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Form F-45012 - Application For A Radioactive Material License For A Nuclear Pharmacy Page 3

F-45012 (Rev. 05/10)

Page 3 of 7

Item 9.2 Chemical/Physical Form of radioisotopes requested.

Are open containers of potentially volatile materials (Iodine-131)

Yes

manipulated at this location?

If yes, process and engineering controls must be described.

Are sealed sources used at this location?

Yes

If yes, please fill out Items 9.3 – 9.5, otherwise proceed to Item 9.6

Item 9.3 Sealed Source Manufacturer or Distributor and Model Number of sealed sources requested.

Item 9.4 Device Manufacturer or Distributor and Model Number of devices requested.

Item 9.5 Sealed Source Device Registration Sheet Number of sealed sources requested.

Is Depleted Uranium used as a shielding material?

Yes

If yes, specify the total amount (in Kilograms)

Item 9.6 Maximum possession limit for each radioisotope requested.

Item 9.7 Proposed use for each radioisotope requested.

PURPOSE(S) FOR WHICH LICENSED MATERIAL WILL BE USED

Item 10 Distribution And Redistribution Of Licensed Materials

Item 10.1 Radiopharmaceuticals (Check both boxes)

Confirm that radiopharmaceuticals will be prepared under the supervision of an ANP or will be obtained from a supplier authorized

pursuant to s. DHS 157.13(4)(i), DHS 157.13(1)(j), or under equivalent NRC or Agreement State requirements;

AND

We will describe all licensed material to be distributed or redistributed.

Item 10.2 Generators (Check both boxes if using generators)

Confirm that the generators will be obtained from a manufacturer licensed pursuant to s. DHS 157.13(4)(i), or under equivalent NRC or

Agreement State requirements.

AND

Confirm that unused generators will be redistributed without opening or altering the manufacturer’s packaging.

Form F-45012 - Application For A Radioactive Material License For A Nuclear Pharmacy Page 3