UNITED STATES NUCLEAR REGULATORY COMMISSION "WASHINGTON, D.C. 20586-0001 May 18, 2020 TO: Users of Devices Subject to General License Registration SUBJECT: ANNUAL REGISTRATION OF GENERALLY LICENSED DEVICES ‘The U.S. Nuclear Regulatory Commission (NRC) requires annual registration of certain devices that are possessed under the general license issued in Section 31.5 of Title 10 U.S. Code of Federal Regulations (10 CFR 31.5). Devices subject to registration include those containing the radioactive material and activity listed in Table 1 of the attached NRC Form 664. You are receiving this notice because NRC records indicate that you have one or more such devices. Information about the general license registration program is available NRC website at htto://www.nrc. gov/materials/miau/miau-re4- initiatives! gen-license.htm! Note that under 10 CFR 31.5(c)(11), the attached General Licensee Registration Package must be completed, signed, and returned to the NRC within 30 days from the date of this letter. Read all of the instructions prior to completing the package. Mail the completed package in the enclosed envelope to’ Director, Office of Nuclear Material Safety and Safeguards ATTN: GLTS U.S. Nuclear Regulatory Commission Washington DC 20555-0001 Registration Fee: The NRC has acted to temporarily mitigate the financial impacts and ‘economic disruptions caused by the COVID-19 Pandemic. The registration fee(s) for your generally licensed device(s) scheduled to be issued in April will be deferred until July 22, 2020. For more information on the invoice deferral, you can go to NRC's public website: www.nrc.gov. NRC amended 10 CFR Parts 170.11 and 170,31 to provide that 10 CFR Part 170 fees be assessed to Federal agencies, where applicable, in accordance with the Energy Policy Act of 2005. Therefore, those Federal facilities required to register certain generally licensed devices in their possession will be required to pay the annual registration fee Attachment: NRC Form 664 -- General Licensee Registration and Instructions Sincerely, Digitally signed by Donald Donald B. Lowman plauall/signed by Pona USS. Nuclear Regulatory Commission Office of Nuclear Material Safety and Safeguards Division of Material Safety, State, Tribal and Rulemaking Programs Materials Safety Licensing and Tribal Liaison BranchMN HONE AT u-r27086-25 SECTION 1 oan PAGE 1 of 2 NRC FORM 664 (o-2010) US. MUCLEAR REGULATORY COMMISSION rocrRa15 GENERAL LICENSEE REGISTRATION APPROVED BY OMB: NO. 21500198 ‘OMe EXPIRATION DATE: 73072022 stale burden per response o compy wif is Nanda ctecfon request 20 manus. NRC wil uses Worn Yo Weck gone lenssss andre devaes 0 ensure ahigrer vel of device accourabity. Send carmets regarding buren esate ote foraton Services Branch T-bA‘OM), U. 8, Nudes Reguany ‘Commission. Vashingion, OC 20885.000, or by ema Io ncotets Resoweerve gov. ar othe Desk Ofice.Ofie a narmation and Regan Aas, NEOB-10202, $160-0106), Olea of Managemont ane sgt Washington, OC 20802, Ita means ved to pose en information colecon doesnot splay a curenty vals OMB conte number, the NRC may na conduct ar sponse, anda parson not request respond to te oration calc, 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-727086-28 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: DEPARTMENT OF VETERANS AFFAIRS | Department: FACILITIES MANAGEMENT SERVICE rT Address Line 1: 1 VACENTER Address Line 2; MDP 185 + 1 + LT | City AUGUSTA CTT] | State: ME Zip Code: 04330 | For NRC Use Only Galagory: (Bo not write here) Packet Receipt Date (MMDDYYYY):IMA SECTION 1 PAGE 2 of 2 vO IMU TE 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). ON L-727086- (05/06/2020 Last Name: ROGERS TT! T | 1 First Name: ROBERT Middle Initial: O Business Telephone Number. (207) 623-8411 Extension: 5279 Business E-mail Address: Title: BOILER PLANT SUPERVISOR Enter the mailing address where correspondence regarding your device(s) should be sent. Department: FACILITIES MANAGEMENT SERVICE ‘Address Line 1: 1 VACENTER ‘Address Line 2: MDP 185, City: AUGUSTA, State: ME Zip Code: 04330 -i INU A I GL-727086-25 Suossose SECTION ICES SUBJECT TO REGISTRATION SECTION 2 Our records indicate that you have these devices, Please update the information as necessary. PAGE 1 of f NRC Device Key 833484 (Internal Control Number) Distributor/Distributed By: Berthold Technologies U.S.A, LLC Distributor License Number. R-01082-B23 Manufacturername; BERTHOLD TECHNOLOGIES U.S.A, LLC Device Model (Not Source Model): LB 300LP Device Serial Number. 17491-10702 Transfer Date: 11/12/2013 ] [J Notin possession of device (Also | complete Section 4.) MM DD yyYY Isotope (e.g. AM241) Activity (e.g, 1005) Unit (e.g. mci 1 cs137 100 mci 2 i} 3 4 5 6IME 0 I A L-727058-25 8/06/2020 SECTION 3 - ADDITION. SECTION 3 - IONAL DEVICES SUBJECT TO REGISTRATION PAGE 1 of 4 Provide information about other devices you have that are subject to registration. Do not report specifically licensed devices. Manufacturer Name Initial Transferor Name Initial Transferor License Number (if known) Device Model Number (Not Source Model) Device Serial Number f T How acquired and date (e.g, © Manufacturer/Inital Transferor listed above from a distributor/manufacturer, 6 Other General Licensee _Date Transferred other licensee, other source)? © Other Sources MM DD yyy Isotope (e.g. AM241) Activity (e.g. 100) Unit (e.9. mci 10.(ODN A AA MN (08/06/2020 SECTION 4 - NOT IN POSSESSION OF DEVICE SECTION 4 Provide information about devic in Section 2 or 6, but no longer in your possession. PAGE 1 of 1 Part 4 Transfer Date: NRC Device Key (from Section 2 or 6) MM pb yyy Location of the Device: © Whereabouts Unknown (Complete Part 1 only) © Transferred to another general icensee (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 Pert 2) Part 2 License Number of Recipient (i transferred to @ specific licensee) Company Name: Department Address Line 1 Address Line 2: City: State’ Zip Code: Part3 Enter the name of the individual responsibe for this device: Last name: First name: Middle Initia Extension:IWIN IMI G1-727056-25 SECTION 5 - CERTIFICATION SECTION 5 0612020 PAGE 1 of 1 Thereby certify that: A. Alllinformation contained in this registration is true and complete to the best of my knowledge and belief. B. _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: cnn govireading-rm/doc-collections/cfr) Moke — og /22 /2020 Suatlntitiesronkoizomnmoulonaanacnmn (DATE WARNING: FALSE STATEMENTS MAY BE SUBJECT TO CIVIL AND/OR 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 ITA 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.I. A A I 61-727088-25 Pssoeiz020 ‘SECTION 6 - DEVICE NOT SUBJECT TO REGISTRATION oroe ‘0 we NRC Device Key: Manufacturer License No Manufacturer Name: Model Number: Serial #: Transfer Date: Isotope: Activity: Unit: