May 23, 2006

Mr. Dennis Burke

Chief of Staff

Policy Office of the Governor

1700 West Washington

Phoenix, AZ 85007 

Dear Mr. Burke:

On May 2, 2006, the Management Review Board (MRB) met to consider the proposed final

Integrated Materials Performance Evaluation Program (IMPEP) report on the Arizona

Agreement State Program. The MRB found the Arizona program to be adequate, but needs

improvement, and compatible with the U.S. Nuclear Regulatory Commission’s (NRC) program.

As noted during the IMPEP review and discussed during the MRB meeting, the Arizona

Radiation Regulatory Agency (the Agency) is facing considerable staffing issues, both present

and future. The Agency has lost a position due to recent budget cuts and is experiencing

difficulty in qualifying and retaining staff. During the review period, two staff members left the

Agency for higher paying jobs shortly after becoming qualified. Currently, there is one health

physicist vacancy in the radioactive materials program. The Agency’s low starting salaries will

make it difficult to recruit and retain individuals with radiation protection experience.

The Agency is also facing knowledge transfer issues. The Agency is currently performing

inspections and licensing actions of high technical quality, as well as responding to incidents

appropriately. However, with several impending retirements, the ability of the Agency to sustain

performance of regulatory actions of high technical quality is threatened. The Agency has

recently hired an inspector, who is in the process of becoming qualified, but the qualification

process will take a considerable amount of time due to the lack of available funds for training. 

The Agency is making commendable efforts to overcome these hardships; however, on-the-job

training involving the inspection of low-risk facilities has caused the Agency to delay performing

inspections of high-risk facilities. The existing vacancy is also a contributing root cause to the

number of overdue high-risk inspections. The review team found the Agency’s performance

with respect to the timeliness of inspections unsatisfactory.

The MRB expressed concern that without adequate staffing levels and proper knowledge

transfer the Agency will continue to get further behind in inspections and, over time, the quality

of inspections will decline. The MRB believes that adequate funding and support is essential to

maintenance of a healthy program, which can ensure that staffing levels are appropriate to

guarantee inspections of radioactive material licensees are completed in a timely manner and

that the existing backlog be diminished. Adequate funding will also ensure that new staff will be

trained and qualified in a reasonable time frame and that high quality staff will be attracted and

retained.
At this time, the NRC is not questioning the State’s ability to adequately protect public health

and safety. As noted earlier, the inspections that are performed are of high quality. However,

given further staff attrition, this picture may change in the future. If the existing issues 

D. Burke - 2 - May 23, 2006

mentioned above continue to go unresolved or the status of the program declines, additional

action on the part of the NRC may be necessary to ensure continued protection of public health

and safety. Additional actions can include placing the State on Heightened Oversight, placing

the State on Probation, or temporarily suspending the Agreement until the NRC believes that

the State can adequately protect public health and safety. As a result of the findings of this

review, the NRC will conduct a periodic meeting with the State approximately one year from the

date of the review to assess the State’s progress in addressing the identified issues.

Section 5.0, page 15, of the enclosed final report contains a summary of the IMPEP team’s

findings and recommendations for the State. A letter dated April 10, 2006, from Aubrey

Godwin, Director of the Agency, adequately discusses the State’s action plan for resolving the

recommendations in the report. No further response is requested at this time. The State’s

actions in response to the recommendations will be evaluated during the periodic meeting. The

State’s progress in addressing the recommendations, as well as the overall performance of the

program, will determine the timing for the next full IMPEP review.

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

also wish to acknowledge the continued support for the Agreement State 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.

If you have any questions regarding this correspondence, please contact Janet R. Schlueter,

Director, Office of State and Tribal Programs, at (301) 415-3340.

Sincerely,

/RA/

Martin J. Virgilio

Deputy Executive Director for Materials, Research, 

 State and Compliance Programs

Office of the Executive Director for Operations

Enclosure:

As stated

cc: Aubrey V. Godwin, Director

Arizona Radiation Regulatory Agency

William A. Wright, Program Manager

Radioactive Materials and

 Nonionizing Compliance

Edgar D. Bailey, California
Organization of Agreement States 

 Liaison to the MRB
D. Burke - 2 - May 23, 2006

mentioned above continue to go unresolved or the status of the program declines, additional

action on the part of the NRC may be necessary to ensure continued protection of public health

and safety. Additional actions can include placing the State on Heightened Oversight, placing

the State on Probation, or temporarily suspending the Agreement until the NRC believes that

the State can adequately protect public health and safety. As a result of the findings of this

review, the NRC will conduct a periodic meeting with the State approximately one year from the

date of the review to assess the State’s progress in addressing the identified issues.

Section 5.0, page 15, of the enclosed final report contains a summary of the IMPEP team’s

findings and recommendations for the State. A letter dated April 10, 2006, from Aubrey

Godwin, Director of the Agency, adequately discusses the State’s action plan for resolving the

recommendations in the report. No further response is requested at this time. The State’s

actions in response to the recommendations will be evaluated during the periodic meeting. The

State’s progress in addressing the recommendations, as well as the overall performance of the

program, will determine the timing for the next full IMPEP review.

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

also wish to acknowledge the continued support for the Agreement State 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.

If you have any questions regarding this correspondence, please contact Janet R. Schlueter,

Director, Office of State and Tribal Programs, at (301) 415-3340.

Sincerely,

/RA/

Martin J. Virgilio

Deputy Executive Director for Materials, Research, 

 State and Compliance Programs

Office of the Executive Director for Operations

Enclosure:

As stated

cc: Aubrey V. Godwin, Director

Arizona Radiation Regulatory Agency

William A. Wright, Program Manager

Radioactive Materials and

 Nonionizing Compliance

Edgar D. Bailey, California

Organization of Agreement States 

 Liaison to the MRB

Distribution: See next page.

DOCUMENT NAME:E:\Filenet\ML061360136.wpd

To receive a copy of this document, indicate in the box: "C" = Copy without attachment/enclosure "E" = Copy with attachment/enclosure "N" = No copy

OFFICE STP STP:DD STP:D DEDMRS

NAME ATMcCraw:kk DKRathbun JRSchlueter MJVirgilio

DATE 5/10/06 5/10/06 5/11/06 5/23/06
ML061360133 Pkg. OFFICIAL RECORD COPY

D. Burke - 3 - May 23, 2006

Distribution: DCD (SP01)

DIR RF

EDO RF

OSiurano, STP KCyr, OGC Chairman Diaz

JTobin, STP JGray, OGC Commissioner McGaffigan

SMinnick, RI JStrosnider, NMSS Commissioner Merrifield

VCampbell, RIV FCameron, OGC Commissioner Jaczko

AJones, STP TCombs, OCA (2 copies) Commissioner Lyons

ATull, NMSS DSollenberger, STP

JMullauer, RIII STreby, OGC

MStephens, FL

RStruckmeyer, NMSS/IMNS SUNSI Review Complete

CMiller, NMSS/IMNS : Publicly Available G Non-Publicly Available

MErnstes, OEDO : Non-Sensitive G Sensitive
INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM

REVIEW OF ARIZONA AGREEMENT STATE PROGRAM

February 6-10, 2006

FINAL REPORT

U.S. Nuclear Regulatory Commission

ENCLOSURE
Arizona Final Report Page 1

1.0 INTRODUCTION

This report presents the results of the review of the Arizona Agreement State Program. The

review was conducted during the period of February 6-10, 2006, by a review team comprised of

technical staff members from the Nuclear Regulatory Commission (NRC) and the State of

Florida. 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 Final General Statement of Policy,” published in the Federal

Register on October 16, 1997, and the February 26, 2004, NRC Management Directive 5.6,

"Integrated Materials Performance Evaluation Program (IMPEP)." Preliminary results of the

review, which covered the period of March 1, 2002 - February 10, 2006, were discussed with

Arizona management on the last day of the review.

A draft of this report was issued to Arizona for factual comment on March 8, 2006. The State

responded by letter on April 10, 2006, from Aubrey Godwin, Director, Arizona Radiation

Regulatory Agency (the Agency). The Management Review Board (MRB) met on May 2, 2006,

to consider the proposed final report. The MRB found the Arizona Agreement State Program

adequate, but needs improvement, and compatible with NRC's program. The MRB directed

that a periodic meeting with the State take place approximately one year from the date of the

review in order to assess the State’s performance and establish a date for the next full IMPEP

review.

The Arizona Agreement State Program is administered by the Agency. The Director of the

Agency reports directly to the Governor. The day-to-day operations of the Arizona Agreement

State Program are managed by the Radioactive Materials & Nonionizing Radiation Compliance

Program (the Program). The Program Manager spends approximately one-half of his time on

the radioactive materials program. An organization chart for the Agency is included as

Appendix B. At the time of the review, the Arizona Agreement State Program regulated 330

specific licenses authorizing Agreement materials. 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 Arizona.

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

performance indicators was sent to the Agency on December 1, 2005. The Agency provided its

response to the questionnaire on January 23, 2006. A copy of the questionnaire response may

be found on the NRC’s Agencywide Documents Access and Management System (ADAMS)

using the accession numbers ML060240432, ML060240429 and ML060240467.

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

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

regulations; (3) analysis of quantitative information from the Agency’s licensing and inspection 

database; (4) technical review of selected files; (5) field accompaniments of two Arizona

inspectors; and (6) interviews with staff and management to answer questions or clarify issues. 

The review team evaluated the information gathered against the IMPEP performance criteria for

each common and applicable non-common indicator and made a preliminary assessment of the

radiation control Agency’s performance.

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

following the previous review. Results of the current review for the IMPEP common
Arizona Final Report Page 2

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 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 March 1, 2002, six recommendations

were made and transmitted to Aubrey Godwin, Agency Director, on March 29, 2002. The

team’s review of the current status of these recommendations is as follows:

1. The review team recommends that the Agency review all Arizona licenses to ascertain if

they require financial assurance, and take appropriate action on each affected license to

ensure that all licenses meet the State’s financial assurance requirements. (Section 3.4

of the 2002 report)

Current Status: The Agency has completed a review of most of their licenses and made

the appropriate changes to ensure licenses meet the State’s financial assurance

requirements. The Agency has not completed this review for six of their radiography

licenses. This recommendation remains open.

2. The team recommends that the Agency reexamine their procedure for handling

allegations, consider the key elements of procedures outlined in NRC’s Management

Directive 8.8, and incorporate the elements that are appropriate for their program.

(Section 3.5 of the 2002 report)

Current Status: The Agency has prepared and implemented a procedure, effective

February 6, 2005, for handling allegations. The procedure specifically references the

guidance outlined in NRC’s Management Directive 8.8. This recommendation is closed.

3. The team recommends that the Agency submit legally binding requirements to NRC for

review. (Section 4.1.2 of the 2002 report)

Current Status: The Agency has submitted all applicable legally binding requirements to

the NRC for review that are being used in lieu of adopting of NRC regulations. This

recommendation is closed.

4. The team recommends that the Agency review its procedures to improve the timeliness

in incorporating new rule changes into their regulatory program, including immediately

addressing the reporting requirements for generally licensed device distributors which

was due by August 16, 2001. (Section 4.1.2 of the 2002 report)

Current Status: All required NRC amendments have been incorporated into the

Agency’s regulatory program. The proposed regulations for the requirements for

generally licensed device distributors were submitted to the NRC for review. The NRC

had no comments. The final regulations will be submitted when the Agency’s

rulemaking process is completed. The timeliness of regulation submittals has greatly

improved since the last IMPEP review; however, proposed regulations are still routinely
Arizona Final Report Page 3

being submitted late. Although the corrective actions for part of this recommendation

have not been completed, for clarity, the team is closing this recommendation and

incorporating the objective, timely submission of rule changes, into a new

recommendation. See Section 4.1.2 for further discussion. This recommendation is

closed.

5. The review team recommends that the Agency make corrections to the Sealed Source

and Device (SS&D) registration certificates Nos. AZ-244-D-101-S and AZ-244-D-102-S.

(Section 4.2.1 of the 2002 report)

Current Status: The Agency has made corrections to the SS&D registration certificates

for both devices. New registration certificates were issued. This recommendation is

closed.

6. The review team recommends that the Agency establish qualification requirements for

SS&D reviewers and develop a formalized, written training program. (Section 4.2.2 of

the 2002 report).

Current Status: The Agency has established written qualification and training

requirements for SS&D reviewers. They have sent two staff to the September 2003

SS&D workshop. 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 include: (1) Technical Staffing and

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

(4) Technical Quality of Licensing Actions, and (5) Technical Quality of Incident and Allegation

Activities. 

3.1 Technical Staffing and Training

Issues central to the evaluation of this indicator include the Agency’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 Agency’s questionnaire response relative to this

indicator; interviewed Agency management and staff; and reviewed job descriptions, training

plans, and training records. The review team also considered any possible workload backlogs

in evaluating this indicator.

The Program is authorized for four Health Physicist positions, and one-half of the Program

Manager’s effort. In addition, the Agency Director also provides managerial support to the

Program. The Agency receives approximately 60 percent funding from the State’s General

Fund and approximately 40 percent from collecting fees. The last fee change was in 1993 and

is based upon 1987 costs. For the past three years, one vacancy has not been filled due to

budget cuts. This position is contained within the Governor’s budget for 2007. Approval will be

determined in May 2006. If approved, the Program will have the funding to fill the Health

Physicist vacancy in July 2006.
Arizona Final Report Page 4

Currently, the licensing and inspection functions are supported by two materials inspectors and

one materials licensing specialist. The materials licensing specialist also has lead responsibility

for rulemaking development. Two of the staff are fully qualified to perform regulatory actions

independently: one is an experienced inspector and the other is an experienced licensing

specialist. The other inspector, previously from the Agency’s X-ray program, is working toward

qualification. Licensing support and the SS&D Program are augmented by the Program

Manager and Agency Director. The Program Manager reviews all licensing actions and the

Agency Director signs all licenses.

At the time of the on-site review, there were significant backlogs in the inspection program (see

Section 3.2) and no backlogs in licensing actions. The team noted that the Agency has certain

licensing restrictions placed on the Agency by law. Section 41-1073, Article 7.1, Chapter 6,

Title 41 of the Arizona Revised Statutes requires Agencies to adopt a timeframe for each type

of license/amendment approval. The "overall timeframe" consists of the "administrative

completeness review timeframe" and the "substantive review timeframe." Section 41-1077

states that failure of the Agency to meet the overall timeframe results in the Agency: (1) to

refund the application fee; and (2) in cases where a substantive review was not required, the

Agency shall pay a penalty to the State General Fund after the overall timeframe for review was

exceeded, equal to one percent each month of the total fees received by the Agency for the

licensing action until the agency issues written notice to the applicant granting or denying the

license.

Program staff are required to have a Bachelor’s degree in science or equivalent experience for

a State Health Physicist entry position, and a Master’s degree and/or additional radiationrelated work experience for positions beyond entry level. The Program has been able to recruit

and train staff, however, two individuals resigned for higher paying jobs shortly after

qualification during the review period.

The Program has a documented training plan that is consistent with the requirements in the

NRC’s Inspection Manual Chapter (MC) 1246. The Program also has on-the-job training to

supplement the course work so that individuals may broaden their work areas. A new hire is

expected to complete certain necessary courses, which are designated as “core” courses, or

their equivalent, to be fully qualified according to the Program’s training guidelines.

In the past, the Program staff has received “core” course training by attending NRC-sponsored

training. The NRC training combined with on-the-job training allowed new personnel to be fully 

qualified within approximately two years. The Program does not have a budget specifically for

training. The only money available to the Program for training has been through the Department

of Justice (DOJ). The Program has sent staff members to the five-week Oak Ridge Institute of

Science and Education Health Physics course, paid for by DOJ. With Arizona’s current budget,

it is very unlikely that the newly hired inspector will be fully trained within a two-year period.

The review team discussed with Agency management, their concerns about the effect of an

aging workforce. It is expected that all but one staff member will be retired within the next five

years. In light of the budget restraints and the loss of qualified staff to both retirement and

higher paying jobs, the Program is experiencing difficulty in maintaining a qualified staff. 

Immediate funding of the vacant Health Physicist position is essential to the transfer of Program

knowledge and on-the-job training. The review team recommends that the Agency develop and
Arizona Final Report Page 5

implement a staffing plan to fill the current vacancy, meet growing Program needs and maintain

long-term stability.

The Radiation Hearing Board of the State of Arizona, as constituted under law, avoids conflicts

of interest, as required under Arizona Revised Statutes §38-511.

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

that Arizona’s performance with respect to the indicator, Technical Staffing and Training, was

satisfactory but needs improvement.

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 licenses, timely dispatch of inspection findings to licensees,

and the performance of reciprocity inspections. The review team’s evaluation is based on the

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

Agency’s licensing and inspection database, the examination of completed inspection

casework, and interviews with staff.

The review team’s evaluation of the Agency inspection priorities revealed that inspection

frequencies for each type of license were the same as those listed in MC 2800; however, 

Agency management has set inspection goals that are more frequent, such as conduct of initial

inspections of new licensees within six months of license issuance.

The Agency maintains licensee inspection information in a Microsoft Access database. 

Inspection history for each licensee can be viewed on the “inspection data entry” screen that

links to the database. In response to the questionnaire, the Agency used the database to

provide a report, containing a list of licensees sorted by priority, that identified the date of the

last inspection conducted and the due date of the next inspection.

The review team compared the data in the report with the “inspection data entry” screen for 89

licensees and identified numerous inconsistencies. The team manually reviewed all of the

licensees’ inspection files in order to resolve these inconsistencies. The team also confirmed

the accuracy of other inspection data by reviewing a sampling of additional inspection files. The

team discovered that the inspection information in the “inspection data entry” screen was

accurate.

In total, the team evaluated 125 inspections that were due during the review period. The review

team identified 5 initial and 18 Priority 1, 2 and 3 (core) inspections that were completed

overdue as well as 14 initial inspections and 2 routine core inspections that are currently

overdue. Based on this data, the review team determined that 31 percent of the core

inspections sampled were either completed overdue or were overdue at the time of the review.

The Agency received requests for reciprocity from 173 licensees over the review period, of

which 58 were core licensees. The review team determined that the Agency conducted

reciprocity inspections of 17 percent of the core licensees in calendar years 2002 and 2005, but

conducted no reciprocity inspections of core licensees in 2003 and 2004. The Agency did not

meet the 20 percent criterion prescribed in MC 1220 for inspection of licensees operating under

reciprocity.
Arizona Final Report Page 6

The review team discussed the significant number of overdue core inspections, core

inspections completed overdue, and inspection of reciprocity licensees with the Program

Manager and the Agency Director. Several reasons for the inspection delays were identified by

Agency management. The Agency has had two inspectors retire and was budgeted to only fill

one of the resulting vacancies. Since March 2003, the Agency has filled the one budgeted

inspector position with three different staff. Two of the staff were trained by the senior inspector

and subsequently left the program for higher paying jobs after becoming fully-qualified. The

newest staff member is currently being trained by the senior inspector. As a result, staff had to

focus on inspecting the lower priority licenses for training purposes. In addition, the Agency did

not have an active inspection program during a six-month period in 2003 and 2004 when the

senior inspector was unable to conduct inspections.

The review team concluded that one of the root causes for the inspection delays is directly 

related to insufficient staffing during the review period (as discussed in Section 3.1). Another

contributing root cause is that the Program database is not an adequate tool for management

to assess the status of the Program because the reports generated cannot be relied upon for

accuracy. The review team recommends that the Agency take appropriate measures to

conduct core inspections (including initial inspections) in accordance with the inspection priority

schedule in MC 2800, and conduct reciprocity inspections in accordance with MC 1220.

Title 41, Chapter 6, Article 1, Section 41-1009 of the Arizona Revised Statutes requires, in part,

that when an agency conducts an inspection, they must provide a copy of the inspection report

to the licensee within 30 working days after the inspection. The review team evaluated the

timeliness of issuance of inspection reports. In all cases except one, the preliminary findings of

inspection reports were sent to the licensees within 30 days, and generally within 2-5 calendar

days, of the inspection date.

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

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

Program, was unsatisfactory.

3.3 Technical Quality of Inspections

The review team evaluated the inspection reports, enforcement documentation, and interviewed

inspectors for 13 radioactive materials inspections conducted during the review period. The

casework included work performed by six of the Agency’s radioactive materials inspectors, and

covered a variety of license types including: academic broad; medical (broad scope, private

practice, and institutional); high dose remote afterloader; manual brachytherapy; nuclear

pharmacy; industrial radiography; manufacturing and distribution (broadscope and limited); and

service provider. Appendix C lists the inspection casework reviewed, as well as the results of

the inspection accompaniments.

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

aspects of the licensees’ radiation programs. The review team found that inspectors reviewed

previous open items and past violations during the inspections. Inspection reports were

generally very thorough, complete, consistent, and of high quality, with sufficient documentation

to ensure that a licensee’s performance with respect to health and safety was acceptable. The

documentation supported violations, recommendations made to the licensee, unresolved safety

issues, and discussions held with the licensee during exit interviews. Team inspections were
Arizona Final Report Page 7

frequently performed for larger and complex licensees and for training purposes. Based on the

casework evaluated, the review team found very detailed documentation of the inspector’s

observations, interviews of personnel, and performance of independent and/or confirmatory

measurements. The review team noted that a ‘notice of inspection’ signed by the licensee was

maintained in each inspection file reviewed. This notice of inspection is required by State

statute to be provided to the licensee at each inspection and outlines the rights of the licensee

with regard to being inspected. By Arizona law, failure to provide this document constitutes

cause for disciplinary action or dismissal of the inspector. In addition, the Agency cannot use

any information collected during this inspection in any administrative or civil proceeding with the

exception of criminal or major civil actions.

The inspection findings were appropriate and prompt regulatory actions were taken, as

necessary. The Agency issues a ‘preliminary findings of inspection’ report, if potential violations

are identified during an inspection. The Agency identifies proposed violations and any items of

concern to the licensee in this report. The items of concern are not violations of any regulatory

requirement, but have safety concerns which may lead to a violation if licensee management

does not take an appropriate action. The licensee is required to respond to the preliminary

findings within 30 days. If the violations are accepted, a notice of violation is then issued with

the appropriate sanctions. In addition, the Agency has the ability to impose a civil penalty when

it is deemed that the licensee has had a significant breakdown in operations that affect overall

health and safety. All inspection findings are clearly stated and documented in the report which

is reviewed by the Program Manager and the Agency Director. The Agency Director signs all

final inspection actions.

The review team noted the exceptional detail in the documentation supporting inspection

findings during the casework review. Program management informed the team of the

requirements of Title 12, Chapter 3, Article 5 of the Arizona Revised Statutes. If a licensee

challenges an Agency escalated enforcement action in court and prevails by an adjudication on

merits, the Agency may be required to pay any costs prescribed by statute and pay for the

licensee’s expenses for attorneys, expert witnesses, the cost of any study, analysis,

engineering report, test, or project which the court finds directly related to the licensee’s

defense. Agency management stated that as a result of their limited budget they cannot afford

to pursue an escalated action against a licensee unless the Agency has adequate documented

evidence to support the violations and reasonable assurance that they will prevail in a court

case.

The Agency has an adequate number and types of survey meters to support the current

inspection program as well as for responding to incidents and emergency conditions. The

Agency has a contractor calibrate their survey instruments on an annual basis. Appropriate,

calibrated survey instruments such as GM meters, scintillation detectors, ion chambers and

micro-R meters were observed. Air monitoring equipment is also available for emergency use. 

Contamination wipes are evaluated at the Agency on-site laboratory. The Agency also

maintains a mobile laboratory van for use in emergencies and emergency exercises. 

During the review period, the Program Manager performed inspector accompaniments with

each of the inspection staff with the exception of the senior inspector in one calendar year due

to unusual circumstances. The review team concluded that the Agency actions in this area

were acceptable.
Arizona Final Report Page 8

The review team accompanied two materials inspectors (one fully qualified and one in training)

on February 2 and 3, 2006. The accompaniments included inspections of an industrial

radiography home office and a portable gauge. The facilities inspected are identified in

Appendix C. During the accompaniments, each inspector demonstrated appropriate

performance-based inspection techniques and knowledge of the regulations. The inspectors

were properly trained, well prepared for the inspection, and thorough in their audits of the

licensees’ radiation safety programs. Each inspector conducted confirmatory measurements

and utilized good health physics practices. Interviews with licensee personnel were performed

in an effective manner, and the inspections were adequate to assess radiological health and

safety at the licensed facilities.

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

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

satisfactory.

3.4 Technical Quality of Licensing Actions

The review team examined completed licensing casework and interviewed Program staff for

17 specific licenses. Licensing actions were evaluated for completeness, consistency, proper

isotopes, 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, license 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

documents; consideration of enforcement history on renewals, peer or supervisory review as

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

documents and supporting data. The licensing process was also evaluated for tracking of

licensing actions, program codes and categories of license types.

Licensing casework was selected to provide a representative sample of licensing actions that

were completed during the review period. The sampling included the following types of

licenses: research and development, industrial radiography, medical (institution, private

practice, and broad scope), portable gauge and nuclear pharmacy. Licensing actions selected

for evaluation included one new license, three renewals, ten amendments, two terminations and

one administrative change initiated by the Program. A list of the licenses evaluated with casespecific comments can be found in Appendix D.

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

acceptable quality with health and safety issues properly addressed. License tie-down

conditions were stated clearly, backed by information contained in the file, and inspectible. The

licensee's compliance history was taken into account when reviewing renewal applications and

amendments. The materials licensing specialist appropriately used the Agency’s licensing

guides and standard license conditions.

A recommendation was made during the 2002 IMPEP review (Recommendation 1, Section

2.0). In 2002, the review team recommended that the Agency review all Arizona licenses to

ascertain if they require financial assurance and take appropriate action on each affected

license to ensure that all licenses meet the State’s financial assurance requirements. The
Arizona Final Report Page 9

Program has completed a review of most of their licenses and made the appropriate changes to

ensure licenses meet the State’s financial assurance requirements. Six radiography licenses

remain to be evaluated by the Program with respect to financial assurance. Upon review, some

modifications may need to be made with radiography licenses, and therefore this

recommendation remains open.

All licensing actions are reviewed by one materials license specialist who closely monitors the

timeliness of licensing actions. All completed licensing actions are then reviewed by the

Program Manager. The Agency Director conducts a secondary management review on

selected actions and signs all licensing documents. The team noted that Section 41-1073,

Article 7.1, Chapter 6, Title 41 of the Arizona Revised Statutes requires Agencies to adopt a

timeframe for each type of license/amendment approval. The "overall timeframe" consists of

"administrative completeness review timeframe" and the "substantive review timeframe." 

Section 41-1077 states that failure of the Agency to meet the overall timeframe results in the

Agency: 1) to refund the application fee; and 2) in cases where a substantive review was not

required, the Agency shall pay a penalty to the State General Fund after the overall timeframe

for review was exceeded equal to one percent each month of the total fees received by the

Agency for the licensing action until the Agency issues written notice to the applicant granting or

denying the license. 

Licensing checklists are not used routinely due to the experience of the Program staff. The

Program does not routinely issue cover letters with completed licensing actions due to time

constraints and workload. However, the Program will issue deficiency letters when it believes a

formal letter is warranted. The team found that terminated licensing actions were adequately

documented. In general, the files included the appropriate material transfer records and survey

records. No health and safety issues were identified.

The review team examined the licensees that the State had determined met the criteria for the

increased controls, as per COMSECY-05-0028. The review team determined that the Program

had correctly identified the Arizona licensees that require increased controls based on this

criteria. Each licensee was issued a license amendment requiring increased controls in

accordance with the timelines established by the Commission in the SRM for COMSECY-05-

0028. The Program has started to plan for the initial set of inspections of these licensees in

accordance with the increased control requirements.

In 1977, the NRC initiated a review of terminated NRC licenses to determine whether sites had

been adequately decontaminated prior to termination and release of the site. As a result of this

effort, a number of sites were identified as lacking proper documentation of termination

activities, including disposition of materials. Some of these NRC formerly licensed sites were

determined to be located in Agreement States and to be the regulatory responsibility of the

State. Five sites were determined to be located in Arizona. The Program was requested to

report the resolution of each case to the NRC for tracking. The team was able to determine

that all five sites have been closed out and the results were provided to the NRC in a letter

dated August 5, 2002, to the Office of State and Tribal Programs (STP).

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

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

was satisfactory.
Arizona Final Report Page 10
Arizona Final Report Page 11

3.5 Technical Quality of Incident and Allegation Activities

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

team examined the Agency’s response to the questionnaire relative to this indicator, evaluated

selected incidents reported for Arizona in the Nuclear Material Events Database (NMED)

against those contained in the Agency’s Radioactive Incident and Event Response files, and

evaluated reports and supporting documentation for 19 material incidents. A list of the incident

casework reviewed is included in Appendix E. The team also reviewed the Agency’s response

to allegations involving radioactive material.

The incidents selected for review included the following categories: defective or failed

equipment, lost/abandoned/stolen gauges, transportation of radioactive material, lost

radioactive material, leaking sources and medical events. The team found the Agency’s

documentation in response to incidents was generally complete and comprehensive. Initial

responses were prompt and well-coordinated, and the level of effort was commensurate with

the health and safety significance. The Agency dispatched inspectors for on-site investigations

when appropriate, and took suitable enforcement and follow-up actions.

Initial response and follow up to incidents and allegations involving radioactive materials are

coordinated with the Program Manager. Separate written procedures exist for handling

incidents and allegations. Interviews and discussions with the Agency staff and the team

confirmed that the staff is knowledgeable of the Agency’s procedures for handling incidents and

allegations. The Agency conducts on-site investigations for all incidents that present an actual

or potential hazard to public health and safety. The Agency Director is advised of all incidents

reported and the planned response prior to dispatching responders to the site. Review of

incident files indicates that this approach provides effective and appropriate response actions

and does not delay the response time. The procedures and report forms are available to the

staff when responding to any incident, accident or emergency involving radioactive materials. 

All records of reported incidents are maintained in a master file and a duplicate copy is

maintained in individual licensee files.

During the review period, the Agency documented 58 radioactive material incidents in their

Radiological Incident Log. All 58 incidents were reported and investigated in accordance with

the Agency’s procedures for responding to incidents. The team identified and independently

reviewed 19 materials incidents that required reporting under the NRC criteria. The review

team identified four events occurring in 2005 that have not been closed out through NMED,

although the review of incident files revealed that inspection and Agency follow-up actions have

been performed and are complete. The four open incidents were discussed with Agency 

management who stated that no further action is anticipated by the State. The team discussed

with Agency Management the procedures for updating and closing incidents with Idaho National

Laboratory (INL), the contractor maintaining NMED. Agency management indicated that INL

will be contacted for closure and completion of the identified incidents. Except as noted above,

the team found that the NMED database accurately reflected the information contained in the

Agency’s incident files. Overall, the team determined that the Agency reported incidents to the

NRC Headquarters Operations Center in a timely manner and appropriate and timely follow-up

actions were performed.

The team did not identify any performance issues with the Agency’s handling of allegations. 

During the review period, the Agency received seven allegations involving radioactive materials;
Arizona Final Report Page 12

five were referred by the NRC and two were received internally by the Agency. The Agency’s

responses to all seven allegations were evaluated by the review team. The review team noted

that the Agency promptly responded with appropriate investigations, follow up, and close out

actions for six of the seven allegations. However, for one of the allegations referred to the

Agency in March 2005, the alleger had not been informed of the results of Agency’s review, as

requested by the alleger and NRC’s Region IV office. The review team determined that the

Agency took adequate actions in response to the concern raised and plans to follow up with a

response to the Alleger.

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

that Arizona’s performance with respect to the indicator, Technical Quality of Incident and

Allegation Activities, was satisfactory.

4.0 NON-COMMON PERFORMANCE INDICATORS

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

State programs: (1) Compatibility Requirements; (2) Sealed Source and Device Evaluation

Program; (3) Low-Level Radioactive Waste Disposal Program; and (4) Uranium Recovery

Program. Arizona's Agreement State program does not cover low-level radioactive waste

disposal or uranium recovery operations, so only the first two non-common performance

indicators were applicable to this review.

4.1 Compatibility Requirements

4.1.1 Legislation

The authority under which the Agency administers the State’s Radiation Control Program is

Title 30, Chapter 4 of the Arizona Revised Statutes, “Control of Ionizing Radiation.” This statute

gives the Agency specific powers and duties among which are authorities to allow the State to

enter into an agreement with the NRC, promulgate regulations, issue licenses, perform

inspections, collect fees, and issue civil penalties. The Arizona Revised Statutes also require

the Agency to review all regulations every five years.

Other statutes that affect the Agency are contained in Title 30, Chapter 5, “Interstate

Cooperation in Atomic Energy Matters,” and Title 41, Chapter 6, “State Government.” These

statutes describe the State’s administrative procedures for rulemaking, adjudicative

proceedings, licensing timeframe, and hearing procedures. There had not been legislation

passed since the last IMPEP review that affected the radiation control program; however,

House Bill 2097 was pending at the time of this review. House Bill 2097, which provides

legislative authority for the radiation control program to continue, has since passed.

4.1.2 Program Elements Required for Compatibility

The Agency’s regulations are contained in the Arizona Administrative Code under Title 12,

Chapter 1, “Radiation Regulatory Agency,” Articles 1 through 17. The Arizona Regulations

pertaining to radiation control apply to all ionizing radiation, whether emitted from radionuclides

or devices. Arizona requires a license for possession and use of all radioactive material

including naturally occurring materials, such as radium. To the extent possible, the Arizona
Arizona Final Report Page 13

regulations follow the Suggested State Regulations of the Conference of Radiation Control

Program Directors, Inc.

The Program has assigned a materials license specialist the responsibility of rulemaking

development, including scheduled maintenance, to assure continued compatibility of State

regulations with those of the NRC. The review team conducted several interviews with the staff

member to determine the effectiveness of the Agency’s regulatory process.

The Agency’s regulations are reviewed each regulation, the Agency must

describe the effectiveness of the regulation and provide the statutory authority under which the

regulation is issued. The Agency must also demonstrate that the regulation is consistent with

other Agency regulations, and that the regulation is clear and understandable. In addition, in

developing regulations, the Agency is to consider the economic impact on small businesses

and consumers.

The State Regulation Status (SRS) data sheet, as maintained by the NRC’s STP, reflects that

the Agency initially adopts some changes to the NRC regulations by incorporating them into

license conditions, then by adopting the NRC regulations through rulemaking. After preparation

of a package of draft regulations and incorporation of comments, the Agency obtains approval

from the Governor’s Regulatory Review Council (the Council). The Council allows opportunity

for members of the public to comment on proposed regulations, and evaluate the 

to scheduling of the Hearing Board and Council. This rulemaking process appears to

be functioning for the Agency; however, no amendments were finalized within the three-year

timeframe for adoption as required by the Commission’s Policy Statement on Adequacy and

Compatibility of Agreement State Programs (Policy Statement).

The review team evaluated the status of the regulations required for adoption by the State

under the Policy Statement. The review team compared the adoption of regulations by the

State with information contained on the State’s SRS data sheet maintained by STP. A spot

check review of the Arizona Administrative Code was also done to verify adoption of previously

issued NRC regulations. The review team did not find any overdue regulations that had not

been submitted as a proposed regulation, license conditions, or other legally binding

requirements.

During the review period, 20 amendments were finalized and submitted to the NRC for review. 

The review team determined that the Agency consolidates several amendments into a

rulemaking package in order to lower the expense of promulgation of its regulations. The

review team recognized the benefits of this practice in managing the cost of rule development;

however, this practice will need to be balanced against timeliness in incorporating new rule

changes to meet NRC compatibility requirements.

The team noted that the following was incorporated by license condition since the last IMPEP:

! “Increased Controls for Risk-Significant Radioactive Sources,” NRC Order EA-05-090

(70 FR 72128) that became effective December 1, 2005.

The following proposed regulations have been submitted to the NRC for review and comment

and were in the rulemaking process at the time of the IMPEP review:
Arizona Final Report Page 14

! “Medical Use of Byproduct Material,” 10 CFR Parts 20, 32, and 35 amendments

(67 FR 16298) that became effective April 5, 2005.

! “Security Requirements for Portable Gauges Containing Byproduct Material,”

10 CFR Part 30 amendment (70 FR 2001) that becomes effective July 11, 2008.

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

became effective April 5, 2005.

! “Requirements for Certain Generally Licensed Industrial Devices Containing Byproduct

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

February 16, 2004.

The review team requested that the Agency submit the final regulations to the NRC using STP

Procedure SA-201 as a guide after the final regulations are published.

A recommendation was made during the 2002 IMPEP review (Recommendation 4, Section 2.0)

that the Agency review its procedures to improve the timeliness in incorporating new rule

changes into their regulatory program, including immediately addressing the reporting

requirements for generally licensed device distributors which was due by August 16, 2001. The

proposed regulations for the requirements for generally licensed device distributors were

submitted to the NRC for review. The NRC had no comments. The final regulations will be

submitted when the Agency’s rulemaking process is completed. In review of the Agency’s

timeliness, the review team found that the Agency has made significant improvements on the

timeliness of submitted regulations to the NRC; however, during the review period, the

Agency’s proposed regulations were approximately one year overdue. The review team

discussed with Agency management the need to continue to improve the timeliness of

regulation submittals so that new rule changes are submitted within the three-year timeframe

allowed. Although the corrective actions for part of this recommendation have not been

completed, for clarity, the review team is closing this recommendation and incorporating the

objective, timely submission of rule changes, into a new recommendation. The review team

recommends that the Agency develop a process that allows for the adoption of NRC regulations

within the three-year timeframe.

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

adopting alternate legally binding requirements by the date indicated for each amendment:

! “Financial Assurance for Materials Licensees,” 10 CFR Parts 30, 40, and 70

amendments (68 FR 57327) that becomes effective December 3, 2006.

! “Compatibility with IAEA Transportation Safety Standards and Other Transportation

Safety,” 10 CFR 71 amendment (69 FR 3697) that becomes effective October 1, 2007.

! “Medical Use of Byproduct Material - Recognition of Speciality Boards,” 10 CFR 35

amendment (70 FR 16336 and 71 FR 1926) that becomes effective April 29, 2008.

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

that Arizona’s performance with respect to the indicator, Compatibility Requirements, was

satisfactory.
Arizona Final Report Page 15

4.2 Sealed Source and Device Evaluation Program

In conducting this review, three sub-indicators were used to evaluate the Program’s

performance regarding the SS&D Evaluation Program. These sub-indicators include: 

(1) Technical Staffing and Training; (2) Technical Quality of the Product Evaluation Program;

and (3) Evaluation of Defects and Incidents Regarding SS&Ds.

In assessing the Program's SS&D evaluation activities, the review team examined information

provided by the Program in response to the IMPEP questionnaire on this indicator. A review of

selected new and amended SS&D evaluations and supporting documents covering the review

period was conducted. The review team noted the staff's use of guidance documents and

procedures, interviewed the staff and the supervisor involved in SS&D evaluations, and verified

the use of regulations, license conditions, and inspections to enforce commitments made in the

applications.

4.2.1 Technical Staffing and Training

The Program Manager and a Health Physicist from the Radiation Measurement Program,

another program within the Agency, are the reviewers qualified to conduct safety evaluations of

SS&D applications. Both of the Agency staff members have academic degrees in engineering

and have completed the NRC workshop for SS&D reviewers. The review team interviewed

these individuals and found that both are familiar with the SS&D evaluation process and are

familiar with and have access to the applicable reference documents. According to Agency

procedures, both of these reviewers are required to conduct the safety evaluation, and the

Program Manager and the Agency Director signs the certificate. The review team determined

that the reviewers meet the technical training required for SS&D reviews as described under the

guidance. The review team determined that the staffing level of qualified reviewers is sufficient

in view of the relatively low number of Arizona licensees who need registration certificates. 

However, the review team discussed with Agency management the upcoming retirement of one

of the SS&D reviewers. The Agency does not have someone who is qualified to conduct safety

reviews in accordance with Agency procedures to replace the current individual upon his

retirement.

4.2.2 Technical Quality of the Product Evaluation Program

The review team evaluated all six SS&D evaluation amendments and new registrations,

representing the work of two SS&D reviewers. The Agency stated that they currently manage

two active SS&D manufacturer/distributors. Four of these sheets superseded sheets issued in

California. The Agency performed a full SS&D review of the four sheets. A list of SS&D

casework examined along with case-specific comments may be found in Appendix F. Analysis

of the casework and interviews with staff confirmed that the Agency generally follows the

recommended guidance from the NRC SS&D training workshops NUREG-1556, Volume 3. All

applicable and pertinent American National Standards Institute standards, NUREG-1556

Series, NRC Regulatory Guides, and applicable references were confirmed to be available and

were used appropriately in performing the SS&D reviews. The Agency uses license conditions

to incorporate SS&D commitments into the license document for them to be legally enforceable. 

The Agency performed evaluations based on sound conservative assumptions to ensure public

health and safety and also sought the input from other licensing jurisdictions that have

experience with similar products. Appropriate review checklists were used to assure that all
Arizona Final Report Page 16

relevant materials were submitted and reviewed. Registrations clearly summarized the product

evaluation and provided license reviewers with adequate information in the Limitations and

Considerations of Use Section on areas requiring additional attention to license the possession,

use, and distribution of the products.

The review team determined that product evaluations were thorough, complete, consistent, and

adequately addressed the integrity of the products during use and in the event of likely

accidents. While the Agency’s staff obtains and documents adequate quality assurance and

quality control programs (QA/QC) for each SS&D registration, the review team determined that

the Agency, during routine inspections, does not determine that these QA/QC programs are

actually implemented by the licensee. The review team recommends that the Agency develop

and implement a process to ensure that during routine inspections the QA/QC requirements in

the SS&D registry sheets are being implemented by the manufacturer.

The review team discussed a few general issues with Program staff. The review team identified

a few SS&D sheets are listed as active but are currently either no longer being

manufactured/distributed or the licensee has gone out of business. While NUREG-1556,

Volume 3, places the burden of inactivating sheets on the registry holder, it does allow the

Agency to inactivate these sheets on their own initiative. The Agency staff indicated that they

were aware of these and plan to begin to inactivate these sheets as appropriate. Completion of

this task may require additional resources.

4.2.3 Evaluation of Defects and Incidents Regarding SS&Ds

No incidents related to SS&D defects were noted by the State of Arizona during the review

period; however, an incident occurred with a Honeywell device. The review team found that

Agency staff addressed the incident issue in a comprehensive manner. Specifically, the staff

responded to the incident and followed up the case with the equipment manufacturer, DuPont

and the Agreement State, Florida. It was determined that the root cause of the incident was the

rupture of the krypton 85 (Kr-85) source, manufactured by DuPont. DuPont no longer

manufactures the Kr-85 sources, and there have been no source issues since then. The

incident was reported to the NRC, and details are included with all other incidents listed in

Appendix E.

The team conducted a search of the NMED system to determine whether other incidents might

have taken place that were not registered by the Agency staff. No incidents were identified that

could have been related to malfunctioning devices or products considered during the review.

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

that the Agency’s performance with respect to the indicator, Sealed Source and Device

Evaluation Program, was satisfactory.

5.0 SUMMARY

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

unsatisfactory for the performance indicator, Status of Materials Inspection Program;

satisfactory but needs improvement for the performance indicator, Technical Staffing and

Training; and satisfactory for the five remaining performance indicators. Accordingly, the

review team recommended and the MRB agreed in finding the Arizona Agreement State
Arizona Final Report Page 17

Program to be adequate, but needs improvement, and compatible with NRC's program. The

review team and the MRB agreed that a periodic meeting with the State should take place

approximately one year from the date of this review. At that time, a recommendation for the

timing of the next full IMPEP review will be made.

Below are the recommendations, as mentioned earlier in the report, for evaluation and

implementation, as appropriate, by the State.

1. The review team recommends that the Agency develop and implement a staffing plan to

fill the current vacancy, meet growing Program needs and maintain long-term stability.

(Section 3.1)

2. The review team recommends that the Agency take appropriate measures to conduct

core inspections (including initial inspections) in accordance with the inspection priority

schedule in MC 2800, and conduct reciprocity inspections in accordance with MC 1220. 

(Section 3.2)

3. The review team recommends that the Agency review all Arizona licenses to ascertain if

they require financial assurance, and take appropriate action on each affected license to

ensure that all licenses meet the State’s financial assurance requirements. (Section 3.4

of the 2002 IMPEP report)

4. The review team recommends that the Agency develop a process that allows for the

adoption of NRC regulations within the three-year timeframe. (Section 4.1.2)

5. The review team recommends that the Agency develop and implement a process to

ensure that during routine inspections the QA/QC requirements in the SS&D registry

sheets are being implemented by the manufacturer. (Section 4.2.2)
LIST OF APPENDICES AND ATTACHMENT

Appendix A IMPEP Review Team Members

Appendix B Arizona Organization Charts

Appendix C Inspection Casework Reviews

Appendix D License Casework Reviews

Appendix E Incident Casework Reviews

Appendix F Sealed Source and Device Casework Reviews

Attachment April 10, 2006 Letter from Aubrey Godwin

Arizona’s Response to Draft IMPEP Report
APPENDIX A

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Sheri Minnick, RI Team Leader

Technical Staffing and Training

Andrea Jones, STP Technical Quality of Incident and Allegation 

Activities

Ashley Tull, NMSS Compatibility Requirements

James Mullauer, RIII Technical Quality of Licensing Actions

Vivian Campbell, RIV Status of Materials Inspection Program

Technical Quality of Inspections

Inspector Accompaniments

Mike Stephens, Florida Sealed Source and Device Evaluation Program
APPENDIX B

ARIZONA ORGANIZATION CHARTS

ADAMS: ML060240429
APPENDIX C

INSPECTION CASEWORK REVIEWS

NOTE: CASEWORK LISTED WITHOUT COMMENT ARE INCLUDED FOR COMPLETENESS

ONLY. NO SIGNIFICANT COMMENTS WERE IDENTIFIED BY THE IMPEP TEAM.

File No.: 1

Licensee: Cardinal Health License No.: 7-516

Inspection Type: Routine, Unannounced Priority: 2

Inspection Date: 7/27/04 Inspectors: LB, GS

File No.: 2

Licensee: St. Luke’s Medical Center License No.: 7-716

Inspection Type: Routine, Unannounced Priority: 2

Inspection Date: 11/16/04 Inspectors: LB, GS

File No.: 3

Licensee: Cardinal Health License No.: 10-84

Inspection Type: Routine, Unannounced Priority: 2

Inspection Date: 9/1/04 Inspectors: LB, GS, JL

File No.: 4

Licensee: Southwestern Radiation Oncology, Ltd. License No.: 10-59

Inspection Type: Routine, Unannounced Priority: 2

Inspection Date: 11/19/02 Inspector: GS

File No.: 5

Licensee: Arizona Oncology Services License No.: 7-161

Inspection Type: Routine, Unannounced Priority: 2

Inspection Dates: 6/23-29/05 Inspectors: GS, PK

File No.: 6

Licensee: Millennium Diversified Medical, Inc. License No.: 2-16

Inspection Type: Routine, Unannounced Priority: 2

Inspection Date: 1/14/03 Inspectors: GS, DK

File No.: 7

Licensee: University Medical Center Corporation License No.: 10-44

Inspection Type: Routine, Unannounced Priority: 2

Inspection Dates: 4/5-8/04 Inspectors: GS, JL, LB, DK

File No.: 8

Licensee: Acuren Inspections, Inc. License No.: 15-89

Inspection Type: Routine, Unannounced Priority: 1

Inspection Dates: 4/21-22/04 Inspectors: LB, DK, GS
Arizona Final Report Page C.2

Inspection Casework Reviews

File No.: 9

Licensee: Team Cooperheat-MQS License No.: 7-493

Inspection Type: Routine, Unannounced Priority: 1

Inspection Date: 8/23/05 Inspector: GS

File No.: 10

Licensee: Cardinal Health License No.: 7-123

Inspection Type: Routine, Unannounced Priority: 2

Inspection Dates: 1/4-5/06 Inspectors: GS, PK, JL

File No.: 11

Licensee: Phoenix National Labs, Inc. License No.: 7-415

Inspection Type: Routine, Unannounced Priority: 1

Inspection Date: 9/21/05 Inspectors: GS, PK

File No.: 12

Licensee: Honeywell International, Inc. License No.: 7-510

Inspection Type: Routine, Unannounced Priority: 1

Inspection Date: 9/10/03 Inspectors: GS, WY

File No.: 13

Licensee: TLS Systems, Inc. License No.: 10-86

Inspection Type: Routine, Unannounced Priority: 5

Inspection Date: 2/9/05 Inspectors: LB, GS

INSPECTOR ACCOMPANIMENTS

The following inspector accompaniments were performed prior to the on-site IMPEP review:

Accompaniment No.: 1

Licensee: AMEC Earth & Environmental, Inc. License No: 7-369

Inspection Type: Routine, Unannounced Priority: 1

Inspection Date: 2/2/06 Inspector: GS

Accompaniment No.: 2

Licensee: Wilcox Professional Services License No: 7-554

Inspection Type: Routine, Unannounced Priority: 5

Inspection Date: 2/3/06 Inspector: PK
APPENDIX D

LICENSE CASEWORK REVIEWS

NOTE: CASEWORK LISTED WITHOUT COMMENT ARE INCLUDED FOR COMPLETENESS

ONLY.

File No.: 1

Licensee: Medi-Physics License No.: 07-346

Type of Action: Amendment Amendment No.: 31

Date Issued: N/A License Reviewer: DK

Comment:

File copy of license was not date stamped or signed. The Program had the licensee fax

a signed copy, however, that copy was still not date stamped. This was a 2001 action

so no further review was performed.

File No.: 2

Licensee: Medi-Physics License No.: 07-346

Type of Action: Amendment Amendment No.: 46

Date Issued: 11/23/05 License Reviewer: DK

File No.: 3

Licensee: Catholic Healthcare West License No.: 07-24

Type of Action: Amendment Amendment No.: 106

Date Issued: 9/26/05 License Reviewer: DK

File No.: 4

Licensee: Catholic Healthcare West License No.: 07-24

Type of Action: Amendment Amendment No.: 104

Date Issued: 10/28/03 License Reviewer: DK

File No.: 5

Licensee: Western Technology, Inc. License No.: 07-49

Type of Action: Renewal Amendment No.: 59

Date Issued: 1/30/06 License Reviewer: DK

Comment:

This license does not contain possession limits and there is no license condition that

either requires the licensee provide a financial assurance program or maintain

possession limits below financial assurance limits. (See Section 3.4)

File No.: 6

Licensee: Geotek License No.: 07-495

Type of Action: Amendment Amendment No.: 08

Date Issued: Still in Review License Reviewer: DK
Arizona Final Report Page D.2

License Casework Reviews

File No.: 7

Licensee: Team Industrial Services, Inc. License No.: 07-493

Type of Action: Amendment Amendment No.: 32

Date Issued: 1/30/06 License Reviewer: DK

Comment:

This license does not contain possession limits and there is no license condition that

either requires the licensee provide a financial assurance program or maintain

possession limits below financial assurance limits. This license was identified by the

Program as needing the license condition due to license possession limits requiring

increased controls. The license contains a license condition that requires the licensee

to comply with the letter sent to the licensee by providing their additional control and

security measures to the program. (See Section 3.4) 

File No.: 8

Licensee: Short/Dolan Investments dba

 Canyon State Inspection License No.: 10–101

Type of Action: Amendment Amendment No.: 40

Date Issued: 1/19/06 License Reviewer: DK

Comment:

This license does not contain possession limits and there is no license condition that

either requires the licensee to provide a financial assurance or maintain possession

limits below financial assurance limits.

File No.: 9

Licensee: Banner Health dba

 Banner Good Samaritan Medical Center License No.: 07-748

Type of Action: Renewal Amendment No.: 22

Date Issued: 1/30/06 License Reviewer: DK

Comment:

This license was identified by the Program as needing the license condition due to

license possession limits requiring increased controls. Although the previous

amendment contained the proper license condition the condition was some how

dropped when the license was renewed. The Program will issue a corrected copy to the

license.

File No.: 10

Licensee: Nuclear Apothecary License No.: 14-35

Type of Action: New Amendment No.: N/A

Date Issued: 2/16/05 License Reviewer: DK
Arizona Final Report Page D.3

License Casework Reviews

File No.: 11

Licensee: Honeywell International, Inc. License No.: 07-513

Type of Action: Amendment Amendment No.: 02

Date Issued: 11/14/03 License Reviewer: DK

Comment:

License Condition 9.B(3) authorizes distribution of Generally Licensed devices, however,

there is no B(3) device listed on the license. This was discussed with the Program

license reviewer who stated that a corrected copy will be issued to the licensee.

File No.: 12

Licensee: LaPaz Regional Hospital License No.: 14-07

Type of Action: Termination Amendment No.: 19

Date Issued: 11/14/03 License Reviewer: DK

File No.: 13

Licensee: Hanson Aggregates License No.: 13-17

Type of Action: Termination Amendment No.: 04

Date Issued: 7/22/02 License Reviewer: DK

File No.: 14

Licensee: Sun Health Corporation dba

 Walter O. Boswell Memorial Hospital License No.: 07-138

Type of Action: Agency Review Amendment No.: 57

Date Issued: 8/15/05 License Reviewer: DK

File No.: 15 

Licensee: Millennium Diversified Medical, Inc. License No.: 02-16

Type of Action: Amendment Amendment No.: 08

Date Issued: 5/6/03 License Reviewer: DK

File No.: 16

Licensee: PETNET Pharmaceuticals, Inc. License No.: 7-515

Type of Action: Amendment Amendment No.: 07

Date Issued: 10/11/05 License Reviewer: DK

File No.: 17

Licensee: ATL, Inc. License No.: 7-116

Type of Action: Renewal Amendment No.: 39

Date Issued: 02/07/06 License Reviewer: DK
APPENDIX E

INCIDENT CASEWORK REVIEWS

NOTE: CASEWORK LISTED WITHOUT COMMENT ARE INCLUDED FOR COMPLETENESS

ONLY; NO SIGNIFICANT COMMENTS WERE IDENTIFIED BY THE IMPEP TEAM.

Incidents Nos. 10, 14 and 17 were not assigned Incident Log Numbers because the events

involved non-Arizona licensees (i.e. reciprocity) or devices or radioactive material not licensed

under the Arizona Radiation Regulatory Agency.

File No.: 1

Licensee: Construction Inspection and Testing License No.: 07-098

Date of Incident: 5/31/02 Incident Log No.: 02-03 (NMED 020556)

Investigation Date: 6/4/02 Type of Incident: Stolen Radioactive Material

Type of Investigation: On-site

File No.: 2

Licensee: Arizona Heart Hospital License No.: 07-443

Date of Incident: 2/26/02 Incident Log No.: 02-09 (NMED 020669)

Investigation Date: 6/24/02 Type of Incident: Medical Event

Type of Investigation: On-site

File No.: 3

Licensee: Geotechnical Testing Services License No.: 14-030

Date of Incident: 8/15/02 Incident Log No.: 02-11 (NMED 020776)

Investigation Date: 8/16/02 Type of Incident: Stolen Radioactive Material

Type of Investigation: On-site

File No.: 4

Licensee: Arizona Heart Hospital License No.: 07-443

Date of Incident: 7/10/02 Incident Log No.: 02-07 (NMED 020957)

Investigation Date: 7/10/02 Type of Incident: Equipment Failure

Type of Investigation: On-site

File No.: 5

Licensee: Construction Inspection and Testing License No.: 07-098

Date of Incident: 1/3/03 Incident Log No.: 03-01 (NMED 030017)

Investigation Date: 1/3/03 Type of Incident: Stolen Radioactive Material

Type of Investigation: On-site

File No.: 6

Licensee: Scottsdale Memorial Hospital License No.: 07-265

Date of Incident: 1/29/03 Incident Log No.: 03-03 (NMED 030116)

Investigation Date: 2/7/03 Type of Incident: Lost Radioactive Material

Type of Investigation: On-site

File No.: 7

Licensee: Phoenix Baptist Hospital

 and Medical Center License No.: 07-146

Date of Incident: 5/27/03 Incident Log No.: 03-08 (NMED 030440)

Investigation Date: 5/29/03 Type of Incident: Medical Event

Type of Investigation: On-site
Arizona Final Report Page E.2

Incident Casework Reviews

File No.: 8

Licensee: Phelps-Dodge, Inc. License No.: 13-005

Date of Incident: 8/25/03 Incident Log No.: 03-13 (NMED 030683)

Investigation Date: 9/15/03 Type of Incident: Equipment Failure

Type of Investigation: On-site

File No.: 9

Licensee: Longview Inspections, Inc. License No.: 07-506

Date of Incident: 8/25/03 Incident Log No.: 03-14 (NMED 030695)

Investigation Date: 8/28/03 Type of Incident: Radiography Source Disconnect

Type of Investigation: Phone

File No.: 10

Licensee: Geotechnical Testing Services License No.: N/A (Reciprocity)

Date of Incident: 9/23/03 Incident Log No.: N/A (NMED 030763)

Investigation Date: 9/24/03 Type of Incident: Uncontrolled Radioactive Material

Type of Investigation: Phone

File No.: 11

Licensee: Western Technologies License No.: 07-080

Date of Incident: 10/9/03 Incident Log No.: 03-19 (NMED 030819)

Investigation Date: 10/9/03 Type of Incident: Transportation

Type of Investigation: Phone

File No.: 12

Licensee: Ninyo & Moore License No.: 07-460

Date of Incident: 12/16/03 Incident Log No.: 03-22 (NMED 031000)

Investigation Date: 12/17/03 Type of Incident: Stolen Radioactive Material

Type of Investigation: Agency Meeting

File No.: 13

Licensee: Walter O. Boswell Hospital License No.: 07-138

Date of Incident: 4/18/04 Incident Log No.: 04-05 (NMED 040429)

Investigation Date: 6/2/04 Type of Incident: Lost Radioactive Material

Type of Investigation: On-site

File No.: 14

Licensee: Honeywell International License No.: 07-510

Date of Incident: 12/9/03 Incident Log No.: N/A (NMED 050018)

Investigation Date: 12/9/05 Type of Incident: Leaking Sealed Source

Type of Investigation: Phone

File No.: 15

Licensee: Walmart License No.: General Licensee

Date of Incident: 02/18/05 Incident Log No.: 05-02 (NMED 030695)

Investigation Date: 02/21/05 Type of Incident: Lost Radioactive Material

Type of Investigation: On-site
Arizona Final Report Page E.3

Incident Casework Reviews

File No.: 16

Licensee: Jerry Huracek License No.: 07-496

Date of Incident: 4/12/05 Incident Log No.: 05-03 (NMED 050257)

Investigation Date: 4/14/05 Type of Incident: Theft of Radioactive Material

Type of Investigation: On-site

File No.: 17

Licensee: National Aircraft Corp. License No.: Non-Licensee

Date of Incident: 6/23/05 Incident Log No.: N/A (NMED 050487)

Investigation Date: 6/23/05 Type of Incident: Uncontrolled Radioactive Material

Type of Investigation: Phone

File No.: 18

Licensee: Ricker, Atkinson, McBee & Associates License No.: 07-406

Date of Incident: 11/4/05 Incident Log No.: 05-09 (NMED 031000)

Investigation Date: 11/19/05 Type of Incident: Stolen Radioactive Material

Type of Investigation: Agency Meeting

File No.: 19

Licensee: Quality Testing License No.: 07-491

Date of Incident: 4/18/04 Incident Log No.: 05-10 (NMED 050824) 

Investigation Date: 12/16/05 Type of Incident: Theft of Radioactive Material

Type of Investigation: On-site 
APPENDIX F

SEALED SOURCE AND DEVICE REVIEWS

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS

ONLY.

File No.: 1

Registry No.: AZ-0501-D-105-B SS&D Types: (D) Density Gauge,

(E) Beta Gauge

Manufacturer: Honeywell-International Model Nos.: 1201/2201 Series,

1202/2202 Series, 1203 Series,

2204 Series

Date Issued: 9/9/05 Type of Action: New

SS&D Reviewers: BW, BK

Comments:

a) Page 1 lists Distributor/Manufacturer phone number on page one contrary to the format

listed in NUREG-1556, Vol. 3, Appendix D.

b) “Principal type” lists text first then letter which is the opposite of the format specified in

NUREG-1556, Vol. 3, Appendix C.

c) The company moved from California to Arizona, while not required for superseded

sheets, the Agency performed a full review of the information submitted.

File No.: 2

Registry No.: AZ-0501-D-106-B SS&D Type: (E) Beta Gauge

Manufacturer: Honeywell-International Model No.: 4201 Series

Date Issued: 9/9/05 Type of Action: New

SS&D Reviewers: BW, BK

Comments:

a) Page 1 lists Distributor/Manufacturer phone number on page one contrary to the format

listed in NUREG-1556, Vol. 3, Appendix D.

b) “Principal type” lists text first then letter which is the opposite of the format specified in

NUREG-1556, Vol. 3, Appendix C.

c) The company moved from California to Arizona, while not required for superseded

sheets, the Agency performed a full review of the information submitted.

File No.: 3

Registry No.: AZ-0501-D-107-B SS&D Type: (E) Beta Gauge

Manufacturer: Honeywell-International Model No.: 4202 Series

Date Issued: 9/12/05 Type of Action: New

SS&D Reviewers: BW, BK

Comments:

a) Page 1 lists Distributor/Manufacturer phone number on page one contrary to the format

listed in NUREG-1556, Vol. 3, Appendix D.

b) “Principal type” lists text first then letter which is the opposite of the format specified in

NUREG-1556, Vol. 3, Appendix C.

c) The company moved from California to Arizona, while not required for superseded

sheets, the Agency performed a full review of the information submitted.
Arizona Final Report Page F.2

Sealed Source and Device Casework Reviews

File No.: 4

Registry No.: AZ-0501-D-108-B SS&D Types: (D) Density Gauge,

(E) Beta Gauge

Manufacturer: Honeywell-International Model No.: 4203

Date Issued: 9/9/05 Type of Action: New

SS&D Reviewers: BW, BK

Comments:

a) Page 1 lists Distributor/Manufacturer phone number on page one contrary to the format

listed in NUREG-1556, Vol. 3, Appendix D.

b) “Principal type” lists text first then letter which is the opposite of the format specified in

NUREG-1556, Vol. 3, Appendix C.

c) The company moved from California to Arizona, while not required for superseded

sheets, the Agency performed a full review of the information submitted.

File No.: 5

Registry No.: AZ-0244-D-101-S SS&D Type: (W) Self Luminous Light Source

Manufacturer: TLS Systems, Inc. Model No.: 40108A

Date Issued: 10/11/02 Type of Action: Amendment

SS&D Reviewers: BW, BK

Comments:

a) Page 2, Details of Construction should reference Attachment 2 instead of Attachment 1.

b) Issuance date listed on Page 1 (10/11/02) does not agree with issuance date on Page 4

(11/8/02).

c) Amended sheet issued prior to format established in NUREG-1556, Vol. 3.

File No.: 6

Registry No.: AZ-0244-S-102-B SS&D Type: (W) Self Luminous Light Source

Manufacturer: TLS Systems, Inc. Model No.: 40111

Date Issued: 10/10/02 Type of Action: Amend/New

SS&D Reviewers: BW, BK

Comments:

a) While Attachments 1 and 2 listed on Page 2 under “Source Drawing” are in the Agency’s

sealed source registry (SSR) file, these attachments are not part of the electronic SSR

file posted on NRC’s SSR web site.

b) Issuance date listed on Page 1 (10/10/02) does not agree with issuance date on Page 4

(10/11/02).

c) Amended sheet issued prior to format established in NUREG-1556, Vol.3.
ATTACHMENT

April 10, 2006 Letter from Aubrey Godwin

Arizona’s Response to Draft IMPEP Report 

ADAMS: ML061020208