December 8, 2003

Dianne R. Nielson, Ph.D.

Executive Director

Department of Environmental Quality

168 North 1950 West

Salt Lake City, UT 84116

Dear Dr. Nielson: 

On September 25, 2003, the Management Review Board (MRB) met to consider the proposed

final Integrated Materials Performance Evaluation Program (IMPEP) report on the Utah

Agreement State Program. Subsequent to the MRB meeting, the team requested additional time

to review the updated Training Qualification Forms that were supplied to the team following the

onsite review. Discussions were conducted with State management involving these forms and

the report was further revised. MRB concurrence on the revised language was received on

November 25, 2003. The MRB found the Utah program adequate to protect public health and

safety, and compatible with the Nuclear Regulatory Commission’s program.

Section 5.0, page 16, of the enclosed final report presents the IMPEP team’s recommendation

for the State of Utah. We received the August 14, 2003 letter from Craig W. Jones, Acting

Director, Division of Radiation Control, and request no additional information at this time.

Based on the results of the current IMPEP review, the next full review will be in approximately

four years. 

I appreciate the courtesy and cooperation extended to the IMPEP team during the review. I also

wish to acknowledge your continued support for the Radiation Control Program and the

excellence in program administration demonstrated by your staff as reflected in the team’s

findings. I look forward to our agencies continuing to work cooperatively in the future.

Sincerely,

/RA/

Carl J. Paperiello 

Deputy Executive Director for Materials,

 Research and State Programs

Enclosure: 

As stated

cc: William J. Sinclair, Deputy Director

Utah Department of Environmental Quality

Dane Finerfrock, Director

Division of Radiation Control

Edgar Bailey, CA

OAS Liaison to the MRB
December 8, 2003

Dianne R. Nielson, Ph.D.

Executive Director

Department of Environmental Quality

168 North 1950 West

Salt Lake City, UT 84116

Dear Dr. Nielson: 

On September 25, 2003, the Management Review Board (MRB) met to consider the proposed

final Integrated Materials Performance Evaluation Program (IMPEP) report on the Utah

Agreement State Program. Subsequent to the MRB meeting, the team requested additional time

to review the updated Training Qualification Forms that were supplied to the team following the

onsite review. Discussions were conducted with State management involving these forms and

the report was further revised. MRB concurrence on the revised language was received on

November 25, 2003. The MRB found the Utah program adequate to protect public health and

safety and compatible with the Nuclear Regulatory Commission’s (NRC) program.

Section 5.0, page 16, of the enclosed final report presents the IMPEP team’s recommendation

for the State of Utah. We received the August 14, 2003 letter from Craig W. Jones, Acting

Director, Division of Radiation Control, and request no additional information at this time.

Based on the results of the current IMPEP review, the next full review will be in approximately

four years. 

I appreciate the courtesy and cooperation extended to the IMPEP team during the review. I also

wish to acknowledge your continued support for the Radiation Control Program and the

excellence in program administration demonstrated by your staff as reflected in the team’s

findings. I look forward to our agencies continuing to work cooperatively in the future.

Sincerely,

/RA/

Carl J. Paperiello 

Deputy Executive Director for Materials,

 Research and State Programs

Enclosure: 

As stated

cc: William J. Sinclair, Deputy Director bcc: Chairman Diaz

Utah Department of Environmental Quality Commissioner McGaffigan

Commissioner Merrifield

Dane Finerfrock, Director

Division of Radiation Control

Edgar Bailey, CA

OAS Liaison to the MRB

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Utah File
INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM

REVIEW OF UTAH AGREEMENT STATE PROGRAM

June 23-27, 2003

FINAL REPORT

U.S. Nuclear Regulatory Commission
Utah Final Report Page 1

1.0 INTRODUCTION

This report presents the results of the review of the Utah radiation control program. The review

was conducted during the period June 23-27, 2003 by a review team comprised of technical staff

members from the Nuclear Regulatory Commission (NRC) and the Agreement State of Maine. 

Review team members are identified in Appendix A. The review was conducted in accordance

with the "Implementation of the Integrated Materials Performance Evaluation Program and

Rescission of a Final General Statement of Policy," published in the Federal Register on October

16, 1997, and the November 5, 1999, NRC Management Directive 5.6, "Integrated Materials

Performance Evaluation Program (IMPEP)." Preliminary results of the review, which covered the

period November 20,1998, to June 27, 2003 were discussed with Utah management on June 27,

2003.

A draft of this report was issued to Utah for factual comment on July 24, 2003. The State

responded by letter dated August 14, 2003. The Management Review Board (MRB) met on

September 25, 2003 to consider the proposed final report. The MRB found the Utah radiation

control program adequate to protect public health and safety and compatible with NRC’s

program.

The Utah Agreement State program is administered by the Division of Radiation Control (the

Division) located in the Department of Environmental Quality (the Department). Organization

charts for the Division and Department are included as Appendix B. The Utah program regulates

approximately 200 specific licenses authorizing agreement materials and a low-level radioactive

waste site. The review focused on the materials program as it is carried out under the Section

274b. (of the Atomic Energy Act of 1954, as amended) Agreement between the NRC and the

State of Utah.

In preparation for the review, a questionnaire addressing the common and non-common

performance indicators was sent to the Division on April 15, 2003. The Division provided a

response to the questionnaire on June 2, 2003, and a corrected copy of the response was

provided electronically on July 9, 2003, following the review. A copy of the corrected

questionnaire response may be found on NRC’s Agencywide Document Access and

Management Systems using the Accession Number ML031910180.

The review team's general approach for conduct of this review consisted of: (1) examination of

Utah's response to the questionnaire; (2) review of applicable Utah statutes and regulations; 

(3) analysis of quantitative information from the radiation control program licensing and

inspection database; (4) technical review of selected licensing and inspection actions; (5) field

accompaniments of three Utah inspectors; and (6) interviews with staff and management to

answer questions or clarify issues. The review team evaluated the information that it gathered

against the IMPEP criteria for each common and applicable non-common performance indicators

and made a preliminary assessment of the Utah Agreement State program’s performance. 

Section 2 below discusses the State's actions in response to recommendations made following

the previous IMPEP review and the team’s conclusions regarding close-out of the

recommendations. Results of the current review for the IMPEP common performance indicators

are presented in Section 3. Section 4 discusses results of the applicable non-common

performance indicators, and Section 5 summarizes the review team's findings and 

recommendations. Recommendations made by the review team are comments that relate
Utah Final Report Page 2

directly to program performance by the State. A response is requested from the State to all

recommendations in the final report. 

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS

During the previous IMPEP review, which concluded on November 20, 1998, one

recommendation and one suggestion were made and transmitted to Dianne R. Nielson, Ph.D.,

Executive Director, Department of Environmental Quality, on February 9, 1999. The team

determined that the State considered the suggestion and took appropriate action. The team’s

review of the current status of the recommendation is as follows: 

1. The review team recommends that the State continue in their ongoing efforts to meet the

reciprocity inspection frequencies outlined in NRC Inspection Manual Chapter

(IMC) 1220.

Current status: The Division has implemented a system for tracking licensees working in

the State under reciprocity. The Division has met or exceeded the reciprocity inspection

frequencies for each year of the review period. This recommendation is closed.

3.0 COMMON PERFORMANCE INDICATORS

IMPEP identifies five common performance indicators to be used in reviewing both NRC

Regional and Agreement State programs. These indicators are: (1) Technical Staffing and

Training; (2) Status of Materials Inspection Program; (3) Technical Quality of Inspections; (4)

Technical Quality of Licensing Actions; and (5) Response to Incidents and Allegations.

3.1 Technical Staffing and Training

Issues central to the evaluation of this indicator include the Division’s staffing level and staff

turnover, as well as the technical qualifications and training histories of the staff. To evaluate

these issues, the review team examined the Division's questionnaire response relative to this

indicator, interviewed Division management and staff, reviewed job descriptions and training

records, and considered any possible workload backlogs.

The Division consists of the Division Director, four administrative staff, including the Support

Services Coordinator (SSC), and two technical Sections; the Radioactive Materials and X-Ray

Section (the Materials Section), and the Waste and Environmental Section. The Radioactive

Materials and X-Ray Section includes a Section Manager and eight full-time Health Physicist

positions, four in the radioactive materials program and four in the X-Ray program. The Waste

and Environmental Section consists of a Section Manager and eleven full-time positions in five

program areas; Indoor Radon, Uranium Mills, Waste Isolation Pilot Project (WIPP)

Transportation Project, Generator Site Access, and the Envirocare Low-Level Radioactive Waste

site. Details of the Waste and Environmental Section staffing is discussed further under Section

4.3.1. 

Technical staffing in the Materials Section has been stable since the previous review and the

review team believes that this staffing level is adequate. One staff member from the materials

program left the program on June 20, 2003. The review team was informed that the paperwork

needed to fill this position had been initiated and approved at the Department level. 
Utah Final Report Page 3

The Division has a documented training and qualification program in place for staff which is

based on the NRC/Organization of Agreement States Joint Working Group report. Adequate

qualification is determined through a combination of education and experience, formal classroom

training, and on-the-job training. Staff members are required to have a bachelor’s degree or

equivalent experience in the physical sciences. The Division maintains a training matrix, listing

the “required courses” and “recommended courses” for each staff position by program activity. 

These staff positions are: Health Physicist, Low-Level Waste Inspector, Radiological

Transportation & Safety Specialist, Engineer, Hydrologist, and Section Manager. 

Records show that Materials Section staff have all received their required and recommended

courses for their positions, and are very familiar with Utah regulations, policies, and procedures. 

During team interviews with the staff and the Division Radiation Safety Officer (RSO), the RSO

discussed plans to conduct an in-house refresher course on some new survey equipment. The

RSO agreed that the course should include refresher training for all technical staff on the

capabilities and use of the other radiological instrumentation in the Division. This training will be

documented in training files. 

The Utah Radiation Control Board is appointed by the Governor, with consent of the Senate, and

guides development of Radiation Control policy and regulations. The Board meets at least ten

times per year, and the minutes of the meetings are posted on the web site. All members are

subject to the Utah Public Officer’s and Employees’ Ethics Act.

Based on the IMPEP evaluation criteria, the review team recommended and the MRB agreed

that Utah's performance with respect to the indicator, Technical Staffing and Training, was

satisfactory. 

3.2 Status of Materials Inspection Program

The team focused on five factors in reviewing this indicator: inspection frequency, overdue

inspections, initial inspection of new licensees, the timely dispatch of inspection findings to

licensees, and the performance of reciprocity inspections. The evaluation is based on the

Division’s questionnaire response relative to this indicator, data gathered independently from the

Division’s licensing and inspection data tracking system, the examination of completed licensing

and inspection casework, and interviews with managers and staff.

The staff uses a custom database management system for their tracking system. The data is

maintained on a network and is available to all staff. This allows them to project the next

inspection due date and to sort the inspection data as needed. The staff updates the information

on this system continuously to keep it up-to-date.

The team's review of the Division’s inspection priorities verified that inspection intervals for

various types of material licenses are generally at least as frequent as, or more frequent than,

similar license types listed in NRC IMC 2800. Thirty-seven of the 78 license categories

established by the Division are inspected more frequently than similar license types listed in NRC

IMC 2800. Two categories, Instrument Calibration (< 100Ci) and Strontium-90 Eye Applicator,

had inspection intervals greater than the interval outlined in NRC IMC 2800. However, the

Division has no licensees in these categories. 
Utah Final Report Page 4

In their response to the questionnaire, the Division indicated that no inspections were overdue by

more than 25 percent of the NRC frequency. This information was verified by review of the

inspection data provided to the team. The Division performs approximately 80 routine

inspections annually. The team determined that only four core routine inspections were

conducted overdue during the review period. The team also determined that, in those instances

where the licensee was inspected past the due date, there was clear documentation that showed

that an inspection was attempted by the due date or other extenuating circumstances existed. In

all cases where inspections were conducted past the due date, Division management was fully

aware of the circumstances.

With respect to initial inspections of new licensees, the review team noted that the Division

conducted initial inspections in accordance with NRC IMC 2800 guidelines. There were 38 new

licenses issued during the review period.

The timeliness of the issuance of inspection findings was evaluated during the inspection

casework review. There were no instances identified where inspection correspondence was not

sent within 30 days after the inspection. The team also determined that licensee responses were

received and responded to in a timely manner.

During the review period, the Division granted 85 reciprocity permits, of which, 83 permits were

core licensees based on NRC IMC 2800. The review team noted that the Division has adopted

the criteria outlined in NRC IMC 1220 as the Division’s criteria for inspecting licensees working in

Utah under reciprocity each time the NRC has changed the criteria during the review period. 

The team also determined that the current NRC criteria of inspecting 20 percent of candidate

core licensees operating under reciprocity each year is the criteria currently being used by the

Division. The team determined that the Division met or exceeded the NRC IMC 1220 criteria for

the entire review period.

The Division’s custom database management system is programed to provide the staff with a

“pop-up” window, each day upon logging in, that indicates who is working in the State under

reciprocity during the next 7-day period. If there are no licensees working under reciprocity

during that time period, the “pop-up” window indicates this as well. The system also tracks who

had been in the State, when, where, and for how long. The team recommends that the Division’s

system for tracking licensees that are working in the State under reciprocity be considered a

good practice.

Based on the IMPEP evaluation criteria, the review team recommended and the MRB agreed

that Utah’s performance with respect to the indicator, Status of Materials Inspection Program,

was satisfactory.

3.3 Technical Quality of Inspections

The team evaluated the inspection reports, enforcement documentation, inspection field notes,

and interviewed staff for 10 radioactive material inspections conducted during the review period. 

The casework included all inspectors and the Materials Section Manager. The casework

covered inspections of various types including; panoramic irradiator, medical institutions, medical

private practice, industrial radiography, well logging, nuclear pharmacy, academic broad scope,

academic/medical broad scope, portable gauge, and reciprocity. Appendix C lists the inspection

casework files reviewed for completeness and adequacy with case-specific comments.
Utah Final Report Page 5

Utah’s inspection procedures are consistent with NRC procedures. Inspections are routinely

unannounced. The review team noted that, of the 10 inspections evaluated, only one was

announced, this inspection was an initial inspection.

Based on casework, the review team noted that routine inspections covered all aspects of the

licensees’ radiation programs. The team noted that the inspections are both compliance oriented

and performance-based. Field notes have been developed to cover all types of inspections that

are conducted by the Division. These field notes provide documentation for the scope of the

licensees’ program and cover all areas that need to be reviewed. The information contained in

the field notes is comparable with NRC’s Inspection Procedure 87100. The inspectors also

include various performance-based inspection techniques, such as direct observation of licensed

activities, demonstrations, interviews, etc., when appropriate. Team inspections were performed

when appropriate and for training purposes.

The inspection findings are issued under the signature of the Executive Secretary of the Utah

Radiation Control Board, after a review of the inspection report by a peer and the approval by the

Materials Section Manager. Inspection findings are routinely sent to the licensee well within 30

days. Licensee responses are reviewed and replied to in a timely manner. The inspection files

were found to be complete and in good order. 

The Materials Section Manager has accompanied all four of the inspectors, who conduct

inspections of radioactive material licensees, at least annually since the last review.

During the week of May 5, 2003, a review team member performed accompaniments of two of

the Materials Section’s four inspectors on separate inspections of licensed facilities (see

Appendix C). The inspections were of a nuclear pharmacy, a medical institution, and a portable

gauge licensee. During the accompaniments, inspectors demonstrated appropriate inspection

skills and knowledge of the regulations. The inspectors were well prepared and thorough in the

review of licensee programs. The technical performance of both inspectors was excellent. The

inspections were adequate to assess radiological health and safety at the licensed facilities. 

The Division has available a variety of portable instruments for routine confirmatory surveys and

use in incidents and emergency conditions. The instruments are calibrated annually, or as

needed. The calibrations are done by the Division RSO, using a one curie cesium-137 source in

a J. L. Shepherd calibrator and an electronic pulser for exposure rate instruments. Instruments

used for contamination surveys are calibrated with a variety of alpha and beta sources.

Based on the IMPEP evaluation criteria, the review team recommended and the MRB agreed

that Utah’s performance with respect to the indicator, Technical Quality of Inspections, was

satisfactory.

3.4 Technical Quality of Licensing Actions

The review team reviewed the response to the questionnaire, completed licensing casework and

interviewed license reviewers for 27 specific licenses to assess this indicator. Licensing actions

were evaluated for completeness, consistency, proper isotopes and quantities used,

qualifications of authorized users, adequate facilities and equipment, and operating and

emergency procedures sufficient to establish the basis for licensing actions. Licenses were

evaluated for overall technical quality including accuracy, appropriateness of the license, its
Utah Final Report Page 6

conditions, and tie-down conditions. Casework was evaluated for timeliness, adherence to good

health physics practices, reference to appropriate regulations, documentation of safety

evaluation reports, product certifications or other supporting documentation, consideration of

enforcement history on renewals, pre-licensing visits, peer or supervisory review as indicated,

and proper signature authority. The files were checked for retention of necessary documents

and supporting data.

The licensing actions reviewed included the following types of licenses: academic/medical broad

scope; academic broad scope; pool irradiator; industrial radiography; large medical; small

medical; research and development; manufacturing & distribution, brachytherapy/HDR, storage

only, portable gauge; and fixed gauge. Licensing actions reviewed included two new licenses,

nine amendments, four renewals, four terminations, two bankruptcies, and verified the status of

six formerly terminated sites, which were handed over to the Division by the NRC in 2001. A list

of these licenses with case-specific comments may be found in Appendix D.

The review team found that the SSC logs all licensing actions into the Division’s radioactive

materials database. The SSC then reviews the licensing action and distributes the action to the

appropriate license reviewer, which is automatically assigned by the database. 

The review team noted that the Division developed a new database with significant input by the

Materials Section. This database allows the Division to efficiently assign and track all actions

throughout the cycle of the license action.

The review team noted that each licensing action is thoroughly reviewed using a two phase

process. A second qualified or senior reviewer reviews all actions before they are sent to the

Materials Section Manager. The Materials Section Manager reviews all high priority actions

before they are sent to the Executive Secretary of the Utah Radiation Control Board, or their

designee, for issuance. In addition, complex cases are completed using a team of reviewers,

including the Materials Section Manager, and often include frequent interactions with senior NRC

reviewers. Furthermore, the Materials Section Manager reviews every tenth action and most

complex actions. The Materials Section Manager’s review includes the use of a checklist. The

checklists generally follow the NUREG-1556 series, with the exception of the Volume 9, Medical

Use of Byproduct Material.

The review team found that the licensing actions were thorough, complete, consistent, and of

high quality, with health and safety issues properly addressed. Tie-down conditions are backed

by information contained in the file, and are inspectable. Deficiency letters clearly state

regulatory positions, are used at the proper time, and identify deficiencies in the licensees'

documents. Terminated licensing actions are well documented, showing appropriate transfer

and survey records. License files are complete and well organized. Applicable guidance

documents are complete, well organized, available to reviewers, and appear to be followed. 

Safety and security issues for all uses of radioactive material are being addressed throughout the

licensing process and/or through the use of license conditions, particularly in the safety and

security of portable gauges.

The review team noted that license reviewers also work as inspectors. The review team

identified several occasions when the results of an inspection were used in an effective manner
Utah Final Report Page 7

to improve a license through either a licensing amendment or renewal. Similarly, license

reviewers also mark items for follow-up during routine inspections of those licensees.

The review team found that in 2001, the NRC transferred six files to the Division for follow-up

and eventual closure. The NRC terminated these sites before the State of Utah became an

Agreement State. The Program accepted the challenge to assist the NRC in this extremely

important project. The Division has dedicated sufficient time and resources to ensure the closure

of the files, while continuing to protect radiological health and safety. The review team noted that

these six files should be closed by the end of the year. The status of these may be found in

Appendix D.

Based on the IMPEP evaluation criteria, the review team recommended and the MRB agreed

that Utah’s performance with respect to the indicator, Technical Quality of Licensing Actions, was

satisfactory.

3.5 Response to Incidents and Allegations

In evaluating the effectiveness of the Division’s actions in responding to incidents, the review

team examined the Division’s responses to the questionnaire relative to this indicator, reviewed

the incident reports for Utah in the Nuclear Material Events Database (NMED) against those

contained in the Division files, and evaluated reports and supporting documentation for 13

incidents. A list of the incident casework examined with case-specific comments is included in

Appendix E. The review team also reviewed the Division’s response to 18 allegations involving

radioactive material and the low-level radioactive (LLRW) waste site, including 6 allegations

referred to the Division by the NRC during the review period. 

The incidents selected for review included the following categories: lost/stolen material, leaking

sources, contamination, loss of control, and damaged equipment. The Division has excellent

written guidance for handling of incidents in their “Administrative Policy” manual. When

notification of an incident is received, the appropriate Section Manager and the staff discuss

what level of initial response is appropriate. The review team found that the Division’s response

to incidents was complete and comprehensive. Initial responses were prompt and wellcoordinated, and the level of effort was commensurate with the health and safety significance. 

The Division dispatched inspectors for on-site investigations when appropriate, and took suitable

enforcement and follow-up actions. 

The review team identified 14 reportable incidents in NMED for Utah during the review period. 

The Division reports incidents that require immediate notification to the NRC within 24 hours of

notification, and incidents that require notification to the NRC within 30 days at the end of each

month. It was noted that the Division closes events in NMED as required. Lost and stolen

material (i.e., portable gauges) are also closed out in NMED even if they have not yet been

found. This issue was discussed with Sam Petijohn, the NRC NMED contact, who related that

this is an acceptable practice if all information available to the State has been reported to NMED,

and that the State can always reopen the case if the device is found.

In evaluating the effectiveness of Utah's actions responding to allegations, the review team

examined the Division’s questionnaire responses relative to this indicator. The casework for six

allegations (one radioactive materials allegation and five LLRW waste site allegations) referred
Utah Final Report Page 8

by the NRC was reviewed as well as the case work for an additional twelve materials allegations

reported directly to the State.

After receiving an allegation, the Division evaluates each allegation and determines the proper

level of response. The review of the casework files indicated that the Division took prompt and

appropriate action in response to the concerns raised. All of the allegations reviewed were

appropriately closed and appropriate parties were notified of the actions taken. There were no

performance issues identified from the review of the casework documentation.

The Division has excellent written guidance for handling allegations in their “Administrative

Policy” manual which was revised May 2003. However, from discussions and interviews with

Section Managers and Division staff, it was apparent that one of the Section Managers and

some of the technical staff are not thoroughly familiar with all of the elements of the

Administrative Policy regarding allegations, and in particular the threshold of concerns to be

reported as allegations. Initially, the review team made a recommendation involving providing

additional training in the revised Administrative Policy regarding allegations to all Division

managers and technical staff, and assuring that the policy is fully implemented. In the August

14, 2003 Letter from Craig W. Jones, Acting Director, Division of Radiation Control, response to

the draft report, it was noted that special training involving allegations would be held on

September 9, 2003. At the September 25, 2003 MRB meeting, the Division noted that this

training had taken place, including reviewing the “threshold of concern” for allegations.

The review team noted that the Utah Code Annotated, “Government Records Access and

Management Act (GRAMA),” requires that public documents be made available upon request

with some exceptions. If the Division releases allegation records, the records can be redacted to

protect the privacy of the alleger. The State makes every effort to protect an alleger’s identity,

but it cannot be guaranteed. During the initial contact, the alleger is advised that their anonymity

cannot be guaranteed, particularly if the Division is compelled by court action to divulge the

information. 

Based on the IMPEP evaluation criteria, the review team recommended and the MRB agreed

that Utah’s performance with respect to the indicator, Response to Incidents and Allegations,

was satisfactory.

4.0 NON-COMMON PERFORMANCE INDICATORS

IMPEP identifies four non-common performance indicators to be used in reviewing Agreement

State programs: (1) Legislation and Program Elements Required for Compatibility; (2) Sealed

Source and Device Evaluation Program; (3) Low-Level Radioactive Waste Disposal Program;

and (4) Uranium Recovery Program. Utah’s Agreement currently does not include a uranium

recovery program, and the Sealed Source and Device Evaluation Program was returned to NRC

on June 1, 1996. Accordingly, the review team did not evaluate the second and fourth indicators.

4.1 Legislation and Program Elements Required for Compatibility

4.1.1 Legislation

In addition to their response to the questionnaire, the Division provided the review team with the

opportunity to review copies of legislation that affect the radiation control program. The current
Utah Final Report Page 9

effective statutory authority is contained in the Utah Code Annotated, Title 19, Chapter 3,

Radiation Control Act. The Division implements the radiation control program. A Radiation

Control Board (the Board) is appointed by the Utah Governor and guides development of

Radiation Control Policy and regulations in the State. 

Statutory changes to the Radiation Control Act were made by the 2002 General Session of the

Utah Legislature. In summary, the changes were made to implement an amended Agreement

for uranium recovery regulation; added three members to the Board for a total of 13; expanded

the authority for the Board to make rules; authorized the Board to establish fees for uranium mills

and commercial waste facilities; and other administrative changes. The NRC reviewed the Utah

application for an amendment to its Agreement for uranium milling and 11e.(2) byproduct

material dated January 2, 2003, and provided comments dated June 27, 2003 (ML031810623).

4.1.2 Program Elements Required for Compatibility

The State’s regulations for control of radiation are located in Title R313 of the Utah

Administrative Code, and apply to all ionizing radiation. Utah requires a license for possession

and use of all radioactive material including naturally occurring materials, such as radium, and

accelerator-produced radionuclides. 

The review team examined the State’s administrative rulemaking process and found that the

process takes 120 days after filing a draft administrative rule. Draft administrative rules are sent

to the Board for permission to get public comments and to file the proposed rule. The draft rules

are published in the State Bulletin. After a public comment period, the rule is returned to the

Board for final approval. The State has the authority to issue legally binding requirements (e.g.,

license conditions) in lieu of regulations until compatible regulations become effective. 

The review team evaluated the Division’s responses to the questionnaire, reviewed the status of

regulations required to be adopted by the State under the Commission’s adequacy and

compatibility policy, and verified the adoption of regulations with data obtained from the Office of

State and Tribal Program’s (STP) State Regulation Status Data Sheet. 

Current NRC policy requires that Agreement States adopt certain equivalent regulations or

legally binding requirements no later than three years after they become effective. The review

team found that the Program currently has no overdue NRC amendments. 

The State will need to address the following three regulations in upcoming rulemakings or by

adopting alternate legally binding requirements: 

! “Requirements for Certain Generally Licensed Industrial Devices Containing Byproduct

Material,” 10 CFR Parts 30, 31, and 32 amendments (65 FR 79162) that became

effective February 16, 2001. 

! “Revision of the Skin Dose Limit,” 10 CFR Part 20 amendment (67 FR 16298) that

became effective April 5, 2002.

! “Medical Use of Byproduct Material,” 10 CFR 20, 32, and 35 amendments (67 FR 20249)

that became effective April 24, 2002.
Utah Final Report Page 10

Based on IMPEP evaluation criteria, the review team recommended and the MRB agreed that

Utah’s performance with respect to the indicator, Legislation and Program Elements Required for

Compatibility, was satisfactory.

4.2 Sealed Source and Device (SS&D) Evaluation Program

Effective June 1, 1996, NRC reassumed regulatory authority for sealed source and device

evaluations in Utah, in response to a request from the State to relinquish that authority. No

sealed source or device evaluations have been performed in Utah since that relinquishment. 

Accordingly, the review team did not evaluate this indicator.

4.3 Low-Level Radioactive Waste Disposal Program

Envirocare of Utah, Inc., is a commercial shallow-land Low-Level Radioactive Waste (LLRW)

disposal facility located 80 miles west of Salt Lake City in Tooele County. The State of Utah

LLRW Disposal Program is administered by the Division. Regulatory authority is derived from

the Radiation Control Act of Utah Code Title 19 Chapter 3, and the Radiation Control Rules

promulgated in Utah Administrative Code, R313.

Envirocare is licensed by the Division under license number UT 2300249 which expires on

October 22, 2003, and is currently in timely renewal. The license authorizes Envirocare to

receive, store, possess, and dispose of naturally occurring radioactive materials (NORM) and

LLRW less than Class A. In 1991, the license was amended to permit disposal of mixed waste,

LLRW containing hazardous materials. Subsequently, the license was amended several times to

receive, store, possess, and/or dispose of aqueous liquids and liquid mercury, Class A

containerized waste, and special nuclear materials. The license was also amended to conduct

waste treatment and processing at the site. Currently, in accordance with Utah Code Annotated

19-3-105, Envirocare may not receive Class B or Class C waste without first receiving approval

of the Executive Secretary of the Utah Radiation Control Board, as well as approval from Utah

Governor and the Legislature. Envirocare is required to maintain compliance with all conditions

and schedules stipulated in the Utah Groundwater Discharge Permit, number UGW 450005,

issued by the Executive Secretary of the Utah Water Quality Board. 

The review of the LLRW disposal program was initiated through an early review of background

materials and information relevant to the Division’s LLRW program and related licensing

activities. On May 20, 2003, three team members accompanied the Waste and Environmental

Section (W&E Section) Manager and a W&E Section inspector during a one-day site visit to the

Envirocare facility to discuss inspection activities, and examine facility operations and the overall

site conditions. On June 25, 2003, a team member accompanied the Generator Site Access

Specialist on an inspection of waste shipments and the manifest record evaluation.

The IMPEP assessment of the State’s regulation and practices in administering the Envirocare

facility was based upon the guidance found in NRC’s Management Directive 5.6 for the LLRW

disposal program non-common performance indicator. This indicator has five sub-indicators as

follows: (1) Technical Staffing and Training; (2) Status of LLRW Disposal Inspection Program;

(3) Technical Quality of Inspections; (4) Technical Quality of Licensing Actions; and

(5) Response to Incidents and Allegations. 
Utah Final Report Page 11

To evaluate the above sub-indicators, the team reviewed background materials on the site,

participated in inspector accompaniments, reviewed the Utah response to the questionnaire,

interviewed managers and staff, and reviewed records, as appropriate.

4.3.1 Technical Staffing And Training

The evaluation of this indicator focused on: (1) qualifications of the technical staff and the 

expertise necessary to regulate a LLRW disposal facility; (2) the development and

implementation of a training program for the staff; and (3) staffing trends that could have an

adverse impact on the quality of the program.

The W&E Section consists of a Section Manager and eleven full-time positions in five program

areas; Indoor Radon, Uranium Mills, Waste Isolation Pilot Project (WIPP) Transportation Project,

Generator Site Access, and the Envirocare LLRW site. Staff members include engineers,

hydrogeologists, health physicists, a transportation specialist, and a generator site access

coordinator. The W&E Section is currently fully staffed, and there were only three turnovers

since the last IMPEP (two retirements and one transfer). Five new professionals have been

added to the W&E Section as follows: a Program Coordinator; a transportation

specialist/inspector; a Hydrologist; a Health Physicist/Environmental Scientist; and an Engineer

for the "Generator Site Access" program. The review team determined that there was a good

balance of technical expertise in the program, and that staff turnover had no adverse impact on

the program. 

An assessment was performed of the staff’s education and experience against the "NRC/OAS

Training Working Group Recommendations for Agreement State Training" and "Suggested State

Requirements and Criteria for a Low-Level Radioactive Waste Disposal Site Regulatory

Program." The team examined individual W&E Section staff training documentation and

conducted interviews with all available staff to assess qualification and training needs. The

Division has a generic training plan that specifies required and recommended training for each

technical position. Individual Training Qualification Forms are maintained for each person. The

initial review of the individual Training Qualification Forms showed that the forms had not been

maintained up to date. 

Following the onsite review, the team requested and received copies of the updated Training 

Qualification Forms. The review team noted ambiguity between the position designations listed in

the questionnaire, the positions listed above, the Training Qualification Forms, and the

information posted on the Utah web site. The review team also noted that the qualifications of

one LLRW inspector were unclear. Following the September 25, 2003 MRB meeting, the review

team leader and the IMPEP project manager contacted Division management to discuss the

ambiguity in the position designations and to clarify the LLRW inspector’s qualifications. During

the call, Division management noted the ambiguity between the position designations and

confirmed that the LLRW inspector has sufficient experience to be qualified for his position. 

Based on the updated forms and Utah’s further clarifications regarding qualifications of staff as

compared with Utah’s required training, the review team acknowledges that the W&E Section

staff have completed their required training based on the job assignments being performed. 

W&E Section staff interviews and the inspector (transportation specialist) accompaniment

showed that the level of knowledge in the health physics and radiation protection areas needs

improvement for selected staff. During the onsite review, the review team discussed the
Utah Final Report Page 12

specialized training planned for all technical staff in the area of health physics instrumentation

(see Section 3.1), as well as, the possibility of utilizing professional organizations, such as the

Health Physics Society, to help accommodate training needs. During the MRB meeting, the

Division reported that weekly training sessions on radiation safety and instrumentation were

being provided to the transportation specialist.

During the MRB meeting, the MRB directed that the recommendation to provide W&E Section

staff recommended training, and update individual Training Qualification Forms be removed

based on the State’s reply that the staff had completed all required training and the forms had

been updated. 

Based on the IMPEP evaluation criteria, Utah’s performance with respect to the sub-indicator,

Technical Staffing and Training, was found satisfactory.

4.3.2 Status of the Low-Level Radioactive Waste Disposal Inspection Program

The Division has adopted NRC inspection guidance and procedures. The review team examined

inspection files and conducted interviews with inspectors to determine that: (1) the LLRW

disposal licensee is inspected at least annually, as prescribed in NRC IMC 2800; (2) any

deviations from the prescribed inspection schedule are coordinated between working staff and

management; and (3) inspection findings are communicated to licensees in a timely manner, as

specified in NRC IMC 0610-10.

The Division conducted annual inspections at Envirocare from 1998 to 2001, and each annual

inspection included all activities at the site. Due to the complexity of the review and timeliness of

inspection needs, in 2001 the Division improved its inspection program by dividing LLRW site

inspections into multiple modules. Modular inspections are performed throughout the year and

may be varied to accommodate additional licensing activities. The modules include, but are not

limited to, radiation safety, engineering, groundwater, and environmental monitoring. The review

team verified that this modular inspection approach is complete and meets the minimum annual

inspection frequency for a LLRW facility. In addition, the Division has conducted inspections of

waste shipments at the Envirocare facility daily, or as needed. 

Modular inspections, as compared to annual inspections, enable the Division to utilize the

technical staff more efficiently, provide for more timely inspections, and provide better oversight

of the waste facility operations and performance. The team commends the Division for adopting

a modular approach for inspection of the Envirocare LLRW facility, and recommends to the MRB

that this be considered as a good practice.

The mixed waste cell is inspected as part of the overall safety program and the radiological

safety aspects of the cell have been evaluated as part of the routine inspections. The review

team, the Division Director, and the W&E Section Manager discussed, and agreed to the

development of an independent mixed waste module to address unique radiation safety issues at

the mixed waste operations facility. 

The review team determined that inspection findings were being communicated to the licensee

within a 30-day period. 
Utah Final Report Page 13

Based on IMPEP evaluation criteria, the review team recommended and the MRB agreed that

Utah’s performance with respect to the sub-indicator, Status of Low-Level Radioactive Waste

Disposal Inspection Program, was satisfactory.

4.3.3 Technical Quality of Inspections

The review team assessed the quality of LLRW disposal inspections by evaluating: (1) an

accompaniment of a transportation specialist; (2) inspection field notes and completed reports (3)

inspection procedures; (4) follow up on previous inspection findings; (5) appropriate and prompt

regulatory actions; and (6) annual supervisory accompaniments. 

The team determined from a review of the inspection files sampled, that inspections were

complete, the findings well-founded, appropriately documented, and reviewed by supervisors.

The procedures for modular inspections have been established and used to help identify root

causes and poor licensee performance. The W&E Section Manager reviews the inspection

findings and periodically issues enforcement letters, penalties, or a notice of violation, as

necessary. The findings and observations are maintained in a detailed inspection log. Field

notes reflect findings during ongoing operations. All open items from the previous inspection

files were either closed out or scheduled for follow-up action during the next modular inspection. 

In addition, the State keeps a database regarding the Envirocare compliance history including

violations. This database is a valuable tool for assessing and monitoring the LLRW disposal

operations and performance. There were no performance issues identified in the inspections

that were sampled.

Some of the inspection report documentation were missing or misplaced in the files. Division

management believe that in some cases documents were lost or misplaced when copies were

requested by a member of the public. In these cases, files were allowed to be copied at an

outside location, not under the control of the Division. The team discussed the need to manage

the control, access, and filing of the records to improve efficiency and eliminate potential losses

due to mishandling of files. The team and Division management also discussed the need for an

electronic filing system to enhance the maintenance of the record keeping system. 

The transportation specialist for the "Generator Site Access" program was accompanied on June

25, 2003. During the accompaniment the specialist demonstrated appropriate inspection skills,

knowledge of the regulations, and is regarded as an expert on U. S. Department of

Transportation (DOT) regulations as related to waste transportation and manifest issues. 

However, the team noted that the specialist would benefit from additional training in health

physics instrumentation as described in Section 3.1 and Section 4.3.1.

Supervisory accompaniments have been conducted only twice in 2002. The records did not

show supervisory accompaniments for 1999, 2000, 2001, and 2003. Staff interviews also

confirmed that supervisory accompaniments are rare. The team concluded that

accompaniments of inspectors by their supervisors are rare and performed non-systematically. 

The review team recommends that LLRW inspectors receive annual supervisory

accompaniments in a systematic fashion, and that accompaniments be appropriately

documented.
Utah Final Report Page 14

Based on IMPEP evaluation criteria, the review team recommended and the MRB agreed that

Utah’s performance with respect to the sub-indicator, Technical Quality of Inspections, was

satisfactory with recommendations for improvement.

4.3.4 Technical Quality of Licensing Actions

Division staff have been engaged in several significant LLRW disposal licensing issues. 

Envirocare is continuously modifying and optimizing its operations to enhance safety aspects

and to remain competitive. The Envirocare license has been amended 16 times since the

previous IMPEP. The major licensing actions were reviewed, and were determined to be

generally thorough, complete, consistent, and of acceptable technical quality. The license

conditions are clear and inspectable, health and safety issues were properly addressed, and the

licensing process appears to be thorough and consistent. 

The Division has the ability to utilize independent analyses and public hearings in the license

review process. The Division hired a technical consultant to address certain complex technical

issues to verify the licensee’s analysis for a licensing action on an open cell . A public hearing

was also held. This demonstrates that the licensing process is fair, thorough, and consistent. 

The team noted that the surface release limits in Table 27-A of the license were based upon

Regulatory Guide 1.86 criteria, and are inconsistent with current DOT regulations. The Division

has this issue under consideration and is evaluating the table for compatibility.

The team noted that the Division incorporated the Envirocare security plan into the license as a

specific license condition, and makes the licensee more accountable for incoming/outgoing

material at the site. The Division will be in a better position to monitor, inspect, and enforce

safety and security aspects regarding release of contaminated tools, containers, or materials

from the site. The team believes that this emphasis will enhance the site safety and security

aspects. The review team recommends to the MRB that incorporation of the security plan on the

license be considered a good practice. 

The team noted that there are some delays in licensing actions that do not meet the licensee’s

schedule. Based on team interviews with the W&E Section Manager, Envirocare is planning for

numerous processing amendments and new projects that will require a significant level of effort

from W&E Section staff. The review team and Division management discussed the additional

level of effort and resources necessary to cope with the increasing demands for licensing

actions.

Based on IMPEP evaluation criteria, the review team recommended and the MRB agreed that

Utah’s performance with respect to the sub-indicator, Technical Quality of Licensing Actions, was

satisfactory.

4.3.5 Response to Incidents and Allegations

During the review period, the State received and addressed a total of eight allegations involving

Envirocare LLRW activities, including allegations provided directly to the State and those referred

to the Division by the NRC. The LLRW incidents and allegations were reviewed under the

common indicator, Section 3.5. The review of the Division’s allegation files indicates that the

State took prompt and appropriate action in response to the concerns raised. The review team
Utah Final Report Page 15

noted that all documentation related to the investigation of allegations was appropriately

maintained in a separate file, except for one file which was inadvertently placed among the

inspection reports files, which are available to staff and potentially to the public. The

improvement in record keeping was discussed under Section 4.3.3. The team also noted the

lack of generic staff training on the threshold for treating licensee employee’s concerns as

allegations. The review team discussed the sensitivity of handling allegations with all of the

Division managers. As discussed in Section 3.5, the Division updated their Incident and

Allegation procedures in May of 2003, and the team recommended that all Division managers

and technical staff receive training on the changes and implementation of this revised procedure. 

As noted in Section 3.5, special training involving allegations was held on September 9, 2003. 

Based on IMPEP evaluation criteria, the review team recommended and the MRB agreed that

Utah’s performance with respect to the sub-indicator, Response to Incidents and Allegations,

was satisfactory.

4.3.6 Summary

The review team recommends a finding of satisfactory for four sub-indicators and satisfactory

with recommendations for improvement for the sub-indicator, Technical Quality of Inspections. 

The team notes that a recommendation for improvement was made involving inspector

accompaniments, and that good practices were identified in two performance areas. Therefore,

based on IMPEP evaluation criteria, the review team recommended and the MRB agreed that

Utah's overall performance with respect to the indicator, Low-Level Radioactive Waste Disposal

Program, was satisfactory. 

5.0 SUMMARY

As noted in Sections 3 and 4 above, the review team and the MRB found Utah’s performance to

be satisfactory for all performance indicators. Accordingly, the review team recommended and

the MRB concurred in finding the Utah Agreement State program adequate to protect public

health and safety and compatible with NRC's program. Based on the results of the current

IMPEP review, it was agreed that the next full review should be in approximately four years. 

Below is a recommendation, for implementation and evaluation, as appropriate, by the State. 

RECOMMENDATION: 

The review team recommends that LLRW inspectors receive annual supervisory

accompaniments in a systematic fashion, and that accompaniments be appropriately

documented. (Section 4.3.3)

GOOD PRACTICES: 

1. The Division’s custom database management system is programed to provide the staff

with a “pop-up” window, each day upon logging in, that indicates who is working in the

State under reciprocity during the next 7-day period. If there are no licensees working

under reciprocity during that time period, the “pop-up” window indicates this as well. The

system also tracks who had been in the State, when, where, and for how long. The team
Utah Final Report Page 16

recommends that the Division’s system for tracking licensees that are working in the

State under reciprocity be considered a good practice. (Section 3.2)

2. Modular inspections, as compared to annual inspections, enable the Division to utilize the

technical staff more efficiently, provide for more timely inspections, and provide better

oversight of the waste facility operations and performance. The team commends the

Division for adopting a modular approach for inspection of the Envirocare LLRW facility,

and recommends to the MRB that this be considered as a good practice. (Section 4.3.2)

3. The team noted that the Division incorporated the Envirocare security plan into the

license as a specific license condition, and makes the licensee more accountable for

incoming/outgoing material at the site. The Division will be in a better position to monitor,

inspect, and enforce safety and security aspects regarding release of contaminated tools,

containers, or materials from the site. The team believes that this emphasis will enhance

the site safety and security aspects. The review team recommends to the MRB that

incorporation of the security plan on the license be considered a good practice. (Section

4.3.4)
LIST OF APPENDICES AND ATTACHMENTS

Appendix A IMPEP Review Team Members

Appendix B Utah Organization Charts

Appendix C Inspection Casework Reviews

Appendix D License Casework Reviews

Appendix E Incident Casework Reviews

Attachment August 14, 2003 Letter from Craig W. Jones, Acting Director,

Division of Radiation Control
APPENDIX A

IMPEP REVIEW TEAM MEMBERS

Name Area of Responsibility

Richard Woodruff, Region II Team Leader

Technical Staffing and Training

Linda McLean, Region IV Response to Incidents and Allegations

Legislation and Program Elements Required

for Compatibility

Michael Fuller, Region IV Status of Materials Inspection Program

Technical Quality of Inspections

Inspector Accompaniments

Shawn Seeley, Maine Technical Quality of Licensing Actions

Boby Abu-Eid, NMSS/DWM Low-Level Radioactive Waste Disposal Program

Susanne Woods, NMSS/DWM
APPENDIX B

STATE OF UTAH

DEPARTMENT OF ENVIRONMENTAL QUALITY

and

DIVISION OF RADIATION CONTROL

ORGANIZATION CHARTS

ML032050445


ATTACHMENT

August 14, 2003 Letter from Craig W. Jones

Utah’s Response to Draft IMPEP Report

ML032300319
Michael 0. Leavitt 

Governor 

Dianne R. Nielson, Ph.D. 

Executive Director 

William 1. Sinclair 

Executive SecreWry 

Radiation Control Board 

Craig W. Jones 

Acting Director 

Where ideas connect 

Department of Environmental Quality 

Division of Radiation Control 

168Nonh 1950 Wesf 

P.O. Box 144850 

Salt lake City, Utah 841 14-4850 

(801) 536-4250 

(801)533-4097 Fax 

(801) 536-4414 T.D.D. 

www.deq.utah.gov 

August 14,2003 

Richard L. Woodruff 

Regional Agreement State Officer 

U.S. Nuclear Regulatory Commission 

Region I1 

61 Forsyth Street SW Suite 23T85 

Atlanta, Georgia 30303-8931 

Dear Mr. Woodruff: 

This correspondence is in response to the Integrated Materials Performance Evaluation Program (IMPEP) 

Draft Report that documents the results of our review held June 22-27, 2003. The Division of Radiation 

Control Staff has reviewed the draft report and provides the following corrections for your consideration: 

Page 5, paragraph 3, first sentence: Reference is made to the "Division Director." This should be 

changed to "Executive Secretary of the Utah Radiation Control Board." 

Page 6, paragraph 5, line 4: "Director" should be changed to "Secretary." 

Page 8, paragraph 3: In the first line, it is recommended that "Department's Statute" be changed 

to "Utah Code Annotated." For the second sentence, we suggest that it be changed to, "If the 

Division releases allegation records, they can be redacted to protect the privacy of the alleger." 

At the end of the third sentence, please add "particularly if the Division is compelled by court 

action to divulge the information." 

Page 8, paragraph 6, line 4: Delete "Title R313, Environmental Quality, Radiation Control" and 

replace with "Radiation Control Act." 

Page 9, paragraph 2, first sentence: Delete "Title 19, Chapter 3," and replace "Utah Code" with 

"Utah Administrative Code." 

Page 10, paragraph 2, line 2 Change "Toole" to "Tooele." 

Page 10, paragraph 3, line 6: Delete "naturally occurring and accelerator produced material 

(NARM)." 

Page 11, paragraph 3, starting with the fourth sentence we have reprinted the text. Additions are 

shown with an underline and deletions are bracketed and interlined. "A review of this plan shows 

that required training was provided to [feffte] staff. However, several of the W&E Section 

staff have not completed the recommended training for their positions. In particular, those hired 

after the last IMPEP review have not completed [v ] all of the recommended 

traininn. [ .] W&E Section staff interviews and 

the inspeczo showed that the level of knowledge 

in [-I the health physics and radiation protection areas needs improvement for selected 

staff. A review of the individual Qualification Forms shows that the forms have not been 

.. 
maintained up to date. However, the affected forms were updated during the review and current 

forms were made available for review. The review team discussed specialized training planned 

for all technical staff in the area of health physics instrumentation (see Section 3.1), and in 

addition, the possibility of utilizing professional organizations information resources, such as the 

Health Physics Society, to help accommodate training needs. The review team recommends that 

W&E Section staff be provided the recommended training listed in the training plan, and that 

individual Qualification Forms continue to be updated, as appropriate." 

Page 12, paragraph 4, last sentence: Before this statement, insert "The radiological safety aspects 

associated with the mixed waste cell have been evaluated as part of routine inspections. 

However, the Management.. .. After "module" please add, "to address unique radiation safety 

issues at the mixed waste operations facility." 

0 Appendix C, Inspector Accompaniments, Accompaniment No.: 4: Please add "/Generator Site 

Access" after "Waste Disposal." 

0 Appendix D, License Casework Reviews, File No.: 4 Please change "exceeds" to "is less than" 

in the comment. A copy of the affected page from the license and page 1 of the Sealed Source 

and Device Registry Sheet are enclosed. 

We appreciated the thoroughness and open nature of the IMPEP review. The various discussions between 

Division staff and IMPEP team members resulted in a mutual exchange of useful information. The 

performance-based nature of this review was also evident. We understand the recommendations as stated 

in the report. For discussion purposes, the following is offered regarding the recommendations: 

The review team recommends that additional training in the revised Administrative Policy 

regarding allegations be provided to all Division managers and technical staff, and to assure the 

policy is fully implemented. Please be advised that a staff training session has been scheduled 

for September 9,2003. It will be noted, during the training, that the policy is fully implemented. 

The review team recommends that W&E Section staff be provided the training listed in the 

training plan, and that individual Qualification Forms be updated, as appropriate. As noted in our 

proposed revision to Section 4.3.1, the W&E Section staff has all received the required training 

that was outlined in the training plan, but some of the staff has not yet received the recommended 

training. The affected Qualification Forms have all been updated and this occurred while the 

IMPEP review team was on-site. 

Thank you for the opportunity to respond to the draft report. If you have questions regarding any of the 

changes we have suggested, please contact me at (801) 536-4264. 

0 

Sincerely, 

Enclosure: As stated 

cc: Dianne R. Nielson, Executive Director, DEQ