July 26, 2010 

Mr. Howard Roitman, Director 

Environmental Programs 

Colorado Department of Public Health 

 and Environment 

4300 Cherry Creek Drive South 

Denver, CO 80246-1530 

Dear Mr. Roitman: 

On June 23, 2010, the Management Review Board (MRB) met to consider the proposed final 

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

Agreement State Program. The MRB found the Colorado Agreement State Program adequate 

to protect public health and safety and compatible with the U.S. Nuclear Regulatory 

Commission=s (NRC) program. 

Section 5.0, page 18, of the enclosed final report contains a summary of the IMPEP review 

team=s findings and recommendations. Mr. Gary W. Baughman’s letter dated May 27, 2010, 

adequately discusses the State’s proposed actions for resolving the review team’s 

recommendations. No further response is requested at this time. 

Based on the results of the current IMPEP review, the next full review of the Colorado 

Agreement State Program will take place in approximately 4 years, with a periodic meeting 

tentatively scheduled for April 2012. During the periodic meeting and at the next IMPEP review, 

NRC will evaluate the effectiveness of the State’s response to the review team’s 

recommendations, as well as the overall implementation of your Agreement State program. 

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

I also wish to acknowledge your continued support for the Agreement State Program. I look 

forward to our agencies continuing to work cooperatively in the future. 

Sincerely, 

 /RA by Cheryl McCrary for/

Michael F. Weber 

Deputy Executive Director for Materials, Waste, 

Research, State, Tribal, and Compliance Programs 

Office of the Executive Director for Operations 

Enclosure: 

Colorado Final IMPEP Report 

cc w/encl.: Steve Tarlton, Manager 

 Radiation Management Program 
July 26, 2010 

Mr. Howard Roitman, Director 

Environmental Programs 

Colorado Department of Public Health 

 and Environment 

4300 Cherry Creek Drive South 

Denver, CO 80246-1530 

Dear Mr. Roitman: 

On June 23, 2010, the Management Review Board (MRB) met to consider the proposed final 

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

Agreement State Program. The MRB found the Colorado Agreement State Program adequate 

to protect public health and safety and compatible with the U.S. Nuclear Regulatory 

Commission=s (NRC) program. 

Section 5.0, page 18, of the enclosed final report contains a summary of the IMPEP review 

team=s findings and recommendations. Mr. Gary W. Baughman’s letter dated May 27, 2010, 

adequately discusses the State’s proposed actions for resolving the review team’s 

recommendations. No further response is requested at this time. 

Based on the results of the current IMPEP review, the next full review of the Colorado 

Agreement State Program will take place in approximately 4 years, with a periodic meeting 

tentatively scheduled for April 2012. During the periodic meeting and at the next IMPEP review, 

NRC will evaluate the effectiveness of the State’s response to the review team’s 

recommendations, as well as the overall implementation of your Agreement State program. 

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

I also wish to acknowledge your continued support for the Agreement State Program. I look 

forward to our agencies continuing to work cooperatively in the future. 

Sincerely, 

 /RA by Cheryl McCrary for/ 

Michael F. Weber 

Deputy Executive Director for Materials, Waste, 

Research, State, Tribal, and Compliance Programs 

Office of the Executive Director for Operations 

Enclosure: 

Colorado Final IMPEP Report 

cc w/encl.: Steve Tarlton, Manager 

 Radiation Management Program 

Distribution: See next page.

ML101790312 EDATS: FSME-2010-0183 

OFFICE FSME/MSSA FSME/MSSA FSME/MSSA FSME/MSSA 

NAME ATMcCraw:knm1 ADias TReis RJLewis 

DATE 06/29/10 07/01/10 07/01/10 07/09/10 

OFFICE Tech Editor FSME DEDMRT 

NAME CPoland CACarpenter MFWeber 

(CMcCrary for) 

DATE 07/14/10 07/15/10 7/26/10 

OFFICIAL RECORD COPY
Letter to H. Roitman from Michael F. Weber dated: July 26, 2010 

Distribution: EDATS: FSME-2010-0183 

MSSA RF DCD (SP01) 

EDO RF 

RidsEdoMailCenter 

RidsFsmeOd 

RidsSecyCorrespondenceMailCenter Chairman Jaczko 

MBeardsley, FSME/MSSA Commissioner Svinicki 

RErickson, RIV/RSAO Commissioner Apostolakis 

JSaxton, FSME/DWMEP Commissioner Magwood 

DLawyer, RI Commissioner Ostendorff 

Tristan Timm, FL SECY 

Jennifer Opila, CO 

AHowell, RIV 

KBrock, OEDO 

CMiller, FSME 

BJones, OGC 

JKinneman, RI 

Mike Broderick, OK 

JOlmstead, OGC 

APowell, OCA (2 copies) 
Enclosure 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE COLORADO AGREEMENT STATE PROGRAM 

April 12-16, 2010 

FINAL REPORT
Colorado Final Report Page 1 

1.0 INTRODUCTION 

This report presents the results of the review of the Colorado Agreement State Program. 

The review was conducted during the period of April 12-16, 2010, by a review team composed 

of technical staff members from the U.S. 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 NRC Management Directive 5.6, “Integrated Materials 

Performance Evaluation Program (IMPEP),” dated February 26, 2004. Preliminary results of the 

review, which covered the period of March 18, 2006, to April 16, 2010, were discussed with 

Colorado managers on the last day of the review. 

A draft of this report was issued to Colorado for factual comment on May 4, 2010. The State 

responded by letter dated May 27, 2010, from Gary W. Baughman, Director, Hazardous 

Materials and Waste Management Division (the Division). A copy of the State’s response is 

included as the Attachment to this report. The Management Review Board (MRB) met on June 

23, 2010, to consider the proposed final report. The MRB found the Colorado Agreement State 

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

The Colorado Agreement State Program is administered by the Radiation Management 

Program (the Program). The Program is part of the Division, within the Department of Public 

Health and Environment (the Department). Organization charts for the Department and the 

Program are included in Appendix B. 

At the time of the review, the Colorado Agreement State Program regulated 346 specific 

licenses authorizing byproduct, source, and certain special nuclear materials (radioactive 

materials). The review focused on the radioactive materials program as it is carried out under 

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

and the State of Colorado. 

In preparation for the review, a questionnaire addressing the common and applicable noncommon performance indicators was sent to the Program on December 2, 2009. The Program 

provided its response to the questionnaire on March 24, 2010. A copy of the questionnaire 

response can be found in NRC’s Agencywide Documents Access and Management System 

(ADAMS) using the Accession Number ML101180100. 

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

the Program’s response to the questionnaire, (2) review of applicable Colorado statutes and 

regulations, (3) analysis of quantitative information from the Program’s database, (4) technical 

review of selected regulatory actions, (5) field accompaniments of seven inspectors, and (6) 

interviews with staff and managers. The review team evaluated the information gathered 

against the established criteria for each common and applicable non-common performance 

indicator and made a preliminary assessment of the Colorado Agreement State Program’s 

performance. 

Section 2.0 of this report covers the State’s actions in response to recommendations made 

during previous reviews. Results of the current review of the common performance indicators 
Colorado Final Report Page 2 

are presented in Section 3.0. Section 4.0 details the results of the review of the applicable noncommon performance indicators, and Section 5.0 summarizes the review team’s findings and 

recommendations. The review team’s recommendations are comments that relate directly to 

program performance by the State. 

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS 

During the previous IMPEP review, which concluded on March 17, 2006, the review team made 

four recommendations in regard to program performance. The status of the recommendation is 

as follows: 

1. The review team recommends the Program conduct reciprocity inspections in 

accordance with the criteria outlined in NRC Inspection Manual Chapter (IMC) 1220, 

“Processing of NRC Form 241 and Inspection of Agreement State Licensees Operating 

Under 10 CFR 150.20.” (Section 3.2 of the 2006 IMPEP Report) 

Status: The Program performed an overall average of 25 percent of all 

reciprocity licensees during the review period. Following the 2006 review year, 

the Program has met the 20 percent goal and continues to complete a continually 

increasing number of reciprocity inspections in each successive year. This 

recommendation is closed. 

2. The review team recommends that the Program develop and implement a process for 

issuance of provisional licenses in a timely manner, as well as timely termination of 

these licenses. (Section 3.4 of the 2006 IMPEP Report) 

 Status: The Program has implemented a process to periodically review the status of 

provisional licenses, as well as the status of other licensing actions. There were 13 

provisional licenses issued during the review period. Only two of these provisional 

licenses involved byproduct, source, or special nuclear materials applicable to this 

review. Most of the provisional licenses were for naturally occurring radioactive material 

or technologically enhanced radioactive material. The two byproduct material 

provisional licenses were issued and terminated within 6 months of determination of a 

need for a provisional license. This recommendation is closed. 

3. The review team recommends that the Program add a section to the 2-page reviewer 

checklist to facilitate the appropriate, thorough, and consistent review of license 

decommissioning and terminations items. (Section 3.4 of the 2006 IMPEP Report) 

Status: The Program incorporated license termination and documentation requirements 

in its License Process Document, most recently revised in April 2009. The Compliance 

Lead is copied on all license termination requests to determine if a close-out inspection 

or survey is needed to justify the licensing action. During the casework evaluations, the 

review team identified some areas in the processing of license terminations that were 

deficient. The review team found several instances where the Program should have 

requested additional information from the licensee or performed confirmatory surveys 

prior to the termination of the license. At the time of the review, the Program had not 

added a section to the 2-page reviewer checklist to facilitate license termination reviews, 
Colorado Final Report Page 3 

but was considering doing so; however, the review team believes that the Program can 

still meet the intent of this recommendation without modifying its 2-page reviewer 

checklist. This recommendation remains open, but has been modified so that the 

emphasis is placed on a performance-based outcome in addressing the intent of this 

recommendation, rather than prescribing a specific means to address this 

recommendation. The review team recommends that the State evaluate its license 

termination and decommissioning processes to ensure that reviews are appropriate, 

thorough, and consistent. 

4. The review team recommends that the Program transfer six sealed source and device 

(SS&D) certificates to inactive status, because their original manufacturers are no longer 

in business. (Section 4.2.2 of the 2006 IMPEP Report) 

Status: The review team verified that the Program transferred the six SS&D certificates 

to inactive status after the 2006 review. The review team noted that the Program’s 

review process was inconsistent from the guidance specified in NUREG-1556, Volume 

3, Revision 1, “Consolidated Guidance About Material Licenses – Applications for 

Sealed Source and Device Evaluation and Registration.” The review team discussed 

with Program managers the importance of documenting and following the NUREG 

guidance for all SS&D evaluations to help ensure nationwide consistency of SS&D 

certificates. Section 4.2.2 of this report documents some of the consistency issues that 

the review team identified during its casework evaluations, including the Program’s 

practices for inactivating SS&D certifications. The review team opened a new 

recommendation in Section 4.2.2 to address issues identified during its casework 

evaluations. This recommendation is closed. 

3.0 COMMON PERFORMANCE INDICATORS 

Five common performance indicators are used to review NRC Regional and Agreement State 

radioactive materials 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) Technical Quality of Incident and Allegation Activities. 

3.1 Technical Staffing and Training

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

indicator, interviewed Program managers and staff, reviewed job descriptions and training 

records, and considered any possible workload backlogs. 

The review team evaluated the Program’s staffing and training as three individual components: 

the radioactive materials program, the sealed source and device evaluation program, and the 

uranium recovery program. This section of the report focuses on the radioactive materials 

program. Staffing and training for the sealed source and device evaluation program and 

uranium recovery program are discussed in Section 4.2.1 and Section 4.4.1, respectively. The 

Program Manager oversees all of the components that comprise the Colorado Agreement State 

Program. The Program expends approximately 13 full-time equivalents (FTE), when fully 
Colorado Final Report Page 4 

staffed, to administer the Agreement State program, an increase of 2 FTE since the previous 

IMPEP review in 2006. 

The Radioactive Materials Unit (the Unit), within the Program, is responsible for radioactive 

materials licensing, inspection, and emergency response activities. When fully staffed, the Unit 

is composed of the Unit Leader, eight technical staff, and one program assistant. The technical 

staff members, classified as Environmental Protection Specialists, perform licensing and 

inspection activities, as well as respond to incidents and allegations. To provide additional 

management oversight of the Unit, one technical staff member has been appointed as the 

Compliance Lead and another has been appointed as the Licensing Lead. 

At the time of the review, there was one technical vacancy in the Unit. The vacancy resulted 

through a series of internal promotions that began at the Program Manager position and ended 

when a technical staff member was appointed as the Licensing Lead. The technical position 

has been vacant since January 2010. At the time of the review, the Program was evaluating its 

options for filling the vacancy, including consideration of the potential for an increase in 

workload in the uranium recovery program. Despite the vacancy, the review team determined 

that the Unit was adequately staffed based on current workload. Filling the vacancy would 

provide depth in the Unit and offset any unforeseen turnover. The Program was aware of an 

impending retirement and was factoring that into the staffing evaluation. 

During the review period, five individuals left the Program, including the former Program 

Manager, and five individuals were hired into the Program. Three of the five departures were 

due to staff retirements. The Program was able to manage the turnover during the review 

period by recruiting and retaining highly qualified and capable staff. The Unit has benefited from 

hiring individuals with operational health physics or nuclear medicine experience when filling 

vacancies. The Program requires new hires to have a Bachelor’s degree or equivalent 

experience in a physical or biological science or engineering. 

The Unit has an established training and qualification program consistent with NRC Inspection 

Manual Chapter (IMC) 1246, “Formal Qualification Programs in the Nuclear Material Safety and 

Safeguards Program Area” and the NRC and Organization of Agreement States (OAS) Training 

Working Group Recommendations for Agreement State Training Programs; however, the 

training and qualification program is not formally documented in a procedure. Qualification is 

achieved through a combination of education and experience, formal classroom training, and 

on-the-job training. As evidenced in later sections of the report, the review team did not identify 

any performance issues that could be attributed to the Unit’s lack of a formalized training and 

qualification procedure. 

The Unit maintains training and accompaniment records for each staff member to demonstrate 

qualification in each of the Unit’s program codes or license types. Staff typically starts by 

achieving qualification to inspect and license fixed and portable gauges and progress through 

increasingly complex license types based on experience and Unit needs. In reviewing staff’s 

qualifications, the review team determined that the Unit has an adequate number of qualified 

inspectors and license reviewers for all active license types in Colorado. The review team 

concluded that the Unit’s staffing and training is adequate to carry out its regulatory duties. 
Colorado Final Report Page 5 

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

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

satisfactory. 

3.2 Status of Materials Inspection Program

The review team focused on five factors while reviewing this indicator: inspection frequency, 

overdue inspections, initial inspections of new licenses, timely dispatch of inspection findings to 

licensees, and performance of reciprocity inspections. The review team’s evaluation was based 

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

Program’s database, examination of completed inspection casework, and interviews with the 

Program managers and staff. 

The review team’s evaluation of the Program’s inspection priorities verified that inspection 

frequencies for all types of Colorado material licenses are at least the same frequency as those 

listed in NRC’s IMC 2800, “Materials Inspection Program.” A few categories of licenses are 

assigned inspection priority codes that prescribe a more frequent inspection schedule than 

those prescribed in IMC 2800. 

The Program conducted a total of 340 inspections of Priority 1, 2, and 3 licensees during the 

review period. The review team determined that 14 of these inspections were conducted 

overdue by more than 25 percent of the inspection frequency prescribed by IMC 2800. The 

review team did not identify any inspections that were overdue at the time of the review. The 

review team also evaluated the Program’s timeliness for conducting initial inspections. The 

review team noted that the Program conducted 61 initial inspections during the review period, of 

which 4 were conducted greater than 12 months after license issuance as prescribed by IMC 

2800. The overdue initial inspections ranged from 31 days late to 174 days late. The review 

team verified that there were no overdue initial inspections at the time of the review. Overall, 

the review team calculated that the Section performed 4.5 percent of all Priority 1, 2, and 3 and 

initial inspections overdue during the review period. 

The review team evaluated the Program’s timeliness of issuance of inspection findings. The 

Program has a goal of communicating inspection findings to licensees within 30 days of the end 

of the inspection. The majority of inspection findings are communicated to the licensee using 

Colorado Form RCD-59, “Compliance Inspection Report,” a form similar to NRC’s Form 591, 

“Safety Inspection Report and Compliance Inspection.” A completed form is typically issued onsite upon the completion of an inspection. The review team determined that, if a Colorado Form 

RCD-59 was not issued at the conclusion of the on-site inspection, a “Notice of Violation” was 

issued from the office within 30 days of the inspection. Of the 33 inspection files reviewed by 

the review team, the Program only issued 2 inspection findings beyond the 30-day goal. 

The Program considers all companies that request to work in Colorado under reciprocity each 

calendar year to be candidates for inspection, which is more conservative than NRC’s guidance 

for identifying candidate reciprocity licensees in IMC 1220. The review team determined that 

the Program received requests for reciprocity from approximately 64 candidate reciprocity 

licensees, as defined in IMC 1220, over the review period. The review team found that; while 

the Program did not fully meet the 20 percent goal in 2006, completing inspections of 16 percent 

of candidate reciprocity licensees; they did exceed the 20 percent goal in each successive year 
Colorado Final Report Page 6 

of the review period. Overall, the Program performed an average of 25 percent of all candidate 

reciprocity inspections over the entire review period. 

The review team determined that the Program adequately planned for the initial set of Increased 

Controls inspections. The Program initially identified 34 licensees that were subject to the 

Increased Controls and performed all of the first-year inspections in a timely manner, with all 

inspections being performed within the first 2 years. Subsequent inspections of Increased 

Controls licensees are now performed in conjunction with health and safety inspections and 

continue to evaluate the ongoing aspects of the licensee’s increased security measures. 

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

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

Program, was satisfactory. 

3.3 Technical Quality of Inspections

The review team evaluated inspection reports, enforcement documentation, inspection field 

notes, and interviewed inspectors for 33 radioactive materials inspections conducted during the 

review period. The casework examined included a cross-section of inspections conducted by 

three former and nine current inspectors and covered a wide variety of inspection types. These 

included medical, academic, and research and development broadscope licensees; industrial 

radiography; well logging; self-shielded irradiator; service provider; gamma knife; positron 

emission tomography (PET); veterinarian nuclear medicine; medical; nuclear pharmacy; 

portable gauges; and reciprocity licensees. The review also included initial and followup 

Increased Controls inspections. Appendix C lists the inspection casework files reviewed, with 

case-specific comments. 

Based on the evaluation of casework, the review team determined that inspections covered all 

aspects of the licensees’ radiation safety and security programs. The review team noted that 

inspection reports were generally thorough, complete, consistent, and of high quality with 

sufficient documentation to ensure that licensees’ performances with respect to health, safety, 

and security were acceptable. The review team noted that inspectors were conducting 

confirmatory reviews of source inventories in the National Source Tracking System for affected 

licensees. Inspection documentation supported violations, recommendations made to 

licensees, unresolved safety issues, and discussions held with licensees during exit interviews. 

While on site, the review team evaluated the Program’s handling and storing of sensitive 

documents. The review team determined that in most cases, license and inspection files 

holding documents containing sensitive information were stored in color-coded folders in a 

locked radiation control file room with controlled electronic access. The review team noted that 

information in non-sensitive, manila folders were offered the same level of access protection. 

The review team noted that, although the sensitive documents were in color-coded folders, 

sensitive documents were not appropriately marked on each page containing sensitive 

information. The review team interviewed the file room staff and found that, while documents 

contained in the red folders were not marked as sensitive, the staff was trained to know that 

anything contained in the red folders was protected and not subject to release under Freedom 

of Information Act-equivalent State law. Additionally, when an open records request comes in, 

the file room staff does not release information without getting Program staff approval. 
Colorado Final Report Page 7 

During casework evaluations, the review team identified sensitive, security-related information 

and personally identifiable information (i.e., alleger identities) that was not appropriately marked 

intermingled with non-sensitive information in unsecured file cabinets within in a large cubicle 

style general work area that is accessible to individuals who do not have a need for access to 

that information. The review team noted that outgoing correspondence that contained sensitive 

information was not appropriately marked as containing sensitive information. The review team 

discussed the importance of these markings to signify that the licensees need to appropriately 

protect the documents. The review team did not discover any evidence of an inadvertent 

release or unauthorized disclosure on the part of the Program or any licensees; however, the 

review team believes that the Program would benefit from formalizing its policies on sensitive 

information. The review team recommends that the State develop and implement a policy and 

procedure for the handling, marking, transmitting, and storing of documents containing sensitive 

information. 

The Compliance Lead has been delegated the responsibility to conduct annual supervisory 

accompaniments of the Program’s inspectors. The review team noted that the Compliance 

Lead conducted annual supervisory accompaniments for all inspectors during the review period; 

however, the Compliance Lead, who regularly performs inspections, was not accompanied 

during the review period. This same issue was noted and discussed with Program managers 

during the 2006 IMPEP review. In 2006, Program managers stated that accompaniments of the 

Compliance Lead had not been performed due to staff turnover at the Unit Leader position. 

There was turnover at the Unit Leader position again during this review period; therefore, the 

Program had not taken any action to address this issue. The current Unit Leader committed to 

ensuring that the Compliance Lead is accompanied annually in the future. 

The review team verified that the Program maintains an adequate supply of appropriately 

calibrated survey instruments to support the inspection program, as well as to respond to 

radioactive materials incidents and emergency conditions. Instruments used to support the 

materials inspection program are sent to the manufacturer for calibration. 

The Program receives laboratory and sample analysis support from the State laboratory located 

near the Program office. The laboratory is an accredited, full service radiochemistry laboratory, 

and has a wide array of analytical equipment capable of detailed radiochemistry analysis. 

The review team accompanied five of the Program’s radioactive materials inspectors during the 

week of February 22-26, 2010. The inspectors conducted inspections at a gamma knife facility, 

an industrial radiography office, a hospital performing radioiodine therapy, a hospital utilizing a 

high dose-rate remote afterloader (HDR) and a PET production facility. The inspectors 

demonstrated appropriate performance-based inspection techniques and knowledge of the 

regulations. The inspectors were well trained, prepared for the inspections, and thorough in 

their audits of the licensees’ radiation safety and security programs. The inspectors conducted 

interviews with appropriate personnel, observed licensed operations in progress, conducted 

confirmatory measurements, and utilized good health physics practices. The inspectors held 

entrance and exit meetings with the appropriate level of licensee management. The review 

team determined that the inspections were adequate to assess radiological health, safety, and 

security at the licensed facilities. 
Colorado Final Report Page 8 

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

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

satisfactory. 

3.4 Technical Quality of Licensing Actions

The review team examined the casework and interviewed license reviewers for 21 licensing 

actions. Licensing actions were reviewed for completeness, consistency, proper radioisotopes 

and quantities, qualifications of authorized users, adequacy of facilities and equipment, 

adherence to good health physics practices, financial assurance, operating and emergency 

procedures, appropriateness of license conditions, and overall technical quality. The casework 

was also reviewed for timeliness, use of appropriate deficiency letters and cover letters, 

reference to appropriate regulations, supporting documentation and data, consideration of 

enforcement history, pre-licensing visits, peer/supervisory review, and proper signatures. 

The licensing casework was selected to provide a representative sample of licensing actions 

completed during the review period. Licensing actions selected for evaluation included four new 

licenses, four renewals, seven amendments, four license terminations, one license application 

denial, and actions associated with decommissioning of a complex site formerly managed by 

NRC’s Site Decommissioning Management Plan (SDMP) and transferred to Colorado. Files 

reviewed included a cross-section of license types, including: medical diagnostic and therapy, 

brachytherapy, gamma knife, industrial radiography, nuclear pharmacy, research and 

development, and industrial licensees. The casework sample represented work from each of 

the Program’s license reviewers. A listing of the licensing casework reviewed, with casespecific comments, can be found in Appendix D. 

The Program assigns a tracking number and logs all licensing actions into a computer tracking 

system. The action is then given to a license reviewer. The license reviewer can make 

notations of needed information and comments about the licensing action on a tracking sheet. If 

needed, the reviewer generates a deficiency letter. Once any deficiency items are resolved, the 

license reviewer produces a draft licensing action. The draft licensing action is forwarded to a 

person with signature authority for final approval. Corrections are made, as needed, and the 

licensing action is issued. The license reviewers have guidance documents for use in preparing 

medical, industrial, and laboratory licenses. 

The review team noted the licensing actions were of high technical quality and consistent with 

NRC’s NUREG-1556 series guidance, the State’s regulations, and good health physics 

practices. The review team noted that some supporting documentation and data that was 

needed to support the licensing action was missing from the license file. In two cases, the basis 

for financial assurance levels was missing from the respective files. The review team also found 

that one file was missing the current license and another file was missing some of the pages of 

the licensee’s application. In determining the extent of condition, the review team found that 

critical documentation was missing from files in the areas of incidents, allegations, sealed 

source and device evaluations, and uranium recovery. In some cases, the documentation was 

no longer available due to State-wide guidance to periodically delete old e-mails and computer 

files. The review team believes that the missing documentation existed at one time; however, 

the Program failed to include the documentation file or filed the documentation improperly. The 

review team believes that the Program’s lack of guidance that clearly defines the roles and 
Colorado Final Report Page 9 

responsibilities of staff and expectations for document retention as the underlying cause for the 

missing documentation. The review team recommends that the State development and 

implement guidance that outlines the roles and responsibilities for staff and the expectations 

regarding record retention to ensure that the Program’s files are complete and comprehensive. 

The review team evaluated the State’s actions implemented through NRC’s Grant Program, for 

sites that were formerly managed by NRC. The State of Colorado had one location for which it 

managed decommissioning activities, using NRC’s grant funding. During the review period, the 

Program produced a final report entitled, “George E. Davis Mill remediation Project HMWMDRAD-01, Gateway Mesa County, Colorado, Project Completion Report, September 2006”, that 

details the site characterization and remediation performed. All of the grant money was 

exhausted through the remediation efforts; however, there was not sufficient funding to perform 

full remediation. The property owners signed an environmental covenant placing restrictions on 

land use. With the restrictions in place, the dose to the property owners and the public is less 

than 25 millirem per year from the site. This was the final formerly licensed site under NRC’s 

Grant Program. 

The review team assessed the Program’s implementation of the pre-licensing guidance. The 

review team noted that the Program performs pre-licensing checks of all new applicants and 

new authorized users in accordance with the original pre-licensing guidance, but has not yet 

implemented all of the essential elements of the revised pre-licensing guidance that was issued 

on September 22, 2008, and transmitted to the Agreement States via Office of Federal and 

State Materials and Environmental Management Programs (FSME) Letter RCPD-08-020, 

“Requesting Implementation of the Checklist to Provide a Basis for Confidence That Radioactive 

Material Will Be Used as Specified on a License and the Checklist for Risk-significant 

Radioactive Material.” FSME Letter RCPD-08-020 required implementation of the essential 

elements of the pre-licensing guidance by March 22, 2009. The review team examined two new 

licenses issued since March 22, 2009, in which the applicant would be classified as an 

“unknown entity” in accordance with the guidance. The Program performed a pre-licensing visit 

of one of the applicants, but not the other. The review team discussed with Program managers 

the essential elements of the revised pre-licensing guidance and several strategies that other 

Agreement States have used to satisfy the essential elements. The review team recommends 

that the State review its implementation of the pre-licensing guidance to ensure that all of the 

essential elements of the guidance are consistently met. 

The review team examined the Program’s licensing practices regarding the Increased Controls, 

Fingerprinting, and National Source Tracking System requirements. The review team noted that 

the Materials Section added legally binding license conditions to the licenses that met the 

criteria for implementing the Increased Controls, Fingerprinting, and National Source Tracking 

System requirements. The review team confirmed that Program evaluates new license 

applications and license amendments using the same criteria. 

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

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

Actions, was satisfactory. 

 
Colorado Final Report Page 10 

3.5 Technical Quality of Incident and Allegation Activities

In evaluating the effectiveness of the Program’s actions in responding to incidents and 

allegations, the review team examined the Program’s response to the questionnaire relative to 

this indicator, evaluated selected incidents reported for Colorado in the Nuclear Material Events 

Database (NMED) against those contained in the Program’s files, and evaluated the casework 

for 14 radioactive materials incidents. A listing of the casework examined, with case-specific 

comments, can be found in Appendix E. The review team also evaluated the Program’s 

response to nine allegations involving radioactive materials, including three that NRC referred to 

the State during the review period. 

When notified of an incident, the Program performs preliminary evaluations of the events to 

determine the appropriate response based on its emergency response procedure. The Program 

maintains a database for tracking the status of all incidents and allegations. If the incident 

meets the reportability thresholds, as established in FSME Procedure SA-300, “Reporting 

Material Events,” the Program promptly notifies the NRC Headquarters Operations Center, 

typically by e-mail, using the information template established for NMED. If the investigation is 

complex and extends over a period of time, NMED is appropriately updated, using the NMED 

software. Of the incidents evaluated by the review team, all had been reported to NRC within 

the required timeframe and had been properly submitted to NMED. 

The incidents selected for review included both medical and industrial events involving lost or 

stolen radioactive material, overexposure, damaged equipment, contamination, radioactive 

material release, and equipment failure. The review team determined that the Program’s 

responses to incidents were thorough, complete, and comprehensive. Initial responses were 

prompt and well coordinated, and the level of effort was commensurate with the health and 

safety significance. The Program immediately dispatched inspectors to a site when the 

possibility of an immediate threat to public health and safety existed. When no immediate threat 

was present and the Program determined that the licensee had qualified, competent individuals 

investigating the incident, the Program generally responded by telephone or e-mail, with an onsite followup at a later date depending on the nature of the incident. 

The 2006 review team noted in its report a commitment from the former Compliance Lead to 

document the Program’s incident response procedures and make them available to staff. 

During this review, the review team examined the Program’s incident response guidance, which 

is part of the Program’s emergency response procedure. The review team noted that the 

guidance included a prioritization for on-site investigations; however, the prioritization does not 

specifically address loss, thefts, and abandonment of risk-significant quantities of radioactive 

material or recurring events, especially at medical facilities. The review team discussed with 

Program managers the importance of conducting on-site investigations for significant or 

repetitive incidents. The Unit Leader committed to evaluate the on-site investigation priorities 

and to consider separating the incident response guidance into its own procedure. 

In evaluating the effectiveness of the Program’s response to allegations, the review team 

evaluated the casework for nine allegations. The review team concluded that the Program 

consistently took prompt and appropriate action in response to concerns raised. The Program 

notified the allegers of the conclusion of their investigation, when possible. The review team 
Colorado Final Report Page 11 

determined that the Program has the ability to adequately protect the identity of allegers that 

request anonymity. 

As noted in earlier sections or the report, the review team identified issues regarding sensitive 

information and documentation with respect to incident and allegation files. The review team 

identified sensitive information that was not appropriately marked in incident and allegation files. 

The review team also noted that some incident and allegation files were missing essential 

documentation of the Program’s responses. 

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

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

Allegation Activities, was satisfactory. 

4.0 NON-COMMON PERFORMANCE INDICATORS 

Four non-common performance indicators are used to review Agreement State Programs: 

(1) Compatibility Requirements, (2) Sealed Source and Device Evaluation Program, (3) Lowlevel Radioactive Waste Disposal Program, and (4) Uranium Recovery Program. NRC’s 

Agreement with Colorado relinquishes regulatory authority for all four program areas covered by 

the non-common performance indicators. 

4.1 Compatibility Requirements

To assess Colorado’s status with respect to this performance indicator, the review team 

examined the Program’s response to the questionnaire relative to this indicator; reviewed 

Colorado’s State Regulation Status Data Sheet (SRS), as maintained by FSME; and conducted 

interviews with managers and staff responsible for this program area. 

4.1.1 Legislation

Colorado became an Agreement State on February 1, 1968. The Department is designated as 

the State’s radiation control agency under the Colorado Revised Statutes (CRS) Title 25, Article 

11, “The Radiation Control Act.” These statutes also authorize the Governor to enter into 

agreements with the federal government in matters relating to radiation safety. 

During the review period, the State did not pass any legislation that had a direct impact on the 

Colorado Agreement State Program. The review team reviewed and discussed with the 

Program Manager the effects of several bills passed during the Colorado Legislature’s 2008 

Session that amended the Colorado Mined Land Reclamation Act. The bills enhanced the 

Department of Natural Resources’ Division of Reclamation, Mining, and Safety’s oversight of 

certain aspects of in situ uranium mining, but did not create any conflicts with the Program’s 

statutory authority or responsibilities under NRC’s Agreement with the State of Colorado. 

The review team also reviewed two pieces of pending legislation that will impact the Agreement 

State program if passed. The first would strengthen the Program’s enforcement process and 

would increase the maximum penalty from $5,000 per day per violation to $15,000 per day per 

violation. The second piece of pending legislation would require uranium recovery facilities in 

standby to remediate any existing environmental contamination prior to restarting operations. 
Colorado Final Report Page 12 

4.1.2 Program Elements Required for Compatibility

The review team examined the procedures used in the Program’s regulation promulgation 

process. The Program drafts all proposed rules and obtains Departmental approval to submit 

the proposed rules to the Radiation Advisory Committee (the Committee) and the affected 

community for preliminary review and comments. During this time, the Program provides NRC 

a draft of the rules for a compatibility review. Once the preliminary comments from the 

Committee, NRC, and the affected community are received, the Program requests a public 

hearing with the State’s Board of Health (the Board) to formally present and discuss the 

proposed rules. Once a hearing date is established, the Board issues a notice requesting public 

comments on the proposed rules. The comment period lasts 60 days, at the end of which, the 

hearing is held. The Program and the Committee will meet, if necessary, before the hearing to 

address any changes considered necessary as a result of comments received during the 

comment period. Once the Board approves the new rule it goes into effect 2 months after the 

hearing. On average, the State can promulgate final effective regulations in 4 to 6 months, 

depending on the resolution of comments received during the various comment periods. The 

Program’s rules and regulations are exempt from the State’s “sunset” law. 

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

legally binding requirements no later than 3 years after the effective date of NRC’s regulations. 

The review team identified one regulation amendment that was overdue for adoption at the time 

of the review: 

● “Minor Amendments,” 10 CFR Parts 20, 30, 32, 35, 40 and 70 amendment (71 FR 

15005), that was due for Agreement State adoption on March 27, 2009. 

The review team identified the following NRC regulation amendments that the State will need to 

address in future rulemakings or by the adoption of alternate legally binding requirements: 

● “Medical Use of Byproduct Material – Minor Corrections and Clarifications,” 10 CFR 

Parts 32 and 35 amendment (72 FR 45147 and 72 FR 54207), that is due for Agreement 

State adoption by October 29, 2010. 

● “Requirements for Expanded Definition of Byproduct Material,” 10 CFR Parts 20, 30, 31, 

32, 33, 35, 61, and 150 amendment (72 FR 55864), that is due for Agreement State 

adoption by November 30, 2010. 

● “Exemptions From Licensing, General Licenses, and Distribution of Byproduct Material: 

Licensing and Reporting Requirements,” 10 CFR Parts 30, 31, 32 and 150 amendment 

(72 FR 58473), that is due for Agreement State adoption by December 17, 2010. 

● “Medical Use of Byproduct Material – Authorized User Clarification,” 10 CFR Part 35 

amendment (74 FR 33901), that is due for Agreement State adoption by September 28, 

2012. 

At the time of the review, the Program was in the process of addressing all overdue and 

upcoming regulation amendments. The Program had several rulemaking packages at various 
Colorado Final Report Page 13 

stages in their rule promulgation process that will address these regulation amendments. The 

Program anticipates these rulemaking packages to be finalized in summer or fall 2010. 

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

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

satisfactory. 

4.2 Sealed Source and Device Evaluation Program

In reviewing this indicator, the review team used three subelements to evaluate the Program’s 

performance regarding the SS&D evaluation program. These subelements were: (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 the 

information provided in response to the IMPEP questionnaire and evaluated the SS&D registry 

sheets and supporting documents processed during the review period. The review team also 

evaluated SS&D staff training records, the use of guidance documents and procedures, and 

interviewed the staff currently conducting SS&D evaluations. 

4.2.1 Technical Staffing and Training

SS&D evaluation responsibilities are mainly distributed between senior license evaluators who 

are fully qualified to perform SS&D evaluations. Since the last review, three individuals have 

been trained to perform SS&D evaluations and have attended NRC’s SS&D Workshop. During 

the review period, one of the fully qualified SS&D evaluators retired from the program. 

At the time of the review, the Program had five reviewers who are qualified to perform safety 

evaluations of SS&D applications. The review team interviewed staff members involved in the 

reviews and determined that they were familiar with the procedures used in the evaluation of a 

source/device and had access to applicable reference documents. The review team determined 

that the Program’s staffing and training with respect to SS&D evaluations is adequate based on 

the Program’s SS&D workload. 

4.2.2 Technical Quality of the Product Evaluation Program

During the review period, the Program conducted 2 new evaluations, issued 8 amendments to 

existing registrations, and inactivated 13 registrations. The review team evaluated 7 of the 23 

SS&D actions, including custom evaluations issued by the Program during the review period. 

The selected casework represented the work of all the individuals involved with SS&D 

evaluations during the review period. During the review, the Program compiled an updated list 

of registrations and determined that there are currently eight active SS&D registrations in the 

State of Colorado. A list of SS&D casework examined, with the case-specific comments, can be 

found in Appendix F. 

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

contained in the Program’s response to the IMPEP questionnaire for this indicator, evaluated 

casework, and interviewed program staff and managers. The review team verified that the 
Colorado Final Report Page 14 

Program’s SS&D reviewers had access to the guidance in NRC’s SS&D Workshop; NUREG1556, Volume 3, Revision 1; and applicable and pertinent American National Standards Institute 

standards, when conducting SS&D evaluations. The review team found that these documents 

were generally used and followed during SS&D reviews. 

The review team noted that the Program’s practice is to print e-mail correspondence and any 

associated attachments and include the documents in the registry file; however, the review team 

found cases where the application or attachments containing critical information; such as 

engineering drawings, radiation profiles, and results of tests conducted by the applicant; for the 

evaluation were not retained or printed out for future reference. This documentation issue is 

consistent with the review team’s observations under other performance indicators. 

The Program uses the manufacturer’s radioactive materials possession license for legal means 

to enforce commitments that a manufacturer makes in its SS&D applications. Without the 

appropriate documentation, the manufacturers’ commitments may not be legally enforceable. 

During the casework evaluations, the review team also noted that the license conditions tying 

the manufacturer to its commitments were inconsistently worded and did not include all the 

registries issued to the manufacturer. The review team concluded that the consistency of the 

wording of the license condition varied between SS&D reviewers and was dependent on the 

reviewer’s experience with SS&D registries. 

Based on casework evaluations and interviews with staff, the review team identified Program 

practices that differ from those specified in NUREG-1556, Volume 3, Revision 1. The review 

team’s observations of these differing practices are noted in Appendix F as comments for 

each of the cases that were reviewed. Some of these issues were repetitive, such as 

documentation of items reviewed when transferring a registry to inactive status, lack of 

protection of proprietary information, and inconsistent issuance dates and review dates. The 

review team determined that the technical quality of the safety evaluations was not 

compromised by any of these administrative issues and practices; however, the review team 

recognized the potential for the Program to experience difficulty in recreating the evaluations 

to support its regulatory decisions if generic health or safety issues with any of the devices for 

which the Program issued certificates are identified. The review team attributed the Program’s 

infrequency of performing reviews as an underlying cause of the observed administrative 

issues and practices. The review team discussed with Program managers the importance of 

retention of all necessary documentation for legal enforceability and adherence to the 

guidance in NUREG-1556, Volume 3, Revision 1, for consistency in registry quality and 

content across the nation. The review team recommends that the State establish a means to 

ensure that SS&D evaluations are appropriately documented and conducted with 

thoroughness; consistency with the current version of NUREG-1556, Volume 3; and 

adherence to existing guidance in product evaluations. 

4.2.3 Evaluation of Defects and Incidents Regarding SS&Ds

No incidents related to SS&D defects involving sources or devices registered by the State of 

Colorado were reported during the review period. Incident procedures are in place should an 

SS&D-related incident occur. The Program is aware of the need to review such incidents as 

potentially generic in nature with possible wide-ranging effects. 
Colorado Final Report Page 15 

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

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

Program, was satisfactory, but needs improvement. 

4.3 Low-level Radioactive Waste Disposal Program

In 1981, NRC amended its Policy Statement, “Criteria for Guidance of States and NRC in 

Discontinuance of NRC Authority and Assumption Thereof by states Through Agreement,” to 

allow a State to seek an amendment for the regulation of low-level radioactive waste (LLRW) as 

a separate category. Those States with existing Agreements prior to 1981 were determined to 

have continued LLRW disposal authority without the need of an amendment. Although the 

Colorado Agreement State Program has authority to regulate a LLRW disposal facility, NRC has 

not required States to have a program for licensing a disposal facility until such time as the 

State has been designated as a host State for a LLRW disposal facility. When an Agreement 

State has been notified or becomes aware of the need to regulate a LLRW disposal facility, it is 

expected to put in place a regulatory program that will meet the criteria for an adequate and 

compatibility LLRW program. There are no plans for a commercial LLRW disposal facility in 

Colorado. Accordingly, the review team did not review this indicator. 

4.4 Uranium Recovery Program

In reviewing this indicator, the review team used five subelements to evaluate the Program’s 

performance regarding the uranium recovery program. These subelements were: (1) Technical 

Staffing and Training, (2) Status of the Uranium Recovery Inspection Program, (3) Technical 

Quality of Inspections, (4) Technical Quality of Licensing Actions, and (5) Technical Quality of 

Incident and Allegation Activities. 

At the time of the IMPEP review, Colorado’s uranium recovery program had regulatory oversight 

of six licenses (one site in standby and five sites in closure). Three of the five sites in closure 

have been remediated and are in the process of NRC concurrence for license termination 

and/or appropriate transfer to the U.S. Department of Energy’s long-term care program. The 

Program was also in the process of reviewing an application for a new facility. The license in 

standby and the new facility application are for conventional mills. The Program anticipates an 

application for an in-situ recovery facility in the near future. 

During the IMPEP period, the Program terminated two additional licenses. One license expired 

after the licensee abandoned the site prior to providing financial assurance. The other license, 

a conventional mill, was terminated and the property transferred to U.S. Department of Energy 

for long-term care. 

4.4.1 Technical Staffing and Training

In reviewing this subelement, the review team considered staffing level, technical qualifications 

of the staff, staff training, and staff turnover. 

At the time of the review, the Program had two technical personnel who perform the vast 

majority of the project management, inspections, and licensing action reviews or Colorado’s 

uranium recovery licensees. The Program has dedicated 1.5 FTE to the uranium recovery 
Colorado Final Report Page 16 

program between these two individuals. The staff has training in health physics or 

geology/geophysics. Technical staff members from the Unit assist with inspection and licensing 

activities at the sites. The Program also has access to individuals from other programs in the 

Division for technical support. 

An equivalent of 1.2 FTE assigned to the uranium recovery program was lost through retirement 

of personnel since the 2006 IMPEP. As noted in Section 3.1 of this report, the Program is 

evaluating its staffing needs in preparation of an anticipated retirement to see if additional 

support is needed in the uranium recovery area given the potential for new sites to come under 

their regulatory purview. 

The review team examined staff training records as well as interviewed various staff members 

regarding training efforts. During the IMPEP review period, the training attended by uranium 

recovery staff was equivalent to two NRC-sponsored courses for each staff member. In 

addition, Colorado will host NRC’s Health Physics for Uranium Recovery (F-104) course in 

July 2010. 

The review team determined that the Program’s staffing levels and qualifications for the uranium 

recovery program were adequate for the Program’s workload at the time of the review. 

4.4.2 Status of the Uranium Recovery Inspection Program 

In reviewing this subelement, the review team evaluated the Program’s inspection frequency for 

uranium recovery licensees and the Program’s timeliness of communicating inspection findings 

to the licensees. The review team’s evaluation is based on Colorado’s response to the 

questionnaire relative to this indicator, the uranium recovery inspection schedule, selected 

inspection casework files, and interviews with inspection staff and managers. 

During the review period, Colorado performed 18 license inspections at 7 licensees. The 

inspections were performed in accordance with frequencies prescribed by NRC’s IMC 2801, 

“Uranium Mill and 11e.(2) Byproduct Material Disposal Site and Facility Inspection Program.” 

The inspection reports were generally completed within 45 days of the inspection, as expected 

for team inspections. Three inspection reports were completed outside of the 45-day period 

(49, 53, and 74 days). 

4.4.3 Technical Quality of Inspections

In reviewing this subelement, the review team examined inspection reports for six inspections 

conducted by Colorado during the review period and accompanied inspectors on an inspection 

at one licensed facility. The uranium recovery program inspection files evaluated by the review 

team, as well as the inspector accompaniment, are listed in Appendix C. The cases selected for 

review represented a range of uranium recovery activities in different stages of operation. The 

review team interviewed inspectors and managers to assess the adequacy of their preparation 

for the inspections, guidance and/or protocols for inspection procedures, the depth and content 

of the actual inspections, and the appropriateness of inspection findings. 

The inspector accompaniments and casework reviews confirmed that Colorado inspections 

were thorough, of good quality, and included operational and record reviews. The inspectors 
Colorado Final Report Page 17 

communicated findings and violations to the licensee during the inspection and exit interviews. 

The inspectors focused on compliance issues, adherence to procedures, and protection of 

public and worker health and safety. The inspectors concentrated on worker’s health and health 

physics monitoring and environmental monitoring during records reviews. Due to time 

limitations, not all records were reviewed at each inspection; however, the Program’s 

procedures require that records not reviewed for one inspection will be reviewed during the next 

inspection. The Program took appropriate enforcement actions based on the severity of 

violations observed during inspections. 

4.4.4 Technical Quality of Licensing Actions

For this subelement, the review team examined files and associated documentation related to 

licensing of in-situ and conventional mill facilities, license amendment files, and other licensing 

documentation. Appendix D lists the licensing files reviewed. Based on the casework 

evaluated, the review team concluded that the licensing actions were of high technical quality 

and were consistent with Program procedures, State regulations, and good health physics 

practices. 

The licensing actions during the review period consisted of a completeness review of a new 

application, license renewals and various amendments, decommissioning plans, annual 

financial assurance updates, compliance monitoring, and post-decommissioning monitoring for 

groundwater compliance. The Program reported over 300 licensing actions completed during 

the review period and 15 licensing actions still open at the time of the IMPEP. Of the 15 

licensing action not completed, the delay for only one action was attributed to staffing levels. 

That action was reassigned and was expected to be completed shortly after the time of the 

review. 

A large portion (133 actions) of the licensing actions consisted of document reviews for one 

licensee, the Cotter Corporation Canon City Mill. In some cases, the review documents did not 

include a decision of record, final evaluation report, or similar documentation with the final 

conclusions of the staff’s evaluation of the proposed action. Intermediate reviews (e.g., request 

for additional information) and final detailed letters of approval did exist for most of the more 

significant licensing actions. The review team concluded that the lack of documentation was 

administrative, as noted in earlier sections of this report, and did not affect the technical quality 

of the Program’s licensing. The review team discussed with Program managers and staff the 

importance of documenting final decisions to instill public confidence in that decision and to 

support requests for technical assistance from Federal or other State agencies. 

In regard to the new application, the review team looked at Colorado’s process for issuing a new 

license. Colorado’s procedure for reviewing an application for a new source and 11e.(2) 

byproduct material license consists of a completeness review, two public meetings by the 

licensee, funding for the county in which the proposed facility is located to provide comments on 

the applicant’s environmental report, a minimum 270-day period for staff review of the 

application and publication of a final licensing decision, and an opportunity for hearing following 

publication of the decision document and issuance of the license. The Program informed the 

review team that the public has the opportunity to submit comments throughout the new 

application’s review period. The Program also informed the review team that any “affected 

party” can request a hearing after the decision document is published and the license is issued. 
Colorado Final Report Page 18 

4.4.5 Technical Quality of Incident and Allegation Activities

For this subelement, the review team examined files and associated documentation related to 

incident and allegation activities, response timeliness, and inspection reports; and interviewed 

the inspection personnel involved with incident and allegation activities. 

The review team evaluated the Program’s response to three incidents involving uranium 

recovery operations. A listing of the incident casework examined can be found in Appendix E. 

The review team concluded that the Program’s investigations were thorough and adequately 

determined the root causes for the three incidents. The Program took appropriate enforcement 

actions based on the severity of the violations noted. 

Based on the IMPEP evaluation criteria, the review team recommends that Colorado’s 

performance with respect to the indicator, Uranium Recovery Program, be found satisfactory. 

5.0 SUMMARY 

As noted in Sections 3.0 and 4.0, Colorado’s performance was found satisfactory for seven of 

the eight performance indicators review and satisfactory, but needs improvement, for the 

performance indicator, Sealed Source and Device Evaluation Program. The review team made 

four recommendations regarding program performance by the State and kept open one 

recommendation from the previous review. Overall, the review team recommended, and the 

MRB agreed, that the Colorado Agreement State Program is adequate to protect public health 

and safety and compatible with NRC’s program. Based on the results of the current IMPEP 

review, the review team recommended, and the MRB agreed, that the next full IMPEP review 

take place in approximately 4 years. 

Below are the recommendations, as mentioned in an earlier section of the report, for evaluation 

and implementation by the State: 

1. The review team recommends that the State develop and implement a policy and 

procedure for the handling, marking, transmitting, and storing of documents containing 

sensitive information. (Section 3.3) (Recommendation also applies to Sections 3.4 

and 3.5) 

2. The review team recommends that the State evaluate its license termination and 

decommissioning processes to ensure that reviews are appropriate, thorough, and 

consistent. (Section 3.4 of the 2006 IMPEP Review) (Modified in 2010) 

3. The review team recommends that the State development and implement guidance that 

outlines the roles and responsibilities for staff and the expectations regarding record 

retention to ensure that the Program’s files are complete and comprehensive. 

(Section 3.4) (Recommendation also applies to Sections 3.5 and 4.4.2) 

(Continued on next page.) 
Colorado Final Report Page 19 

4. The review team recommends that the State review its implementation of the prelicensing guidance to ensure that all of the essential elements of the guidance are 

consistently met. (Section 3.4) 

5. The review team recommends that the State establish a means to ensure that SS&D 

evaluations are appropriately documented and conducted with thoroughness; 

consistency with the current version of NUREG-1556, Volume 3; and adherence to 

existing guidance in product evaluations. (Section 4.2.2) 
LIST OF APPENDIXES AND ATTACHMENT 

Appendix A IMPEP Review Team Members 

Appendix B Colorado Organization Charts 

Appendix C Inspection Casework Reviews 

Appendix D License Casework Reviews 

Appendix E Incident Casework Reviews 

Appendix F Sealed Source & Device Casework Reviews 

Attachment May 27, 2010 Letter from Gary W. Baughman 

Colorado’s Response to the Draft Report 
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Aaron McCraw, FSME Team Leader 

 Technical Staffing and Training 

 Technical Quality of Incident and Allegation 

 Activities 

 Compatibility Requirements 

Randy Erickson, Region IV Status of Materials Inspection Program 

 Technical Quality of Inspections 

 Inspector Accompaniments 

Dennis Lawyer, Region I Technical Quality of Licensing Actions 

Tristan Timm, Florida Technical Quality of Incident and Allegation 

 Activities 

 Sealed Source and Device Evaluation Program 

John Saxton, FSME Uranium Recovery Program 

 Inspector Accompaniments
APPENDIX B 

COLORADO ORGANIZATION CHARTS 

ADAMS ACCESSION NO.: ML101180112 
APPENDIX C 

INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Swedish Medical Center License No.: 251-02 

Inspection Type: Special, Announced Priority: 2 

Inspection Date: 2/22/10 Inspector: ES 

File No.: 2 

Licensee: Acuren Inspection, Inc. License No.: 997-01 

Inspection Type: Special, Announced Priority: 1 

Inspection Date: 2/23/10 Inspectors: MD 

File No.: 3 

Licensee: Medical Center of the Rockies License No.: 1112-01 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 2/24/10 Inspectors: JG 

File No.: 4 

Licensee: Lutheran Medical Center License No.: 227-02 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 2/25/10 Inspector: JJ 

File No.: 5 

Licensee: PETNET Solutions, Inc. License No.: 990-02 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 2/26/10 Inspector: CE 

 

File No.: 6 

Licensee: Western Cardiology Nuclear Imaging Labs License No.: 641-01 

Inspection Type: Routine, Announced Priority: 3 

Inspection Dates: 5/12/06 Inspector: ES 

Comments: 

a) The Program performed the inspection 108 days overdue. 

b) The Program issued the inspection findings to the licensee 54 days after the inspection. 

File No.: 7 

Licensee: Mallinckrodt, Inc. License No.: 859-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 8/6/08 Inspector: JG 
Colorado Final Report Page C.2 

Inspection Casework Reviews 

File No.: 8 

Licensee: National Jewish Medical and Research Center License No.: 222-03 

Inspection Type: Routine/Special, Announced Priority: 1 

Inspection Dates: 3/7/07 and 3/19/07 Inspector: JO 

File No.: 9 

Licensee: St. Anthony North Hospital License No.: 152-02 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 2/17/10 Inspectors: JD, ES 

File No.: 10 

Licensee: Aspen Valley Hospital License No.: 861-01 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 3/23/06 Inspector: JJ 

Comments: 

a) The Program performed the inspection 23 days overdue. 

b) The Program issued the inspection findings to the licensee 49 days after the inspection. 

File No.: 11 

Licensee: University of Colorado Health Science Center License No.: 835-01 

Inspection Type: Special Priority: 2 

Inspection Dates: 1/11/07 Inspector: TP 

File No.: 12 

Licensee: Halliburton Energy Services, Inc. License No.: 120-01 

Inspection Type: Special, Announced Priority: 3 

Inspection Date: 2/15/07 Inspectors: TB, PE 

File No.: 13 

Licensee: Schlumberger Technology Corporation License No.: 039-01 

Inspection Type: Special, Announced Priority: 3 

Inspection Date: 8/17/06 Inspector: TP 

File No.: 14 

Licensee: J-W Wireline Company License No.: 1138-01 

Inspection Type: Initial, Announced Priority: 3 

Inspection Date: 7/23/08 Inspectors: ES, MD 

File No.: 15 

Licensee: Radiation Therapy Center of Thornton License No.: 1134-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 4/4/08 Inspector: JO 
Colorado Final Report Page C.3 

Inspection Casework Reviews 

File No.: 16 

Licensee: Utah Inspection, LLC License No.: 1043-01 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 12/18/07 Inspector: PE 

Comment: 

 The Program performed the inspection 288 days overdue. 

File No.: 17 

Licensee: Poudre Valley Hospital License No.: 123-01 

Inspection Type: Special, Announced Priority: 5 

Inspection Date: 8/16/06 Inspector: JJ 

File No.: 18 

Licensee: Lockheed Martin Space Systems License No.: 012-12 

Inspection Type: Special, Announced Priority: 5 

Inspection Date: 11/1/06 Inspector: JO 

File No.: 19 

Licensee: High Mountain Inspection Services License No.: 1042-01 

Inspection Type: Initial/Special, Announced Priority: 1 

Inspection Date: 1/6/10 Inspectors: ES, CE 

File No.: 20 

Licensee: High Mountain Inspection Services License No.: 1042-01 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 10/23/07 Inspectors: TP, SL 

Comment: 

 The Program performed the inspection 4 days overdue. 

File No.: 21 

Licensee: MDS Nordion License No.: NRC 54-28274-01 

Inspection Type: Reciprocity, Unannounced Priority: 5 

Inspection Date: 6/6/07 Inspectors: JO, JJ, MD 

File No.: 22 

Licensee: SABIA, Inc. License No.: NRC 11-27727-01 

Inspection Type: Reciprocity, Unannounced Priority: 5 

Inspection Date: 12/1/06 Inspector: PE 

File No.: 23 

Licensee: Olsson Associates License No.: NE 59-08-01 

Inspection Type: Reciprocity, Unannounced Priority: 1 

Inspection Date: 3/17/10 Inspector: MD 
Colorado Final Report Page C.4 

Inspection Casework Reviews 

File No.: 24 

Licensee: Nondestructive & Visual Inspection License No.: LA-5601-L01 

Inspection Type: Reciprocity, Unannounced Priority: 1 

Inspection Date: 7/25/07 Inspector: PE 

File No.: 25 

Licensee: Alpha Omega Services, Inc. License No.: CA 3925-19 

Inspection Type: Reciprocity, Unannounced Priority: 5 

Inspection Date: 3/24/09 Inspector: JJ 

File No.: 26 

Licensee: JL Shepherd & Associates License No.: CA 1779-19 

Inspection Type: Reciprocity, Unannounced Priority: 5 

Inspection Dates: 1/27-28/09 Inspector: MD 

File No.: 27 

Licensee: Littleton Equine Medical Center License No.: 1163-01 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 1/20/10 Inspectors: CE, PP 

File No.: 28 

Licensee: Cardinal Health License No.: 392-03 

Inspection Type: Routine, Announced Priority: 2 

Inspection Dates: 10/19/09 and 10/22/09 Inspectors: JG, CE 

File No.: 29 

Licensee: Midwest Inspection Services License No.: 902-01 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 8/7/08 Inspectors: MD, ES 

File No.: 30 

Licensee: Colorado Medical Cyclotron, Inc. License No.: 990-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 12/4/08 Inspectors: JG, CE 

Comment: 

 The Program performed the inspection 118 days overdue. 

File No.: 31 

Licensee: Parkwest Medical Imaging License No.: 1114-01 

Inspection Type: Initial, Announced Priority: 5 

Inspection Date: 10/5/07 Inspector: ES 

Comment: 

 The Program performed the inspection 51 days overdue. 
Colorado Final Report Page C.5 

Inspection Casework Reviews 

File No.: 33 

Licensee: Barry Smith, M.D. License No.: 1110-01 

Inspection Type: Initial, Announced Priority: 3 

Inspection Date: 8/1/07 Inspector: JJ 

Comment: 

 The Program performed the inspection 174 days overdue. 

File No.: 34 

Licensee: Cotter Corporation, Canon City License No.: 369-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 5/6/09 Inspectors: PE, EE, MD, JD 

Comment: 

The Program issued the inspection findings to the licensee 49 days after the inspection. 

File No.: 35 

Licensee: Cotter Corporation, Canon City License No.: 369-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 5/14/08 Inspector: JG 

Comment: 

The Program issued the inspection findings to the licensee 74 days after the inspection. 

File No.: 36 

Licensee: UMETCO Maybell License No.: 660-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 10/15/08 Inspector: PE 

File No.: 37 

Licensee: UMETCO Maybell License No.: 660-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 4/26/06 Inspectors: PE, EE 

File No.: 38 

Licensee: UMETCO Uravan License No.: 660-02 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 8/13/09 Inspectors: PE, ES 

File No.: 39 

Licensee: CSMRI - Creekside License No.: 617-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 2/25/09 Inspector: EE 
Colorado Final Report Page C.6 

Inspection Casework Reviews 

INSPECTOR ACCOMPANIMENTS 

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

Accompaniment No.: 1 

Licensee: Swedish Medical Center License No.: 251-02 

Inspection Type: Special, Announced Priority: 2 

Inspection Date: 2/22/10 Inspector: ES 

Accompaniment No.: 2 

Licensee: Acuren Inspection, Inc. License No.: 997-01 

Inspection Type: Special, Announced Priority: 1 

Inspection Date: 2/23/10 Inspector: MD 

Accompaniment No.: 3 

Licensee: Medical Center of the Rockies License No.: 1112-01 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 2/24/10 Inspector: JG 

Accompaniment No.: 4 

Licensee: Lutheran Medical Center License No.: 227-02 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 2/25/10 Inspector: JJ 

Accompaniment No.: 5 

Licensee: PETNET Solutions, Inc. License No.: 990-02 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 2/26/10 Inspector: CE 

Accompaniment No.: 6 

Licensee: Cotter Corporation, Canon City License No.: 369-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Dates: 3/29-31/10 Inspectors: PE, EE, JG, CE 
APPENDIX D 

LICENSE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Colorado State University, Environmental Health Services License No.: 002-27 

Type of Action: Amendment Amendment No.: 19 

Date Issued: 10/5/09 License Reviewer: JJ 

File No.: 2 

Licensee: University of Colorado License No.: 082-08 

Type of Action: Renewal Amendment No.: 44 

Date Issued: 4/6/09 License Reviewer: CE 

Comment: 

The Program has required the licensee to provide financial assurance; however, the 

basis for the amount of financial assurance was not documented in the file. 

File No.: 3 

Licensee: Red Hill Forest Property Owner’s License No.: 794-1 

 Mutual Water & Cattle Assoc. 

Type of Action: Renewal Amendment No.: 03 

Date Issued: 10/27/06 License Reviewer: EE 

File No.: 4 

Licensee: Presbyterian/St. Luke’s Medical Center License No.: 632-06 

Type of Action: Renewal Amendment No.: 14 

Date Issued: 7/19/06 License Reviewer: JO 

File No.: 5 

Licensee: American Piping Inspection, Inc. License No.: 1169-01 

Type of Action: New Amendment No.: 00 

Date Issued: 12/17/09 License Reviewer: JD 

Comment: 

Part of the licensee’s application was missing from the file. 

File No.: 6 

Licensee: National Inspection Services, LLC License No.: 1159-01 

Type of Action: New Amendment No.: 00 

Date Issued: 7/24/09 License Reviewer: JG 
Colorado Final Report Page D.2 

License Casework Reviews 

File No.: 7 

Licensee: Baker Hughes Oilfield Operations License No.: 1072-01 

Type of Action: Renewal Amendment No.: 11 

Date Issued: 10/30/09 License Reviewer: JD 

Comment: 

 The current license (Amendment No. 11) was not in the file. 

File No.: 8 

Licensee: Presbyterian/St. Luke’s Medical Center License No.: 632-06 

Type of Action: Amendment Amendment No.: 20 

Date Issued: 11/4/09 License Reviewer: JJ 

File No.: 9 

Licensee: Isogenis, Inc. License No.: N/A 

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

Date Issued: 5/22/08 License Reviewer: JG 

File No.: 10 

Licensee: Quinn Testing, LLC License No.: 1137-01 

Type of Action: Termination Amendment No.: 01 

Date Issued: 7/10/09 License Reviewer: JD 

File No.: 11 

Licensee: Gilead Colorado, Inc. License No.: 1002-01 

Type of Action: Termination Amendment No.: 17 

Date Issued: 2/19/10 License Reviewer: CE 

Comment: 

The Program did not request the licensee to submit all applicable information prior to 

terminating the licensee. 

File No.: 12 

Licensee: Conoco Phillips Pipeline Company License No.: 238-01 

Type of Action: Termination Amendment No.: 15 

Date Issued: 4/10/09 License Reviewer: JJ 

Comment: 

The Program did not request the licensee to submit all applicable information prior to 

terminating the licensee. 

File No.: 13 

Licensee: Greeley X-Ray Group, P.C. License No.: 1074-01 

Type of Action: Termination Amendment No.: 06 

Date Issued: 10/2/08 License Reviewer: CE 
Colorado Final Report Page D.3 

License Casework Reviews 

File No.: 14 

Licensee: Aeroflex Colorado Springs, Inc. License No.: 468-01 

Type of Action: Amendment Amendment No.: 05 

Date Issued: 11/03/08 License Reviewer: CE 

File No.: 15 

Licensee: Little Equine Medical Center License No.: 1163-01 

Type of Action: New Amendment No.: 00 

Date Issued: 7/21/09 License Reviewer: CE 

Comment: 

The Program did not perform a pre-licensing visit prior to issuing this license to an 

“unknown” entity. 

File No.: 16 

Licensee: ALS Laboratory Group, Environmental Division License No.: 847-02 

Type of Action: Amendment Amendment No.: 14 

Date Issued: 3/29/10 License Reviewer: EE 

Comment: 

The Program increased the amount of financial assurance required by this licensee; 

however, there was not supporting documentation in the file. 

File No.: 17 

Licensee: Forney Acquisitions, LLC License No.: 1172-01 

Type of Action: New Amendment No.: 00 

Date Issued: 3/18/10 License Reviewer: PP 

File No.: 18 

Licensee: Mallinckrodt, Inc. License No.: 859-01 

Type of Action: Amendment Amendment No.: 29 

Date Issued: 7/21/09 License Reviewer: MD 

File No.: 19 

Licensee: Rocky Mountain Gamma Knife Center, LLC License No.: 857-01 

Type of Action: Amendment Amendment No.: 20 

Date Issued: 8/20/09 License Reviewer: JJ 

File No.: 20 

Licensee: University and Colorado Hospital License No.: 828-01 

Type of Action: Amendment Amendment No.: 27 

Date Issued: 3/12/09 License Reviewer: MD 

File No.: 21 

Site: George E. Davis Mill Remediation Project License No.: N/A 

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

Date Issued: N/A License Reviewer: N/A 
Colorado Final Report Page D.4 

License Casework Reviews 

File No.: 22 

Licensee: Cotter Corporation, Canon City License No.: 369-01 

Type of Action: Document Review – 2008 Annual Report Amendment No.: N/A 

Date Issued: 11/4/09 License Reviewer: PE 

Comment: 

 An Evaluation Summary Report for this action was not in the file. 

File No.: 23 

Licensee: Cotter Corporation, Canon City License No.: 369-01 

Type of Action: Amendment Amendment No.: 52 

Date Issued: 10/6/08 License Reviewer: EE 

File No.: 24 

Licensee: Cotter Corporation, Canon City License No.: 369-01 

Type of Action: Document Review – Impoundment Dewatering Amendment No.: N/A 

Date Issued: 8/1/08 License Reviewer: PE 

Comment: 

 An Evaluation Summary Report for this action was not in the file. 

File No.: 25 

Licensee: Cotter Corporation, Canon City License No.: 369-01 

Type of Action: Document Review – Alternatives Analysis Amendment No.: N/A 

Date Issued: 5/2/08 License Reviewer: ST 

File No.: 26 

Licensee: Cotter Corporation, Canon City License No.: 369-01 

Type of Action: Document Review – Security Procedures Amendment No.: N/A 

Date Issued: 8/27/08 License Reviewer: ST 

File No.: 27 

Licensee: Cotter Corporation, Schwartzwalder Mine License No.: 369-02 

Type of Action: Document Review – Decommissioning Plan Amendment No.: N/A 

Date Issued: 8/27/08 License Reviewer: EE 

Comment: 

 Final decision documentation was not in the file. 

File No.: 28 

Licensee: Cotter Corporation, Schwartzwalder Mine License No.: 369-02 

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

Date Issued: 10/7/09 License Reviewer: EE 

Comment: 

 Final decision documentation was not in the file. 
Colorado Final Report Page D.5 

License Casework Reviews 

File No.: 29 

Licensee: Cotter Corporation, Schwartzwalder Mine License No.: 369-02 

Type of Action: Document Review – Occupational Dose Assessment Amendment No.: N/A 

Date Issued: 3/31/08 License Reviewer: EE 

Comment: 

 Evaluation or decision-supporting documentation was not in the file. 

File No.: 30 

Licensee: Umetco Minerals Corporation, Uravan License No.: 660-02 

Type of Action: Trip Report Amendment No.: N/A 

Date Issued: 4/10/06 License Reviewer: PS 

File No.: 31 

Licensee: Energy Fuels Resources License No.: 1170-01 

Type of Action: New – Completeness Review Amendment No.: N/A 

Date Issued: 12/18/09 License Reviewers: ST, PE, JG, EE, 

LB, CT, NC 
APPENDIX E 

INCIDENT CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Colorado State University License No.: 002-19 

Date of Incident: 8/31/09 NMED No.: 090740 

Investigation Date: None Type of Incident: Lost/Stolen Material 

 Type of Investigation: Licensee Report 

File No.: 2 

Licensee: Colorado State University License No.: 002-19 

Date of Incident: 7/11/07 NMED No.: 070442 

Investigation Date: 7/11/07 Type of Incident: Equipment Failure 

 Type of Investigation: E-mail 

File No.: 3 

Licensee: Suncor Energy USA License No.: 615-02 

Date of Incident: 8/19/09 NMED No.: 090680 

Investigation Date: 8/19/09 Type of Incident: Equipment Failure 

 Type of Investigation: Phone/E-mail 

File No.: 4 

Licensee: Schlumberger License No.: 39-01 

Date of Incident: 4/9/09 NMED No.: 090533 

Investigation Date: 4/10/09 Type of Incident: Abandoned Source 

 Type of Investigation: Licensee Report 

File No.: 5 

Licensee: St. Mary-Corwin Hospital License No.: 235-02 

Date of Incident: 3/18/09 NMED No.: 090646 

Investigation Date: 3/23/09 Type of Incident: Contamination 

 Type of Investigation: Phone/E-mail 

File No.: 6 

Licensee: Cardinal Health License No.: 392-03 

Date of Incident: 2/20/09 NMED No.: N/A 

Investigation Date: 2/20/09 Type of Incident: Compounding/Dispensing Error 

 Type of Investigation: E-mail 

File No.: 7 

Licensee: Skyridge Medical Center License No.: 1053-01 

Date of Incident: 3/4/08 NMED No.: 080146 

Investigation Date: 3/4/08 Type of Incident: Medical Event 

 Type of Investigation: E-mail 
Colorado Final Report Page E.2 

Incident Casework Reviews 

File No.: 8 

Licensee: Non-licensee License No.: Non-Licensee 

Date of Incident: 10/6/08 NMED No.: N/A 

Investigation Date: 10/6/08 Type of Incident: Public survey request 

 Type of Investigation: Site 

File No.: 9 

Licensee: Denver Heath Medical Center License No.: 97-04 

Date of Incident: 2/29/08 NMED No.: 080164 

Investigation Date: 2/29/08 Type of Incident: Contamination 

 Type of Investigation: Licensee Report 

File No.: 10 

Licensee: Suncor Energy USA License No.: 615-02 

Date of Incident: 11/8/07 NMED No.: 080050 

Investigation Date: 11/8/07 Type of Incident: Exposure to Public 

 Type of Investigation: Licensee Report 

File No.: 11 

Licensee: Rocky Mountain Cancer Center License No.: 1012-01 

Date of Incident: 11/28/06 NMED No.: N/A 

Investigation Date: 9/28/08 Type of Incident: Potential Overexposure 

 Type of Investigation: Licensee Report 

File No.: 12 

Licensee: Protechnics License No.: 545-01 

Date of Incident: 4/12/07 NMED No.: 070228 

Investigation Date: 4/13/07 Type of Incident: Contamination 

 Type of Investigation: Site 

File No.: 13 

Licensee: Conam Inspection License No.: 963-01 

Date of Incident: 10/30/07 NMED No.: N/A 

Investigation Date: 10/30/07 Type of Incident: Loss of control 

 Type of Investigation: Telephone/Interviews 

Comments: 

a) The Program did not appropriately mark or secure sensitive information in the file. 

b) The documentation of the interview with the radiation safety officer was not in the file. 

File No.: 14 

Licensee: Centura Health Penrose – St. Francis License No.: 197-02 

Date of Incident: 7/21/09 NMED No.: 090668 

Investigation Date: 7/21/09 Type of Incident: Medical Event 

 Type of Investigation: Telephone/Interviews 
Colorado Final Report Page E.3 

Incident Casework Reviews 

File No.: 15 

Licensee: Cotter Corporation, Canon City License No.: 369-01 

Date of Incident: 12/26/05 NMED No.: N/A 

Investigation Date: 1/12/06 Type of Incident: Employee Acid Burn 

 Type of Investigation: Site 

File No.: 16 

Licensee: Cotter Corporation, Canon City License No.: 369-01 

Date of Incident: 3/2/06 NMED No.: N/A 

Investigation Date: 5/31/06 Type of Incident: Yellowcake Drum Burst 

 Type of Investigation: Record Review 

File No.: 17 

Licensee: Cotter Corporation, Canon City License No.: 369-01 

Date of Incident: 2/15/06 NMED No.: N/A 

Investigation Date: 2/18/06 Type of Incident: Ore Truck Accident 

 Type of Investigation: Site 
APPENDIX F 

SEALED SOURCE & DEVICE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Registry No.: CO-1012-D-103-S SS&D Type: (T) Other 

Manufacturer: Thermo MF Physics Corporation Model No.: A-3031 

Date Issued: 6/1/09 Type of Action: New 

 SS&D Reviewers: ES, JJ 

Comments: 

a) The application and its attachments were not in the file or available for review. 

b) The issuance date (June 1, 2009) was prior to the date of the secondary review (signed 

on June 9, 2009). 

File No.: 2 

Registry No.: CO-1012-D-101-S SS&D Type: (T) Other 

Manufacturer: Thermo MF Physics Corporation Model No.: A-3000 Series 

Date Issued: 6/8/09 Type of Action: Amendment 

 SS&D Reviewers: ES, N/A 

Comment: 

 First page of the certificate lists “Custom Source” instead of “Custom Device.” 

File No.: 3 

Registry No.: CO-1230-D-101-S SS&D Type: (T) Other 

Manufacturer: Hazen Research, Inc. Model No.: NEM 16 Series Models 

Date Issued: 6/16/09 Type of Action: Amendment 

 SS&D Reviewers: JJ, ES 

Comments: 

a) The amended text was not shown in bold, which is the conventional method to show 

changes. 

b) First page of the certificate lists “Custom Source” instead of “Custom Device.” 

c) The issuance date (June 16, 2009) was prior to the date of the secondary review (signed 

on June 19, 2009). 

File No.: 4 

Registry No.: CO-1217-D-102-G SS&D Type: (N) Ion Generator 

Manufacturer: Particle Measuring Systems Model No.: Ion Mobility Spectrometry (IMS) 

Date Issued: 3/5/07 Type of Action: New 

 SS&D Reviewers: MD, JJ 

Comment: 

The first page lists the sealed source and model number designation on the same line as 

the isotope and maximum activity, which is not in accordance with the standard format in 

NUREG-1556, Vol. 3, Rev. 1. 
Colorado Final Report Page F.2 

Sealed Source & Device Casework Reviews 

File No.: 5 

Registry No.: CO-1113-S-801-S SS&D Type: (V) General Medical Use 

Manufacturer: Syncor Pharmaceuticals, Inc. Model No.: IBT-125-1 

Date Issued: 9/25/07 Type of Action: Inactivation 

 SS&D Reviewers: ES, TP 

Comment: 

No documentation in the file covering the items reviewed for “Transfer to Inactive Status” 

in accordance with the guidance in Section 13.4, NUREG-1556, Vol. 3, Rev. 1. 

File No.: 6 

Registry No.: CO-8187-D-801-E SS&D Type: (P) Ion Generators, Smoke Detectors 

Manufacturer: Statitrol Corporation Model No.: A-403, A-405, 1503, 1600, 1602 

Date Issued: 9/19/06 Type of Action: Inactivation 

 SS&D Reviewers: ES, JJ 

Comments: 

a) No documentation in the file covering the items reviewed for “Transfer to Inactive Status” 

in accordance with the guidance in Section 13.4, NUREG-1556, Vol. 3, Rev. 1. 

b) The issuance date (September 19, 2006) was prior to the date of the secondary review 

(signed on October 3, 2006). 

File No.: 7 

Registry No.: CO-8184-D-801-G SS&D Type: (T) Other 

Manufacturer: Lear Sigler, Inc. Model No.: Argos I 

Date Issued: 9/19/06 Type of Action: Inactivation 

 SS&D Reviewers: ES, JJ 

Comments: 

a) No documentation in the file covering the items reviewed for “Transfer to Inactive Status” 

in accordance with the guidance in Section 13.4, NUREG-1556, Vol. 3, Rev. 1. 

b) The issuance date (September 19, 2006) was prior to the date of the secondary review 

(signed on October 3, 2006).
ATTACHMENT 

May 27, 2010 Letter from Gary W. Baughman 

Colorado’s Response to the Draft Report 

ADAMS Accession No.: ML101540293