July 12, 2010 

Kevin Kinsall 

Policy Advisor on 

 Natural Resources 

Office of the Governor 

1700 West Washington Street 

Phoenix, AZ 85007 

Dear Mr. Kinsall: 

On June 22, 2010, the Management Review Board (MRB) met to consider the proposed final 

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

Agreement State Program. The MRB found the Arizona Program adequate to protect public 

health and safety, but needs improvement, and compatible with the U.S. Nuclear Regulatory 

Commission’s (NRC’s) program. Because of the significance of the findings, the MRB extended 

the period of Heightened Oversight of the Arizona Agreement State Program. Heightened 

Oversight is an increased monitoring process that NRC uses to follow the progress of 

improvement needed in an Agreement State program. It involves preparation of a program 

improvement plan, bimonthly conference calls, and submission of status reports prior to each 

call with the appropriate Arizona and NRC managers and staff members. 

Section 3.0, page 11, of the enclosed final report contains a summary of the review team’s 

findings and recommendations for the Arizona Agreement State Program. I request that you 

revise your existing Program Improvement Plan to address the review team’s 

recommendations, as some recommendations have changed since your plan was first 

implemented. I encourage you to take a close look at your Program Improvement Plan to 

ensure that the specific milestones listed in the plan meet the State’s needs for a path toward 

improvement. The revised plan should be submitted to NRC within 30 days of receipt of this 

letter. Upon review and approval of your revised Program Improvement Plan, NRC staff will 

commence bimonthly conference calls with the State. 

Based on the results of the current IMPEP review, a full IMPEP review will be scheduled 

approximately 2 years from the date of the 2010 followup IMPEP review. NRC will also conduct 

a periodic meeting with the State approximately 1 year after the 2010 followup IMPEP review. 

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. 
K. Kinsall - 2 - 

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/ 

 Michael F. Weber 

 Deputy Executive Director for Materials, Waste, 

 Research, State, Tribal, and Compliance Programs 

 Office of the Executive Director for Operations 

Enclosure: 

Arizona Final Followup IMPEP Report 

cc w/encl.: Aubrey Godwin, Director 

 Arizona Radiation 

 Regulatory Agency 
K. Kinsall - 2 - 

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/ 

 Michael F. Weber 

 Deputy Executive Director for Materials, Waste, 

 Research, State, Tribal, and Compliance Programs 

 Office of the Executive Director for Operations 

Enclosure: 

Arizona Final Followup IMPEP Report 

cc w/encl.: A. Godwin, Director 

 Arizona Radiation 

 Regulatory Agency 

DISTRIBUTION: 

See next page

 ML101790007 EDATS: FSME-2010-0182 

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

NAME ATMcCraw:knm1 ADias TReis RJLewis (TReis for) 

DATE 06/28/10 06/29/10 06/30/10 6/30/10 

OFFICE Tech Editor FSME DEDMRT 

NAME CPoland CACarpenter MFWeber 

DATE 07/01/10 07/02/10 07/12/10 

OFFICIAL RECORD COPY
Letter to K. Kinsall from Michael F. Weber dated: July 12, 2010 

Distribution: EDATS: FSME-2010-0182 

MSSA RF DCD (SP01) 

EDO RF 

RidsEdoMailCenter 

RidsFsmeOd 

RidsSecyCorrespondenceMailCenter Chairman Jaczko 

DJanda, RI Commissioner Svinicki 

RErickson, RIV/RSAO Commissioner Apostolakis 

EUllrich, RI Commissioner Magwood 

Santiago Rodriguez, NM Commissioner Ostendorff 

MBeardsley, FSME/MSSA SECY 

AHowell, RIV 

KBrock, OEDO 

CMiller, FSME 

BJones, OGC 

JKinneman, RI 

Gary Robertson, Washington 

JOlmstead, OGC 

APowell, OCA (2 copies) 
Enclosure 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

FOLLOWUP REVIEW OF THE ARIZONA AGREEMENT STATE PROGRAM 

March 29 – April 1, 2010 

FINAL REPORT
Arizona Final Followup Report Page 1 

1.0 INTRODUCTION 

This report presents the results of the followup review of the Arizona Agreement State Program, 

conducted March 29 – April 1, 2010. The followup review was conducted by a review team 

composed of technical staff members from the U.S. Nuclear Regulatory Commission (NRC) and 

the State of New Mexico. Review team members are identified in Appendix A. The followup 

review was conducted in accordance with NRC Management Directive 5.6, “Integrated Materials 

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

followup review, which covered the period of March 15, 2008, to April 1, 2010, were discussed 

with Arizona managers on the last day of the review. 

A draft of this report was issued to Arizona for factual comment on May 3, 2010. The State 

responded by letter dated June 4, 2010, from Aubrey Godwin, Director, Radiation Regulatory 

Agency (the Agency). A copy of the State’s response is included as the Attachment to this 

report. The Management Review Board (MRB) met on June 22, 2010, to consider the proposed 

final report. The MRB found the Arizona Agreement State Program adequate to protect public 

health and safety, but needs improvement, and compatible with NRC’s program. Because of 

the significance of the findings, the MRB extended the period of Heightened Oversight of the 

Arizona Agreement State Program. 

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

reports directly to the Governor. An organization chart for the Agency is included as 

Appendix B. 

At the time of the review, the Agency regulated 376 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 Arizona. 

On July 21, 2008, the MRB found the Arizona Agreement State Program adequate to protect 

public health and safety, but needs improvement, and compatible with NRC’s program. 

Because of the significance of the findings, the MRB placed the State on Heightened Oversight. 

The MRB requested that a followup review take place approximately 1 year after the 2008 

IMPEP review. This followup review was delayed for 1 additional year to provide the Agency 

adequate time to implement the actions necessary to address the recommendations from the 

2008 IMPEP review, as outlined in the Agency’s Program Improvement Plan (the Plan). 

As part of the Heightened Oversight process, NRC conducted bimonthly conference calls with 

the Agency to discuss Arizona’s progress in implementing the Plan. The Agency submitted the 

Plan on September 22, 2008; however, NRC did not approve the Plan until May 19, 2009, at 

which point the Agency had resolved all of NRC staff’s comments on the original Plan and the 

bimonthly conference calls began. Conference calls were held July 30, 2009; September 30, 

2009; and January 14, 2010. A listing of correspondence and summaries from the bimonthly 

calls is included as Appendix C. Arizona’s actions and respective statuses, as documented in 

the Plan and subsequent status updates, were reviewed in preparation for this followup review. 

The followup review focused on the State’s performance in regard to the common performance 

indicators: Technical Staffing and Training, Status of Materials Inspection Program, Technical 
Arizona Final Followup Report Page 2 

Quality of Inspections, and Technical Quality of Licensing Actions. The followup review also 

included evaluation of the actions taken by the State to address the recommendations made 

during the 2008 IMPEP review. Other aspects of the program not fully evaluated as part of the 

followup review were discussed at a periodic meeting held in conjunction with the review. The 

periodic meeting summary is included as Appendix D. 

In preparation for the followup review, a questionnaire addressing the applicable performance 

indicators was sent to the Agency on December 11, 2009. The Agency provided responses to 

the questionnaire on March 18, 2010, and March 26, 2010. A consolidated copy of the 

questionnaire responses can be found in NRC’s Agencywide Documents Access and 

Management System (ADAMS) using the Accession Number ML101120109. 

The review team's general approach for conduct of this followup review consisted of: 

(1) examination of Arizona’s response to the questionnaire; (2) review of the Heightened 

Oversight information, including status reports; (3) review of applicable Arizona statutes and 

regulations; (4) analysis of quantitative information from the Agency’s licensing and inspection 

database; (5) technical evaluation of selected regulatory actions; (6) field accompaniments of 

three Arizona inspectors; and (7) interviews with staff and managers. The review team 

evaluated the information gathered against the IMPEP performance criteria for the four common 

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

performance. 

Results of the review of four common performance indicators are presented in Section 2.0. 

Section 3.0 summarizes the followup review team's findings and the open recommendations. 

2.0 COMMON PERFORMANCE INDICATORS 

The followup review addressed four of the five common performance indicators used to review 

NRC Regional and Agreement State radioactive materials programs. These indicators that 

were reviewed during the followup review were: (1) Technical Staffing and Training, (2) Status 

of Materials Inspection Program, (3) Technical Quality of Inspections, and (4) Technical Quality 

of Licensing Actions. 

2.1 Technical Staffing and Training

During the followup review, the review team evaluated actions taken by the Agency in response 

to the finding of satisfactory, but needs improvement, made during the 2008 IMPEP review, as 

well as the status of the staffing and training of the Agency. 

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

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

these issues, the review team examined the Agency’s questionnaire responses relative to this 

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

records, and considered any possible workload backlogs. 

The Agency is composed of several regulatory programs, one of which is the Radioactive 

Materials Program (the Program), which handles the day-to-day operations of the Arizona 

Agreement State Program. The Program is responsible for radioactive materials licensing, 
Arizona Final Followup Report Page 3 

inspection, and some emergency response activities. During the review period, activities 

involving non-ionizing radiation were moved out of the Program and to another program within 

the Agency. Since the 2008 IMPEP review, three staff members, including the Program 

Manager, left the Program. One staff member, who was already a qualified materials inspector 

through working in the Arizona and Nevada Agreement State Programs, was hired in March 

2010. At the time of the followup review, the Program was budgeted for one vacant Program 

Manager position and four technical staff positions, two of which were vacant. 

Due to State budget constraints, the vacant positions in the Program can only be filled on a 

case-by-case basis. In order to maintain Program stability, the Agency Director used two 

qualified technical staff members from the Emergency Response Program to conduct 

radioactive materials inspections. In addition, the X-Ray Program Manager assumed the duties 

of the Radioactive Materials Program Manager, which account for approximately 30 percent of 

his duties. By sharing resources among Agency programs, the Program worked off the backlog 

of overdue inspections that was identified during the 2008 IMPEP; however, the review team 

believes that long-term stability of the Program could be at risk if the vacant positions are not 

filled in a timely manner. During the 2006 IMPEP review, a recommendation was made that the 

Agency develop and implement a staffing plan to meet Program needs and maintain long-term 

stability. In response to the recommendation, the Agency submitted a staffing and budget plan 

covering Arizona Fiscal Years 2007 to 2011. The plan was last updated for Fiscal Year 2008. 

The review team recommends that the State review and update, if appropriate, the Agency’s 

staffing and budget plan to ensure Program needs are met and to maintain long-term stability of 

the Program. 

The Agency has a documented training plan equivalent to the guidance in NRC’s Inspection 

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

Safeguards Program Area.” Through interviews, the review team verified that managers and 

technical staff who participate in Program activities, including those staff members who are 

assigned to the Emergency Response and X-Ray Programs, were aware of the Agency’s 

training plan and qualification journals. Technical staff members attend NRC training courses, 

including two X-Ray inspectors who are being cross-trained to perform radioactive materials 

inspections in the future. 

The review team’s evaluation of the Agency’s responses to Recommendations 1 and 2 of the 

2008 IMPEP report is presented below: 

Recommendation 1: 

The review team recommends that the State develop and use qualification journals to track and 

monitor training for technical staff. (Section 3.1 of the 2008 IMPEP report) 

Status: 

The Agency developed a training program for radioactive materials inspectors and license 

reviewers and implemented the use of qualification journals to track and monitor training for 

technical staff. The qualification journals are maintained by the X-Ray/Radioactive Materials 

Program Manager. This recommendation is closed. 
Arizona Final Followup Report Page 4 

Recommendation 2: 

The review team recommends that the State ensure that license reviewers be provided 

appropriate training to ensure familiarity with medical license modalities. (Section 3.1 of the 

2008 IMPEP report) 

Status: 

The review team noted that, since the last review, the materials license reviewer received 

additional training in the medical licensing area. This training included on-the-job mentoring 

from a qualified NRC license reviewer and successful completion of two NRC qualification 

courses: 1) Diagnostic and Therapeutic Nuclear Medicine and 2) Brachytherapy and Gamma 

Knife. The review team noted that the technical quality of medical licensing actions improved 

since the last review. This recommendation is closed. 

The review team concluded that the Agency’s training program improved; however, staffing 

continued to be a concern due to the number of vacant positions in the Program. Based on the 

IMPEP evaluation criteria, the review team recommended, and the MRB agreed, that Arizona’s 

performance with respect to the indicator, Technical Staffing and Training, continued to be 

satisfactory, but needs improvement. 

2.2 Status of Materials Inspection Program

During the followup review, the review team evaluated actions taken by the Agency in response 

to the finding of unsatisfactory made during the 2008 IMPEP review, as well as the overall 

status of the inspection program. 

The review team evaluated the timeliness of inspections performed since the last review period, 

the current and projected backlog of overdue inspections, and the timeliness of communication 

of inspection findings to licensees. The team reviewed data provided by the Agency from their 

inspection tracking system to determine the timeliness of inspections and reviewed inspection 

files to determine the date of the issuance of inspection findings to licensees relative to the date 

of inspection. 

Arizona law requires, in part, that when an agency conducts an inspection, they must provide a 

copy of the inspection report to the licensee within 30 working days after the inspection. The 

review team evaluated the Program’s timeliness of issuance of inspection reports. In most 

cases, the preliminary findings of inspection reports were sent to the licensees within 30 

calendar days of the inspection date. 

The review team’s evaluation of the Agency’s response to Recommendation 3 of the 2008 

IMPEP report is presented below: 

 
Arizona Final Followup Report Page 5 

Recommendation 3: 

The review team recommends that the State take appropriate measures to conduct core 

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

IMC 2800, “Materials Inspection Program,” and conduct reciprocity inspections in accordance 

with IMC 1220, “Processing of NRC Form 241 and Inspection of Agreement State Licensees 

Operating under 10 CFR 150.20.” (Section 3.2 of the 2008 IMPEP Report) 

Status: 

The review team noted that the Agency’s inspection priorities are determined by a license 

category assigned to each license. During the 2008 IMPEP, the review team identified a 

significant number of licenses authorized for medical uses requiring a written directive that were 

incorrectly categorized and assigned a longer inspection frequency than prescribed by IMC 

2800. After this issue was identified, the Agency revised their inspection frequencies for these 

types of licenses. The review team determined that the Agency’s inspection frequencies for all 

types of radioactive material licenses are now, at least, the same as NRC’s inspection 

frequencies listed in IMC 2800. 

The review team evaluated inspection files for 161 Priority 1, 2, and 3 and initial inspections 

conducted by the Agency during the review period. The review team determined that 14 

percent of these inspections were conducted overdue per the criteria in IMC 2800. The review 

team identified one initial inspection was overdue at the time of the review. All other inspections 

were up to date. This demonstrated a significant improvement in the timeliness of inspections 

since the 2008 IMPEP, when the Agency was found to have 77 percent of its Priority 1, 2, and 3 

and initial inspections performed overdue. 

During 2008 and 2009, the Agency received reciprocity requests from 44 licensees that were 

candidates for inspection. The review team determined that the Agency conducted 20 percent 

of the candidate reciprocity inspections during 2008 and 2009, which meets the requirements 

prescribed by IMC 1220. At the time of the review, for Calendar Year 2010, the Agency 

received reciprocity requests from 14 licensees that were candidates for inspections. The 

review team determined that the Agency had not conducted any reciprocity inspections at the 

time of the on-site review because the Agency was focusing its inspection efforts on the backlog 

of overdue inspections. The Agency intends to increase its inspection of reciprocity licensees 

now that the inspection backlog has been significantly decreased. This recommendation is 

closed. 

The review team concluded that the Agency’s radioactive materials inspection program 

significantly improved with respect to timeliness of conducting Priority 1, 2, and 3 and initial 

inspections. Based on the IMPEP evaluation criteria, the review team recommended, and the 

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

Inspection Program, was satisfactory, but needs improvement. 

 
Arizona Final Followup Report Page 6 

2.3 Technical Quality of Inspections

During the followup review, the review team evaluated actions taken by the Agency in response 

to the finding of satisfactory, but needs improvement, made during the 2008 IMPEP review, as 

well as the status of the technical quality of inspections performed since the 2008 review. 

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

notes; interviewed inspectors for 24 radioactive materials inspections conducted during the 

review period; and conducted accompaniments of 3 of the Agency’s inspectors. The casework 

examined included a cross-section of inspections conducted by two former and four current 

inspectors and covered a wide variety of inspection types. These included academic 

broadscope, medical broadscope, industrial radiography, self-shielded irradiator, service 

provider, gamma knife, positron emission tomography (PET), high dose-rate remote afterloader 

(HDR), veterinarian teletherapy, strontium-90 eye applicator, nuclear medicine, and reciprocity. 

The review also included followup Increased Controls inspections, as well as the Agency’s 

review of licensee compliance with the National Source Tracking System requirements. 

Appendix E 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. Inspection report documentation supported violations, 

recommendations made to licensees, unresolved safety issues, and discussions held with 

licensees during exit interviews. The review team noted that the Agency issues separate 

reports for health and safety inspections and security inspections. 

The review team also accompanied three of the Agency’s inspectors during the week of 

March 1-3, 2010. The inspectors conducted inspections at a cancer center authorized for PET, 

radiopharmaceuticals and HDR treatments, a hospital authorized for radioiodine therapy and 

prostate seed implants, and an industrial radiography facility. Appendix E lists the inspector 

accompaniments. 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 inspectors also reviewed the licensees’ continued implementation of the 

additional security measures and compliance with fingerprinting requirements, when applicable. 

The inspectors performed confirmatory reviews of source inventories under the National Source 

Tracking System, when applicable. The review team determined that the inspections were 

adequate to assess radiological health, safety, and security at the licensed facilities. 

The review team’s evaluation of the Agency’s responses to Recommendations 4-6 of the 2008 

IMPEP report is presented below: 

 
Arizona Final Followup Report Page 7 

Recommendation 4: 

The review team recommends that the Agency conduct followup inspections of licensees with 

unresolved violations or issues with regard to the Increased Controls requirements to ensure 

that appropriate corrective actions were implemented. (Section 3.3 of the 2008 IMPEP Report) 

Status: 

The review team reviewed 10 of the Agency’s Increased Controls inspection files. The review 

team found that most inspections were without violations; however, of the reports identifying 

violations with regard to the Increased Controls requirements, all had response letters from the 

licensees in the files. 

Followup discussions with Agency staff revealed a practice not identified until approximately 

1 month after the 2008 IMPEP review team completed their review. Agency staff stated they 

discovered that the former Program Manager had received the missing documentation and filed 

it in a separate drawer in her office. This information was not conveyed to the staff; therefore, 

the documents had not been placed into the appropriate licensee file prior to the 2008 IMPEP 

review. In addition, because the licensee responses were not in the files, this prevented the 

inspectors from following up at subsequent inspections. 

Following the 2008 IMPEP review, the Agency placed the missing documentation into the 

appropriate license files. Agency staff conducted followup inspections for those licensees 

identified during the 2008 IMPEP and will continue to conduct followup inspections for licensees 

with Increased Controls violations to ensure that appropriate corrective actions are 

implemented. In addition, Agency staff ensures that all incoming licensee responses are 

properly placed into the appropriate license files by holding onto the files until the 

documentation is received. At that time, the files are returned to the file cabinets. This 

recommendation is closed. 

Recommendation 5: 

The review team recommends that the State review its Increased Controls files to ensure that all 

sensitive, security-related documents are labeled accordingly. 

(Section 3.3 of the 2008 IMPEP Report) 

Status: 

The review team noted, during a review of inspection files, that sensitive, security-related 

information was properly marked. Agency staff indicated that initially they did not have a 

complete understanding of how to properly mark security-related documentation; however, in 

response to the recommendation, the Agency obtained a stamp to denote sensitive information, 

and Agency staff now mark each page containing sensitive information. Each individual who 

creates sensitive information is required to properly mark each page at the time of creation. 

The review team also found that file folders containing sensitive information were marked so 

that anyone picking up the files can ascertain that sensitive information is contained in the file. 

This recommendation is closed.
Arizona Final Followup Report Page 8 

Recommendation 6: 

The review team recommends that an Agency manager accompany each inspector, at least 

annually, to ensure quality and consistency in the inspection program. (Section 3.3 of the 2008 

IMPEP Report) 

Status: 

The Program Manager is responsible for performing annual supervisory accompaniments. The 

review team noted that, during the review period, supervisory accompaniments were not 

performed for two inspectors in 2008 and two inspectors in 2009. The Program Manager stated 

that during this 2-year period, one inspector was out of work with a long-term illness and, 

therefore, was not accompanied in 2008. The Program Manager also noted that, during the 

same time, the previous Program Manager left the Agency and the current Program Manager 

transitioned into the position. The new Program Manager then experienced health-related 

issues in 2009 and missed two accompaniments. The review team noted that, even though 

some of the 2008 and 2009 supervisor accompaniments were not performed in a timely 

manner, no inspector went more than 2 years without being accompanied. 

While the Agency is working towards timely completion of annual inspector accompaniments, 

they have yet to demonstrate long-term success in this area. This recommendation remains 

open. 

The review team concluded that the technical quality of the inspection program improved since 

the 2008 review. Based on the IMPEP evaluation criteria, the review team recommended, and 

the MRB agreed, that Arizona’s performance with respect to the indicator, Technical Quality of 

Inspections, was satisfactory. 

2.4 Technical Quality of Licensing Actions

During the followup review, the review team evaluated actions taken by the Agency in 

response to the finding of unsatisfactory made during the 2008 IMPEP review, as well as 

new licensing actions completed since that review. During the review period, the Program 

processed 631 actions (431 amendments, 119 renewals, 45 new applications, and 36 

terminations). The review team evaluated the casework for 36 licensing actions processed 

by the Program since the 2008 IMPEP review. 

Licenses were reviewed for accuracy, appropriateness of the license and its conditions, tiedown conditions, markings, and overall technical quality. Casework was evaluated for 

timeliness; adherence to good radiation safety practices; references to appropriate regulations; 

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

documents; pre-licensing visits; peer or supervisory review, as indicated; and proper signature 

authority. 

The 36 licensing actions selected for review included work by the single license reviewer on 

staff. Other staff members performed license reviews in the past but did not conduct reviews 

during this review period. The cross-section sampling included all of the State’s major 

licenses as defined by the State, including the following types of licenses: academic 
Arizona Final Followup Report Page 9 

broadscope, medical broadscope, limited scope medical, portable gauge, self-shielded 

irradiator, radiography, and nuclear pharmacy. The selected licensing actions included 3 new 

applications, 4 renewals, 5 terminations, and 24 amendments. A list of the licenses reviewed, 

with case-specific comments, can be found in Appendix F. 

The review team’s evaluation of the Agency’s responses to Recommendations 7-10 of the 

2008 IMPEP report is presented below: 

Recommendation 7: 

The review team recommends that the State ensure its licensees are properly categorized and 

assigned the correct inspection frequency. (Section 3.4 of the 2008 IMPEP Report) 

Status: 

Each of the selected licenses reviewed had its category listed on the license. The review team 

compared the category listed on the licenses to the description of the activities that comprise the 

categories and found that all licenses reviewed were appropriately categorized. The review 

team cross-referenced the categories used by the State with a list of the NRC program codes 

and the inspection frequencies for those program codes, and determined that the selection of 

the program codes for the various categories was appropriate. This recommendation is closed. 

Recommendation 8: 

The review team recommends that the State ensure proper documentation of training and 

experience for authorized users, authorized medical physicists, authorized nuclear pharmacists 

and radiation safety officers. (Section 3.4 of the 2008 IMPEP Report) 

Status: 

At the time of the last review, the State allowed training and experience information for medical 

applicants to be provided by letter. Since that time, the State has required new applicants for 

these positions on medical licenses to submit the training and experience information on forms 

similar to those used by NRC to ensure that all the required information is provided for the 

various options. Individuals who are already named on another medical license to perform the 

requested activities do not need to submit the forms. Persons who request to be named as 

authorized users or radiation safety officers on non-medical licenses may still provide their 

training and experience by letter, as is also accepted by NRC. The review of medical licensing 

actions included several actions requesting approval of authorized users, authorized nuclear 

pharmacists, and radiation safety officers. The review team determined that the documentation 

of training and experience for these actions were acceptable. This recommendation is closed. 

Recommendation 9: 

The review team recommends that the State implement a detailed and documented license 

review system to ensure accuracy and consistency for all licensing actions. (Section 3.4 of the 

2008 IMPEP Report) 
Arizona Final Followup Report Page 10 

Status: 

The State has license application guidance documents that they send to licensees to ensure 

that licensees provide sufficient information for the requested activities. Since the last IMPEP 

review, the State developed new checklists for the review of the license applications. License 

review checklists were used with all the new license applications reviewed and were maintained 

in the license files. License review checklists were not used for most amendment actions 

because the scope of most amendment requests did not require the use of the full checklist. 

The full checklist could be used, if needed or desired. The review team determined that the 

majority of the licensing actions received a thorough review and contained all necessary 

documentation. Exceptions are noted as comments in the licensing casework files listed in 

Appendix F. This recommendation is closed. 

Recommendation 10: 

The review team recommends that the State implement the pre-licensing checklist and 

guidance for all licensing actions to provide assurance that radioactive material will be used as 

specified on the license. (Section 3.4 of the 2008 IMPEP Report) 

Status: 

At the time of the last IMPEP review, the use of the pre-licensing checklist and guidance was 

required for all licensing actions. In September 2008, NRC revised the guidance so that the 

checklist is required only for all new license applications and for transfer of control (changeof-ownership) actions. The review team found that the Agency used the pre-licensing 

checklist on all new licensing actions that were selected for review, but did not use it for the 

one change-of-ownership action that was selected for review. In addition, on two checklists, 

the reviewer identified that a new applicant was a known entity because individuals who were 

to be named as authorized users or radiation safety officers were listed on other licenses; 

however, these individuals were not the entity responsible for those licenses and this would 

not justify considering the new license applicant to be a known entity. The review team 

discussed with the Agency staff the essential elements of the revised pre-licensing guidance 

and how to properly implement them. This recommendation remains open. 

During the followup review, the review team identified several issues related to financial 

assurance that require review and clarification of pertinent licenses. State regulations reference 

the financial assurance requirements contained in 10 CFR 30.35, 40.46, and 70.25; however, 

the license condition that limits quantities of radioactive materials to amounts below those that 

require financial assurance references only 10 CFR 30.35 quantities. This limiting license 

condition does not address the four separate categories of materials that require financial 

assurance: unsealed byproduct material (10 CFR 30.35), sealed byproduct material (10 CFR 

30.35), dispersible source material (10 CFR 40.46) and unsealed special nuclear material (10 

CFR 70.25). Because of this, the review team found some licenses that need to have financial 

assurance or need to be amended to limit quantities below those that require financial 

assurance. In addition, although the unity rule (sum-of-fractions) applies within each category, 

the total financial assurance to be provided is the sum of that required for each category. 

Examples of these licensing actions can be found in Appendix F, Licensing Casework Reviews. 
Arizona Final Followup Report Page 11 

The review team recommends that the State review its radioactive materials licenses regarding 

the requirements for financial assurance, and either obtain financial assurance for licenses that 

are authorized to possess the applicable quantities, or revise the license conditions to ensure 

clear quantity limits that will not require provision of financial assurance. 

The review team also identified that decay-in-storage requirements were not consistently 

applied. The review team determined that the Agency authorizes radioactive waste disposal by 

decay-in-storage by tying the procedures in the license application to the license. The review 

team found that, in at least two actions reviewed, the licensees did not specify that decay-instorage would be limited to radionuclides with half-lives of 120 days or less, although most other 

license applications did state that limit. One license authorized, by license condition, decay-instorage for radionuclides with half-lives up to 207 days. The reviewer explained this was done 

by license condition because it was different from the Agency’s normal expectation. If the 

Agency intends to restrict decay-in-storage to short-lived radioactive materials, by tie-down 

condition, applications must include this restriction. The review team discussed with the Agency 

staff the inconsistencies in their approach to decay-in-storage authorizations. The Agency staff 

agreed to review their approach and make any necessary changes. 

The review team concluded that the technical quality of the licensing program improved. Based 

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

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

satisfactory, but needs improvement. 

3.0 SUMMARY 

Arizona’s performance was found satisfactory for the indicator, Technical Quality of Inspections, 

and satisfactory, but needs improvement, for the indicators Technical Staffing and Training, 

Status of Materials Inspection Program, and Technical Quality of Licensing Actions. The review 

team noted that State made progress in management oversight of the Agreement State 

program activities for the three performance indicators found satisfactory, but needs 

improvement, through the use of technical staff from other programs within the Agency, the 

recent hiring of an experienced technical staff member, and additional training of Agency staff 

members; however, the review team believes that additional time and actions are necessary 

before the Agency reaches and sustains a level of satisfactory performance. 

Accordingly, the review team recommended, and the MRB agreed, that the Arizona Agreement 

State Program is adequate to protect public health and safety, but needs improvement, and 

compatible with NRC’s program. The review team recommended, and the MRB agreed, that 

the period of Heightened Oversight of the Arizona Agreement State Program continue and that 

the Agency’s Program Improvement Plan be amended to address the recommendations of the 

followup IMPEP review. 

Based on the results of the review, the review team recommended, and the MRB agreed, that a 

periodic meeting take place in approximately 1 year and the next full IMPEP review take place 

in approximately 2 years. 

 
Arizona Final Followup Report Page 12 

Below are the recommendations, as mentioned in Section 2.0, for evaluation and 

implementation by the State: 

RECOMMENDATIONS 

1. The review team recommends that the State review and update, if appropriate, the 

Agency’s staffing and budget plan to ensure Program needs are met and to maintain 

long-term stability of the Program. (Section 2.1) 

2. The review team recommends that an Agency manager accompany each inspector, at 

least annually, to ensure quality and consistency in the inspection program. 

(Section 2.3) 

3. The review team recommends that the State implement the pre-licensing checklist 

and guidance for all licensing actions to provide assurance that radioactive material 

will be used as specified on the license. (Section 2.4) 

4. The review team recommends that the State review its radioactive materials licenses 

regarding the requirements for financial assurance, and either obtain financial assurance 

for licenses that are authorized to possess the applicable quantities, or revise the license 

conditions to ensure clear quantity limits that will not require provision of financial 

assurance. (Section 2.4) 
LIST OF APPENDIXES AND ATTACHMENT 

Appendix A IMPEP Review Team Members 

Appendix B Arizona Organization Charts 

Appendix C Heightened Oversight Program Correspondence 

Appendix D Periodic Meeting Summary 

Appendix E Inspection Casework Reviews 

Appendix F License Casework Reviews 

Attachment June 4, 2010 Letter from Aubrey Godwin 

Arizona’s Response to the Draft Report
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Donna Janda, Region I Team Leader 

Technical Staffing and Training 

Periodic Meeting 

Santiago Rodriguez, New Mexico Status of Materials Inspection Program 

Randy Erickson, Region IV Technical Quality of Inspections 

 Inspector Accompaniments 

 Periodic Meeting 

Elizabeth Ullrich, Region I Technical Quality of Licensing Actions 
APPENDIX B 

ARIZONA ORGANIZATION CHARTS 

ADAMS ACCESSION NO.: ML101120125 
APPENDIX C 

HEIGHTENED OVERSIGHT PROGRAM CORRESPONDENCE 

Summaries of Bimonthly Conference Calls: 

1. July 30, 2009 Summary (ML092310424) 

2. September 30, 2009 Summary (ML092820511) 

3. January 14, 2010 Summary (ML100211158) 

Letters from/to Arizona: 

1. August 13, 2008 Letter to Dennis Burke from M. J. Virgilio – Arizona Final IMPEP Report 

(ML082060548) 

2. September 22, 2008 Letter to M. J. Virgilio from Aubrey Godwin – Response to Final 

IMPEP Report, including Program Improvement Plan (ML082730307) 

3. May 19, 2009 Letter to Aubrey V. Godwin from Robert J. Lewis – Approval of Program 

Improvement Plan (ML091330010) 
APPENDIX D 

PERIODIC MEETING SUMMARY 

A periodic meeting was held with the Agency Director and the Program Manager by Donna 

Janda, Team Leader, and Randy Erickson, Team Member and Regional State Agreements 

Officer, during the followup IMPEP review pursuant to the Office of Federal and State Materials 

and Environmental Management Programs (FSME) Procedure SA-116, “Periodic Meetings 

Between IMPEP Reviews.” Topics normally documented during periodic meetings that were 

reviewed and documented as part of the followup IMPEP review are not discussed in this 

Appendix. The following topics were discussed: 

1. Status of Recommendations from Previous IMPEP Reviews

See Section 2.0 for details on the status of recommendations identified during previous 

IMPEP reviews. 

2. Strengths and/or weaknesses of the State program as identified by the State including 

identification of actions that could diminish weaknesses. 

The Agency Director noted that, following the termination of two former staff members, the 

staff enjoys better communication between the programs and they work much more 

cohesively. He also acknowledged the resilience of the staff to the ever changing budget 

situation and the uncertainty associated with those changes as positive strengths. The staff 

seems resolute to stay the course until they become more stable. 

The Agency Director noted the loss of staff and frozen positions and the vulnerable position 

it now places the Program in as a weakness for the Program. If the Program experiences 

staff losses, they could easily have those positions frozen, which will make it increasingly 

difficult to function effectively. They have been able to replace one position, but those hires 

are on a case-by-case basis with no guarantee the request will be successful. The Agency 

Director noted that not having a Deputy Director position available to him adds to the 

difficulty in managing the Program. 

According to the Agency Director, the fee collection system and the State rules associated 

with that function need to be improved. There is a designation between “old money versus 

new money” and how those funds are handled. It makes it difficult for the Program to 

adequately assess fees related to budgeting, and that a lot of resources are used in the 

collection of fees that, with a better system, could be used in other areas. 

The Agency Director also noted the new database as a true weakness for the program. 

Following the previous IMPEP review, a decision was made to implement a new database; 

however, during the time they were building the system, a new Governor was elected and 

the system was never completed; therefore, it does not work as expected. It has been a 

huge hindrance to the program to the point that they decided to reactivate their old 

database. They have made a few changes to the old database and are now using it as the 

Program’s primary database. 
Arizona Final Followup Report Page D.2 

Periodic Meeting Summary 

3. Feedback on NRC’s program as identified by the State and including identification of any 

action that should be considered by NRC. 

The Agency Director stated that NRC should consider clearly defining the requirements and 

responsibilities for authorized users utilizing diagnostic quantities of radioactive materials to 

treat patients. He indicated that for therapy (10 CFR 35.300 and above), the authorized user 

must select the patient for treatment, and in some cases be there for the treatment. 

However, with diagnostic use, the referring physician refers the patient and the authorized 

user generally has no part in selecting them, instead they rely on standing orders, etc., to 

allow the technologist to effectively perform the test. The Agency Director believes that 

there are tests that if incorrectly performed, including those involving iodine-131 in diagnostic 

quantities, that a patient could be harmed in the process. He believes that this is a hole in 

NRC’s regulations that needs to be corrected. 

4. Status of State Program Including: 

a. Staffing and Training: 

See Section 2.1 for details on the status of recommendations identified during previous 

IMPEP reviews. 

b. Materials Inspection Program: 

See Sections 2.2 and 2.3 for details on the status of recommendations identified during 

previous IMPEP reviews. 

c. Regulations and Legislative Changes: 

Earlier this year, the Arizona Legislature proposed legislation that would require the 

Agency, prior to adopting any regulations, to prepare two economic impact statements 

on new regulations. The Agency and the Governor’s Regulatory Review Council must 

consider any submission that compares the cost of new regulations with the costs in 

other western states and its effect on business competitiveness. For promulgation of 

new rules, the Agency must submit clear and convincing evidence that the benefits of 

the new rule outweigh the costs of the new rule. After finalized, any affected individual 

can petition to repeal the rule on the grounds of having a negative economic impact. At 

the time of the followup review, this legislation had not yet been adopted. 

To better facilitate rule development, in May 2009, the Agency replaced the former 

individual responsible for regulation development with an individual from their X-ray 

program. 

d. Program Reorganizations: 

There have been no major reorganizations. Internally, the non-ionizing program has 

been moved out of the radioactive materials program. The radioactive materials 

program is now an independent program. 
Arizona Final Followup Report Page D.3 

Periodic Meeting Summary 

e. Changes in Program Budget/Funding: 

Arizona’s budget is ever changing. This is in part due to disagreements between the 

Legislature and the Governor’s Office on how to manage shrinking revenues. A budget 

for FY 2011 has been passed by the Legislature assuming a one cent sales tax 

requested by the governor passes a public vote. If not, the real possibility exists for 

additional budget cuts. In March 2010, the Legislature passed a bill that requires cuts to 

staff performance pay and adds six furlough days for the next two fiscal years. These 

changes become effective on June 15, 2010. 

5. Event Reporting: 

The Agency has responded to five events since the 2008 IMPEP review. The Program 

reported that all NMED information is up to date. 

6. Response to Incidents and Allegations: 

The Program continues to be sensitive to notifications of incidents and allegations. Incidents 

are reviewed for their affect on public health and safety. Staff is dispatched to perform onsite investigations, when necessary. The Agency Director has placed a high emphasis on 

maintaining an effective response to incidents and allegations. 

7. Information Exchange and Discussion: 

a. Current State Initiatives: 

None noted at the time of the meeting. 

b. State’s Mechanisms to Evaluate Performance: 

The Agency Director noted that, in addition to inspector accompaniments, the staff 

conducts peer reviews of 100 percent of all licensing and inspection activities. The peer 

reviews require staff signatures verifying the review. Additionally, managers also review 

all licensing and inspection documentation. They cited these activities as another 

method for ensuring that performance is continuously evaluated. 
APPENDIX E 

INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Ironwood Cancer & Research Centers, PC License No.: 07-571 

Inspection Type: Initial, Unannounced Priority: 2 

Inspection Date: 3/1/10 Inspector: PK 

File No.: 2 

Licensee: Banner Estrella Medical Center License No.: 07-547 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 3/2/10 Inspector: DK 

Comment: 

 The Agency conducted the inspection 51 days overdue. 

File No.: 3 

Licensee: AMEC Earth and Environmental, Inc. License No.: 07-369 

Inspection Type: Special, Unannounced Priority: 1 

Inspection Date: 3/3/10 Inspector: BG 

File No.: 4 

Licensee: Desert Samaritan Medical Center License No.: 07-106 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 3/17/10 Inspector: WY 

Comment: 

 The Agency conducted the inspection 145 days overdue. 

File No.: 5 

Licensee: Banner Desert Surgery Center License No.: 07-614 

Inspection Type: Initial, Unannounced Priority: 3 

Inspection Date: 3/22/10 Inspector: DK 

Comment: 

 The Agency conducted the inspection 82 days overdue. 

File No.: 6 

Licensee: Arizona Oncology Associates License No.: 07-639 

Inspection Type: Initial, Unannounced Priority: 2 

Inspection Dates: 2/19/10 Inspector: DK 

Comment: 

 The Agency conducted the inspection 127 days overdue. 
Arizona Final Followup Report Page E.2 

Inspection Casework Reviews 

File No.: 7 

Licensee: John C. Lincoln Hospital-Deer Valley License No.: 07-311 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 3/23/10 Inspector: WY 

Comment: 

 The Agency conducted the inspection 184 days overdue. 

File No.: 8 

Licensee: Southwest Veterinary Oncology License No.: 10-132 

Inspection Type: Special, Unannounced Priority: 2 

Inspection Date: 9/17/08 Inspector: BG 

File No.: 9 

Licensee: Arizona Oncology Associates License No.: 10-141 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Dates: 2/19/10 Inspector: BG 

Comment: 

 The Agency conducted the inspection 156 days overdue. 

File No.: 10 

Licensee: American Red Cross Blood Services License No.: 10-143 

Inspection Type: Special, Unannounced Priority: 5 

Inspection Date: 9/18/08 Inspector: BG 

File No.: 11 

Licensee: Saint Joseph’s Medical Center License No.: 07-424 

Inspection Type: Special, Unannounced Priority: 2 

Inspection Date: 12/23/08 Inspector: BG 

File No.: 12 

Licensee: Nucletron Corporation License No.: MD 27-03501 

Inspection Type: Reciprocity, Unannounced Priority: 2 

Inspection Date: 11/14/08 Inspector: BG 

File No.: 13 

Licensee: Elekta Inc. License No.: GA 1153-1 

Inspection Type: Reciprocity, Unannounced Priority: 2 

Inspection Date: 12/23/08 Inspector: BG 

File No.: 14 

Licensee: Varian Medical Systems License No.: NRC 45-30957-01 

Inspection Type: Reciprocity, Unannounced Priority: 3 

Inspection Date: 4/16/09 Inspector: BG 
Arizona Final Followup Report Page E.3 

Inspection Casework Reviews 

File No.: 15 

Licensee: Payson Regional Medical Center License No.: 04-016 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 6/24/08 Inspector: HS 

File No.: 16 

Licensee: Canyon State Inspection License No.: 10-101 

Inspection Type: Special, Unannounced Priority: 1 

Inspection Date: 4/24/09 Inspector: PK 

File No.: 17 

Licensee: Phoenix National Laboratories, Inc. License No.: 07-415 

Inspection Type: Special, Unannounced Priority: 1 

Inspection Date: 2/26/10 Inspector: DK 

File No.: 18 

Licensee: Spectra Eye Institute License No.: 07-601 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 5/7/08 Inspector: JS 

File No.: 19 

Licensee: Western Technologies, Inc. License No.: 07-049 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 3/19/09 Inspector: BG 

File No.: 20 

Licensee: 21st Century Oncology of Arizona License No.: 07-153 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 3/24/10 Inspector: WY 

File No.: 21 

Licensee: University Medical Center Corporation License No.: 10-044 

Inspection Type: Special, Unannounced Priority: 2 

Inspection Dates: 1/21-22/10 Inspectors: BG, PK 

File No.: 22 

Licensee: University Medical Center Corporation License No.: 10-024 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Dates: 5/19-22/08 Inspectors: BG, PK 

File No.: 23 

Licensee: Surgery Center of Gilbert License No.: 07-549 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 6/3/09 Inspector: HS 
Arizona Final Followup Report Page E.4 

Inspection Casework Reviews 

File No.: 24 

Licensee: Arizona Center for Cancer Care License No.: 07-606 

Inspection Type: Initial, Unannounced Priority: 2 

Inspection Date: 6/25/09 Inspector: BG 

INSPECTOR ACCOMPANIMENTS 

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

Accompaniment No.: 1 

Licensee: Ironwood Cancer & Research Centers, PC License No.: 07-571 

Inspection Type: Initial, Unannounced Priority: 2 

Inspection Date: 3/1/10 Inspector: PK 

Accompaniment No.: 2 

Licensee: Banner Estrella Medical Center License No.: 07-547 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 3/2/10 Inspectors: DK 

Accompaniment No.: 3 

Licensee: AMEC Earth and Environmental, Inc. License No.: 07-369 

Inspection Type: Special, Unannounced Priority: 1 

Inspection Date: 3/3/10 Inspectors: BG 
APPENDIX F 

LICENSING CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Board of Regents dba The University of Arizona License No.: 10-24 

Type of Action: Amendment Amendment No.: 77 

Date Issued: 3/25/10 License Reviewer: PK 

Comment: 

License conditions regarding authorized possession limits and financial assurance are 

contradictory. License review did not include determination of the financial assurance 

requirement for source and special nuclear material. 

File No.: 2 

Licensee: Board of Regents dba Arizona State University License No.: 7-737 

Type of Action: Amendment Amendment Nos.: 81 

Date Issued: Not recorded License Reviewer: PK 

Comment: 

License conditions regarding authorized possession limits and financial assurance are 

contradictory. License review did not include determination of the financial assurance 

requirement for source and special nuclear material. 

File No.: 3 

Licensee: Gateway Community College License No.: 7-464 

Type of Action: Renewal Amendment No.: 05 

Date Issued: 7/16/09 License Reviewer: PK 

File No.: 4 

Licensee: Univ. Medical Ctr and Board of Regents License No.: 10-44 

 dba Univ. of AZ 

Type of Action: Amendment Amendment No.: 63 

Date Issued: 5/6/09 License Reviewer: PK 

Comment: 

License conditions regarding authorized possession limits and financial assurance are 

contradictory. 

File No.: 5 

Licensee: VHS of Phoenix, Inc. License No.: 7-146 

 dba Phoenix Baptist Hospital & Med Ctr 

Type of Action: Amendment Amendment No.: 63 

Date Issued: In progress License Reviewer: PK 

 
Arizona Final Followup Report Page F.2 

Licensing Casework Reviews 

File No.: 6 

Licensee: Carondelet St. Joseph’s Hospital License No.: 10-40 

Type of Actions: Amendments Amendment Nos.: 75, 76 

Dates Issued: 6/2/09, 8/19/09 License Reviewer: PK 

Comment: 

License authorized use of SirSpheres under 10 CFR 35.300 and not under 10 CFR 

35.1000. Because the State has not yet adopted 10 CFR 35.1000, the Agency does not 

require the additional training and experience for authorized users described in 10 CFR 

35.1000. 

File No.: 7 

Licensee: Flagstaff Medical Center License No.: 3-3 

Type of Action: Renewal Amendment No.: 75 

Date Issued: Not recorded License Reviewer: PK 

Comment: 

Radioactive waste disposal by decay-in-storage is authorized by tie down; however, the 

application does not commit to any limitations on the half-life of the radioactive materials 

that will be disposed by this method. 

File No.: 8 

Licensee: Scottsdale Memorial Health Services Co., Inc. License No.: 7-265 

Type of Action: Amendment Amendment No.: 72 

Date Issued: Not recorded License Reviewer: PK 

File No.: 9 

Licensee: MD MED, Inc. License No.: 02-106 

Type of Action: Termination Amendment No.: 09 

Date Issued: In progress License Reviewer: PK 

File No.: 10 

Licensee: Banner Del E. Webb Medical Center License No.: 7-324 

Type of Action: Amendment Amendment No.: 47 

Date Issued: 12/9/08 License Reviewer: PK 

File No.: 11 

Licensee: Banner Health dba Banner Lakes Imaging Center License No.: 7-539 

Type of Action: Amendment Amendment No.: 05 

Date Issued: 11/11/09 License Reviewer: PK 

Comment: 

Decay-in-storage authorization does not limit the half-life of the radioactive materials that 

will be disposed in this manner; “group” material authorization is not restricted to 

radionuclides with short half-lives and would require financial assurance if restriction is 

not in place; no documentation was in the file regarding the reason that the material 

authorization was limited to an amount different from the licensee’s request. 
Arizona Final Followup Report Page F.3 

Licensing Casework Reviews 

File No.: 12 

Licensee: Prescott Cardiology License No.: 13-030 

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

Date Issued: 11/16/09 License Reviewer: PK 

Comment: 

RSO was authorized on the license without documentation of RSO credentials. No 

additional clarification was requested on discrepancy in licensee’s application regarding 

use of dosimetry. 

File No.: 13 

Licensee: Red Rock Health Care LLC License No.: 4-023 

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

Date Issued: 1/5/09 License Reviewer: PK 

Comment: 

RSO was authorized on the license without documentation of RSO credentials. The 

licensee was incorrectly identified as a “known entity” on the pre-licensing checklist; no 

pre-licensing visit was conducted. 

File No.: 14 

Licensee: Advanced Medical Imaging System LLC License No.: 7-435 

Type of Action: Termination Amendment No.: 09 

Date Issued: 1/9/10 License Reviewer: PK 

File Nos.: 15 

Licensee: Yavapai Regional Medical Center License No.: 13-025 

Type of Actions: Amendment, Termination Amendment Nos.: 04, 05 

Dates Issued: 1/14/10, 2/10/10 License Reviewer: PK 

Comment: 

No documentation in file regarding amending this license to reflect new owner and new 

name when the licensee had requested that another license, No. 13-06, not this one, be 

amended to reflect the new information. Subsequently, the new owner submitted a 

request to amend license no.13-06 as originally requested and to terminate this license. 

File No.: 16 

Licensee: AZ Tech Radiology and Open MRI License No.: 11-024 

Type of Action: Amendment Amendment No.: 04 

Date Issued: 2/6/09 License Reviewer: PK 

File No.: 17 

Licensee: Sonoran Heart, PC License No.: 7-603 

Type of Action: Amendment Amendment No.: 01 

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

 
Arizona Final Followup Report Page F.4 

Licensing Casework Reviews 

File No.: 18 

Licensee: Alliance Healthcare Services Inc. License No.: 15-78 

Type of Action: Amendment Amendment No.: 32 

Date Issued: 1/13/10 License Reviewer: PK 

File No.: 19 

Licensee: Phoenix Children’s Hospital License No.: 7-505 

Type of Action: Amendment Amendment No.: 11 

Date Issued: 9/15/09 License Reviewer: PK 

File No.: 20 

Licensee: Medtronics Microelectronics Center License No.: 7-633 

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

Date Issued: 2/2/10 License Reviewer: PK 

Comment: 

License reviewer did not request SSD sheet for tritium foils because the reviewer 

considers foils to be unsealed material; however, if foils are considered unsealed 

materials, this license, based on the maximum possession limit, would require financial 

assurance be provided. 

File No.: 21 

Licensee: Immunodiagnostic Systems Inc. License No.: 7-521 

Type of Action: Renewal Amendment No.: 03 

Date Issued: 2/17/09 License Reviewer: PK 

File No.: 22 

Licensee: Arizona Department of Transportation License No.: 7-31 

Type of Action: Amendment Amendment No.: 64 

Date Issued: Not recorded License Reviewer: PK 

Comment: 

The license did not have any procedures tied down or a license condition prohibiting the 

licensee from possessing “risk significant quantities” at any one location on this portable 

gauge license. 

File No.: 23 

Licensee: Krazen and Associates License No.: 7-560 

Type of Action: Amendment Amendment No.: 01 

Date Issued: 12/2/08 License Reviewer: PK 

Comment: 

The licensee requested Series 3241 gauges, but was authorized for only the Model 

3241-C gauge. There was no documentation in the file regarding this decision. 

 
Arizona Final Followup Report Page F.5 

Licensing Casework Reviews 

File No.: 24 

Licensee: American Soils Engineering LLC License No.: 8-039 

Type of Action: Termination Amendment No.: 05 

Date Issued: 2/16/10 License Reviewer: PK 

File No.: 25 

Licensee: Staker and Parson Companies License No.: 15-74 

 dba Western Rock Products 

Type of Action: Amendment Amendment No.: 04 

Date Issued: Not recorded License Reviewer: PK 

File No.: 26 

Licensee: Professional Service Industries License No.: 7-430 

Type of Action: Amendment Amendment No.: 24 

Date Issued: 9/24/08 License Reviewer: PK 

File No.: 27 

Licensee: Acclaim Materials Testing and Inspections LLC License No.: 8-042 

Type of Action: Amendment Amendment No.: 1 

Date Issued: 12/5/08 License Reviewer: PK 

File No.: 28 

Licensee: Team Industrial Services, Inc. License No.: 7-493 

Type of Action: Amendment Amendment No.: 53 

Date Issued: 7/27/09 License Reviewer: PK 

File No.: 29 

Licensee: American Red Cross Blood Services License No.: 10-143 

Type of Action: Amendment Amendment No.: 08 

Date Issued: 11/16/09 License Reviewer: PK 

File No.: 30 

Licensee: PETNET Solutions Inc. License No.: 7-515 

Type of Action: Amendment Amendment No.: 08 

Date Issued: Not recorded License Reviewer: PK 

File No.: 31 

Licensee: Cardinal Health 414 LLC License No.: 8-036 

Type of Action: Amendment, Renewal Amendment Nos.: 03, 04 

Date Issued: Not recorded, In progress License Reviewer: PK 

File No.: 32 

Licensee: Patient Care Infusion LLC License No.: 7-572 

Type of Action: Amendment Amendment No.: 05 

Date Issued: 6/10/09 License Reviewer: PK 

 
Arizona Final Followup Report Page F.6 

Licensing Casework Reviews 

File No.: 33 

Licensee: Medical Radiation Physics Inc. License No.: 7-553 

Type of Action: Termination Amendment No.: 01 

Date Issued: 2/24/09 License Reviewer: PK 
ATTACHMENT 

June 4, 2010 Letter from Aubrey Godwin 

Arizona’s Response to the Draft Report 

ADAMS Accession No.: ML101580362