Address Line 1: 416 FORD AVENUE | Address Line 2 City ALPENA State; MI Zip Code: 49707 Td - For NRC Use Only (Do not write here) “ | Packet Receipt Date (MMDDYYYY): ‘Accession Number:HE INNO. S00 05/06/2020 SECTION 1 PAGE 2 of 2 SECTION 1 - GENERAL LICENSEE INFORMATION (Continued) Enter the name, telephone number and title of the person who is the responsible individual for the device(s). Last Name: VANMASSENHOVE FirstName: DANIEL Middle Initial: G Business Telephone Number: (989) 356-8518 Extension: 2243 Business E-mail Address: Title: MANUFACTURING MANAGER address where correspondence regarding your device(s) should be sent. Department: ENGINEERING Address Line 1; 416 FORD AVENUE Address Line 2: City’ ALPENA 1 | State: Ml Zip Code: 49707 -Ii cL-1918-25 osvoer20z0 Our records indicate that yi NRC Device Key Distributor/Distributed By: Canberra Industries, Inc. NinieVelair| [Rieislelalclelh) [Co le |p ] Distributor License Number: 37-02401-04G LT] _ Manufacturer name: NUCLEAR RESEARCH CORP ] | Device Model (Not Source Model): LS-101 | I IMA 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 devices. Please update the information as necessary. PAGE 1 of 6 (internal Control Number) Device Serial Number: CS8019NR Transfer Date: 09/01/1980 Net ingososon doves (Ase | | O Sle Boston 6) MM bo yyy Isotope (e.g. AM241) Activity (e.g. 1005) Unit (e.g. mCi) 1 8137 50 mCi 2 3 4 Ls 5 6 LNU 61-1918-25 OWE MN Seon SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 ‘Our records indicate that you have these devices. Please update the information as necessary. PAGE 2of 6 NRC Device Key 34501 (Internal Control Number) Distributor/Distributed By: Canberra Industries, Inc. NJulcltle late [Rie |s fe la elelh| [Clo |r Distributor License Number. 37-02401-04G > Manufacturername: NUCLEAR RESEARCH CORP. Device Model (Not Source Model): LS-101 Device Serial Number: CS-8016NR Transfer Date: 09/01/1980 T [[) Notin possession of device (Also J | complete Section 4) MM pp yyy Isotope (e.9. AM241) Activity (e.9. 1005) Unit (e.g. mci) 1 esi37 50 mei I T | | 2 3 l 4 | 1 5 6IO HM I] cl-91825 Sussoz0 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 Our records indicate that you have these devices. Please update the information as necessary. PAGE 30f6 NRC Device Key 34502 (Internal Control Number) Distributor/Distributed By: Canberra Industries, Inc. Nlalclilelalel |Mlels lela clo) [Clo ie Distributor License Number: 37-02401-04 a5 | Manufacturer name: NUCLEAR RESEARCH CORP Device Model (Not Source Model): LS-101 Device Serial Number: CS8014NR I | | ‘Transfer Date: 11/15/1980 | 7 Notin possession f device (Also ccomplate Section 4.) MM pp yyyY Isotope (e.g. AM241) Activity (e.g. 1008) Unit (2.9. mci) 1 est37 50. mCi T | 2 | 3 J} 1 4 5 6GL-1918-25 (05/06/2020 (Our records indicate that you have these devices. Please up: NRC Device Key Distributor/Distributed By I SECTION 2 - DEVICES SUBJECT TO REGISTRATION date the information as necessary 658551 (Internal Control Number) ll IM Thhl ele imo E Lisielhlelr Sleli Distributor License Number. &) 0/3] 5) 2/4 Manufacturer name: THERMO MEASURETECH Device Model (Not Source Model): 7063, | | Device Serial Number: 109324 Transfer Date: 12/01/1979 SECTION 2 PAGE 4 0f6 ic Not in possession of device (Also IO] Oe Scie) MM bp yyyY Isotope (e.g. AM241) Activity (e.g. 1005) Unit (e.g. mCi) 1 ¢si37 500 mei 2 3 ] | || 4 5 6 | | lAV UT il cL1916-25, Suooeoe SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2 Our records indicate that you have these devices. Please update the information as necessary. PAGE 50f6 NRC Device Key 658552 (Internal Control Number) Distributor/Distributed By: Tihlelrimio | LF Distributor License Num ols/sia [yy | Manufacturername: THERMO MEASURETECH chleiel] [Si clile nei lelic Device Model (Not Source Model): 7063, f 7 | Lt | Device Serial Number: 10932B 7 | | | | ‘Transfer Date: 12/01/1979 | [3 Notin possession of devs iso complete Section &) MM oD yyyY Isotope (e.g. AM241) Activity (e.g. 1008) Unit (e.g. mci) 1 8137 500 mCi 2 T | | 3 T | I 4 5 T 6o11918-25 i AINA ll 05/06/2020 ‘SECTI 2-DEVICES SUBJECT TO REGISTRATION SECTION 2 cine ndlete tht you tvs thos Gece Pineau ts ntrmato oo resem pace bore NRC Device Key 658553 (Internal Control Number) Dietibro/eated By O[Waalele ela la Clo |elp Distributor License Number: B/4-| 010 1613 /4|-013 G Manufacturername: OHMART/VEGA CORPORATION Device Model (Not Source Model): BW24 Device Serial Number, 2418 MODEL SHRM-BW. Transfer Date: 11/01/1975 T [7 Notin possession of device (Also ‘complete Section 4.) MM ob yyYY Isotope (e.g. AM241) Activity (e.g. 1008) Unit (e.g. mci) 1 csi37 36 mci L 2 T 3 4 5 6 |IO 0 05/06/2020 SECTION 3 SECTION 3 - ADDITIONAL DEVICES SUBJECT TO REGISTRATION PAGE 1 of 1 Provide information about other devices you have that are subject to registration. Do not report specifically licensed devices. Manufacturer Name Initial Transferor Name 1 = 1 Initial Transferor License Number (if known) Device Model Number (Not Source Model) Device Serial Number How acquired and date (eg, © ManufactuerntalTransferor listed above © Other Sources MM DD yyy Isotope (e.g. AM241) Activity (e.g. 100) Unit (e.g. mCi) 10.Oe IN 0 05/06/2020 SECTION 4 - NOT IN POSSESSION OF DEVICE SECTION 4 Provide information about devices listed in Section 2 or 6, but no longer in your possession. PAGE 1 of 1 Part1 ‘Transfer Date: NRC Device Key [ ILI (from Section 2 or 6) MM ob yyy Location of the Device: (© Whereabouts Unknown (Complete Part 1 only) (© Transferred to another general licensee (Complete Parts 2 and 3) © Never Possessed the Device (Complete Part 1 only) © Transferred to a Specific Licensee (Not the manufacturer) © Retumed to Manufacturer (Complete Part 1 only) (Complete Part 2) Part2 License Number of Recipient (i transferred to a specific licensee) ‘Company Name: Department: Address Line 1 Address Line Zip Code: T 2 a s Part 3 Enter the name of the individual responsibe for this device: Last name: First name: Midale Initia Business Telephone Number: ri q Extension:CV IN GL-1910-25 SECTION 5 - CERTIFICATION SECTION 5 70572020 PAGE 1 of 1 hereby certify that: ‘A. Allinformation contained in this registration is true and complete to the best of my knowledge and belie. 8. —_Aphysical inventory of the devices subject to registration has been completed, and the device information on this form has been checked against the device labeling C. —_ Lamaware of the requirements of the general license, provided in 10 CFR 31.5, (Copies of applicable regulations may be viewed at the NRC website at: http:/www.nre. goviteading-rm/doc-collections/oft) Spout) 6 ViWesalee. 5-lo-Loro _ SIGNATURE - RESPONSIBLE INDIVIDUAL (Listed in Section 1) DATE WARNING: FALSE STATEMENTS MAY BE SUBJECT TO CIVIL ANDIOR CRIMINAL PENALTIES. NRC. REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRC BE COMPLETE AND ACCURATE IN ALL MATERIAL ASPECTS. 18 U.S.C SECTION 1001 MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY WRONG STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTER IN ITS JURISDICTION.A MN Sooo. SECTION 6 ‘SECTION 6 - DEVICE NOT SUBJECT TO REGISTRATION PAGE 1 of 1 NRC Device Key: Manufacturer License No: Manufacturer Name: Mode! Number: Serial #: Transfer Date: Isotope: Activity: Unit: