June 14, 2010 

Ms. Kathryn Perkins, Assistant Commissioner 

Division of Regulatory Services 

Texas Department of State Health Services 

8404 Wall Street, Room S101 

Austin, TX 78754 

Dear Ms. Perkins: 

On May 19, 2010, the Management Review Board (MRB) met to consider the proposed final 

Integrated Materials Performance Evaluation Program (IMPEP) report on the Texas Agreement 

State Program. The MRB found the Texas 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 22, of the enclosed final report contains a summary of the IMPEP review 

team’s findings. Based on the results of the current IMPEP review, the next full review of the 

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

meeting tentatively scheduled for February 2012. 

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: 

Texas Final IMPEP Report 

cc w/encl: Richard Ratliff, Manager 

 Radiation Safety Licensing Branch 

 Texas Department of State Health Services 

 Roger Mulder, State Liaison Officer 

 Texas State Energy Conservation Office 
June 14, 2010 

Mr. Mark Vickery, Executive Director 

Texas Commission on Environmental Quality 

MC-109, P.O. Box 13087 

Austin, TX 78711-3087 

Dear Mr. Vickery: 

On May 19, 2010, the Management Review Board (MRB) met to consider the proposed final 

Integrated Materials Performance Evaluation Program (IMPEP) report on the Texas Agreement 

State Program. The MRB found the Texas 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 22, of the enclosed final report contains a summary of the IMPEP review 

team’s findings. Based on the results of the current IMPEP review, the next full review of the 

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

meeting tentatively scheduled for February 2012. 

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: 

Texas Final IMPEP Report 

cc w/encl: Susan Jablonski, Director 

 Radioactive Materials Division 

 Texas Commission on Environmental Quality 

 Roger Mulder, State Liaison Officer 

 Texas State Energy Conservation Office 
Mr. Mark Vickery, Executive Director 

Texas Commission on Environmental Quality 

MC-109, P.O. Box 13087 

Austin, TX 78711-3087 

Dear Mr. Vickery: 

On May 19, 2010, the Management Review Board (MRB) met to consider the proposed final 

Integrated Materials Performance Evaluation Program (IMPEP) report on the Texas Agreement 

State Program. The MRB found the Texas 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 22, of the enclosed final report contains a summary of the IMPEP review 

team’s findings. Based on the results of the current IMPEP review, the next full review of the 

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

meeting tentatively scheduled for February 2012. 

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: 

Texas Final IMPEP Report 

cc w/encl: Susan Jablonski, Director 

 Radioactive Materials Division 

 Texas Commission on Environmental Quality 

 Roger Mulder, State Liaison Officer 

 Texas State Energy Conservation Office 

Distribution: See next page.

 ML101460615 EDATS: FSME-2010-0158 

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

NAME ATMcCraw:knm1 ADias TReis RJLewis 

DATE 6/1/10 6/1/10 6/5/10 6/7/10 

OFFICE Tech Editor FSME DEDMRT 

NAME CPoland CLMiller (CAC for) MFWeber 

DATE 6/7/10 6/8/10 6/14/10 

OFFICIAL RECORD COPY
Letters to K. Perkins and M. Vickery from Michael F. Weber dated: June 14, 2010 

Distribution: EDATS: FSME-2010-0158 

MSSA RF DCD (SP01) 

EDO RF 

RidsEdoMailCenter 

RidsFsmeOd 

RidsSecyCorrespondenceMailCenter Chairman Jaczko 

JLynch, RIII Commissioner Svinicki 

JKatanic, FSME/MSSA Commissioner Apostolakis 

CGrossman, FSME/DWMEP Commissioner Magwood 

JSaxton, FSME/DWMEP Commissioner Ostendorff 

RBrowder, RIV/RSAO SECY 

Earl Fordham, Washington 

George Johns, Minnesota 

Sandi Kessinger, Illinois 

MBeardsley, FSME/MSSA 

AHowell, RIV 

KBrock, OEDO 

CCarpenter, FSME 

BJones, OGC 

MDapas, RI 

Robert Gallaghar, Massachusetts 

JOlmstead, OGC 

APowell, OCA (2 copies) 
Enclosure 1 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE TEXAS AGREEMENT STATE PROGRAM 

February 22-26, 2010 

FINAL REPORT
Texas Final Report Page 1 

1.0 INTRODUCTION 

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

The review was conducted during the period of February 22-26, 2010, by a review team 

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

the States of Illinois, Minnesota, and Washington. 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 September 17, 2005, to 

February 26, 2010, were discussed with Texas managers on the last day of the review. 

A draft of this report was issued to Texas for factual comment on March 25, 2010. The Texas 

Department of State Health Services (the Department) responded to the findings and 

conclusions of the review by letter dated April 14, 2010, from Kathryn C. Perkins, RN, MBA, 

Assistant Commissioner, Division of Regulatory Services. The Texas Commission on 

Environmental Quality (the Commission) responded to the findings and conclusions of the 

review by letter dated April 14, 2010, from Mark R. Vickery, P.G., Executive Director. The 

Department’s and Commission’s responses are included as the Attachments to this report. The 

Management Review Board (MRB) met on May 19, 2010, to consider the proposed final report. 

The MRB found the Texas Agreement State Program adequate to protect public health and 

safety and compatible with NRC’s program. 

The Texas Agreement State Program is administered by two State agencies, the Department 

and the Commission. Organization charts for the Department and the Commission are included 

as Appendix B. 

The Department regulates approximately 1,657 specific licenses authorizing byproduct, source, 

and certain special nuclear materials (radioactive materials). The Commission has regulatory 

responsibility for low-level radioactive waste (LLRW) disposal activities in Texas. Effective June 

2007, the Texas Legislature transferred jurisdiction over uranium recovery facilities from the 

Department to the Commission. The review focused on the State’s regulation of radioactive 

materials 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 Texas. 

The Department’s portion of the Agreement State program is located in the Division for 

Regulatory Services. The Division for Regulatory Services has two sections: the Health Care 

Quality Section, which includes all licensing functions, and the Environmental and Consumer 

Safety Section, which includes the inspection and quality assurance programs. 

The Commission’s portion of the Agreement State program is located in two offices. The Office 

of Permitting and Registration, Radioactive Materials Division, performs licensing functions. 

The Commission’s inspection program is located in the Office of Compliance and Enforcement, 

Homeland Security Program. 

In preparation for the review, a questionnaire addressing the common and applicable noncommon performance indicators was sent to the Department and the Commission on 
Texas Final Report Page 2 

November 9, 2009. Both agencies provided responses to the questionnaire on 

February 5, 2010. Copies of the Department’s and the Commission’s questionnaire responses 

can be found in NRC’s Agencywide Documents Access and Management System (ADAMS) 

using the Accession Numbers ML100400116 and ML100471013, respectively.

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

Texas’s responses to the questionnaire; (2) review of applicable Texas statutes and regulations; 

(3) analysis of quantitative information from the State’s databases; (4) technical review of 

selected regulatory actions; (5) field accompaniments of eight of the Department’s inspectors 

and two of the Commission’s 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 Texas Agreement State Program’s performance. 

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

during the previous reviews. Results of the current review of the common performance 

indicators are presented in Section 3.0. Section 4.0 details the results of the review of the 

applicable non-common performance indicators, and Section 5.0 summarizes the review team's 

findings. 

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS 

The Texas Agreement State Program was placed on heightened oversight following a March 

2005 periodic meeting with the Department due to concerns with staff turnover, the status of 

inspections, the timeliness of reporting events, and the status of regulations. The Texas 

Agreement State Program remained on heightened oversight following a routine IMPEP review 

conducted in September 2005. The MRB found the Texas Agreement State Program adequate 

to protect public health and safety, but needs improvement, and compatible with NRC’s 

program. The review team made eight recommendations regarding program performance by 

the State. The MRB directed NRC staff to conduct a followup review approximately 1 year later. 

The followup review of the Texas Agreement State Program was conducted in November 2006. 

The review team concluded that the State had made considerable progress since the previous 

review. As a result, the MRB discontinued the period of heightened oversight and implemented 

a period of monitoring. Four of the recommendations from the 2005 IMPEP review were closed. 

A periodic meeting held with the State in June 2008 demonstrated additional improvements in 

the program, and the monitoring process was discontinued. 

At the time of this review, four recommendations from previous reviews remained open. The 

current status of each of the open recommendations is as follows: 

1. The review team recommends that the Department report all significant and routine 

events, as well as followup event information, to NRC in accordance with Office of 

Federal and State Materials and Environmental Management Programs (FSME) 

Procedure SA-300, “Reporting Material Events.” (Section 3.5 of the 2001 IMPEP report) 

Current Status: The Department’s Incident Investigation Program has developed a 

database to report, track, and document events. Use of the database, coupled with an 
Texas Final Report Page 3 

increased understanding of the reporting requirements and mechanisms, has led to 

improved quality of documentation and timeliness of reporting events. The information 

contained in the database was routinely queried by the Incident Investigation Program 

and reviewed for accuracy. The review team confirmed that most events were reported 

to NRC, as appropriate. The Department did not report several events involving 

equipment failures in a timely manner due to a misunderstanding of the reporting 

requirements. Once the Incident Investigation Program was notified and understood 

NRC’s reporting expectations, they immediately queried their database and reported the 

applicable events to NRC. This recommendation is closed. 

2. The review team recommends that the Department develop and implement an 

inspection program to verify that the quality assurance/quality control (QA/QC) 

requirements in the Sealed Source and Device (SS&D) Registry sheets are being 

implemented by the manufacturer. (Section 4.2.2 of the 2005 IMPEP report) 

Current Status: During the on-site portion of this IMPEP review, the review team 

determined that the Department developed QA/QC inspection guidance following the 

2005 IMPEP review; however, the review team discovered through interviews with the 

Radioactive Materials Inspection Group Supervisor and various inspectors that staff was 

not fully aware of the QA/QC inspection guidance. The review team found through 

interviewing staff that, during inspections of manufacturers, the inspectors ask basic 

QA/QC program questions of the licensee, but do not verify implementation of the 

QA/QC program as required by the procedure. Based on the information obtained 

during the on-site portion of the IMPEP review, the review team initially concluded that 

this recommendation should remain open, pending full implementation of the 

Department’s QA/QC inspection guidance. 

In its April 14, 2010 response to the draft IMPEP report, the Department asked that this 

recommendation be withdrawn because the Department believed that the 

recommendation imposed requirements above and beyond the expectations of an 

Agreement State program. The Department contended that the recommendation implies 

that a manufacturer’s or distributor’s QA/QC program must receive a full inspection at 

every routine inspection of the facility, which is not a documented requirement. The 

2005 IMPEP review team’s intent for the recommendation was to ensure that the 

Department was fully reviewing the licensee’s QA/QC program at a pre-licensing visit or 

during an initial inspection and then verifying the continued implementation of the 

QA/QC program during future routine inspections. The 2005 IMPEP review team’s 

intent also was to ensure that the Department had a policy in place for reviewing a 

licensee’s QA/QC program if a source or device is believed to have a generic failure. 

During its May 19, 2010 meeting, the MRB decided that the recommendation should 

remain open, based on the information at hand; however, the MRB allowed the 

Department the opportunity to provide additional information to the review team that 

could be used as a basis to close the recommendation. 

Subsequent to the MRB meeting, the Department provided the review team with 

examples of inspection reports of manufacturers and distributors, demonstrating 

verification of continued implementation of the licensees’ QA/QC programs. The 

Department also discussed in detail with the review team the Department’s policy for 
Texas Final Report Page 4 

conducting full QA/QC program inspections when an event trend analysis indicates a 

potential generic issue with a particular source or device. The review team believes that 

there was a disconnect between what the staff interviews during the on-site portion of 

the review revealed and how the Department implements its QA/QC inspection program. 

Based on the additional information provided by the Department and the Department’s 

clarification of its implementation of its policies and procedures, the review team 

concluded that the Department is aware of the expectations of an effective QA/QC 

inspection program and that the Department has met the intent of the recommendation. 

This recommendation is closed. 

3. The review team recommends that the Department conduct an evaluation of the uranium 

recovery program workload and hire the necessary staff to adequately address the 

workload. (Section 4.4.1 of the 2005 IMPEP report) 

Current Status: The review team determined that the staffing levels are adequate for the 

existing and future uranium recovery workload, based on discussions with the respective 

managers. This recommendation is closed. 

4. The review team recommends that the Department prepare necessary supporting 

documentation identifying the bases for the licensing actions associated with reclamation 

plans for the three conventional mills. (Section 4.4.4 of the 2001 IMPEP report) 

Current Status: The review team evaluated the State’s approach and technical review of 

these issues and was satisfied with the technical quality of reports completed to date, 

including reviews of compliance monitoring and groundwater modeling. 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

The Department’s staffing and training for the radioactive materials program will be covered in 

this section of the report. The Commission’s staffing and training for the low-level radioactive 

waste and uranium recovery programs will be covered in Sections 4.3.1 and 4.4.1 of this report, 

respectively. 

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

this indicator, interviewed Department managers and staff, reviewed job descriptions and 

training records, and considered any possible workload backlogs. 
Texas Final Report Page 5 

The Department is organized into functional groups rather than program groups. The Radiation 

Safety Licensing Branch Manager is designated as the radiation control program director and 

provides a coordinating role among the functional groups. As such, communication between 

the groups is paramount to achieve an effective radioactive materials program. 

At the time of the review, there were 46 individuals, totaling approximately 43.5 full-time 

equivalents (FTE), with various degrees of involvement in the radioactive materials program. 

Licensing functions, including sealed source and device review, are performed in the Austin 

office by the Radiation Safety Licensing Branch. The inspection and incident response 

programs are located in the Inspection Radiation Branch. Most of the inspection staff is located 

in 11 regional offices located throughout the State. The Policy/Standards/Quality Assurance 

Group coordinates rule development, prepares enforcement cases for referral to the 

Enforcement Review Committee, and plays a major role in quality assurance for the inspection 

program. 

During the review period, 21 individuals left the radioactive materials program, including five 

managers. Twelve staff members were added during the review period, including several 

Regional inspector positions. Currently, the program has three vacancies, a recently-created 

incident investigator position and two environmental specialist positions. The environmental 

specialist positions do not play a significant part in the Agreement State program. 

In January 2010, the Texas Governor requested that each State agency submit a plan 

identifying a 5 percent savings in appropriations for fiscal years 2010 and 2011. As a result of 

the Governor’s request, the Texas Health and Human Services Commission, implemented a 

hiring freeze and other personnel-related cost saving actions. The Division for Regulatory 

Services requested a waiver from those actions in the interest of public health and safety. The 

Department notified the MRB during the May 19, 2010 meeting that the Department’s waiver 

request was approved. 

The Department has a documented training plan for technical staff that is consistent with the 

guidance in the NRC/Organization of Agreement States Training Working Group Report and 

NRC’s Inspection Manual Chapter (IMC) 1246, “Formal Qualification Programs in the Nuclear 

Material Safety and Safeguards Program Area.” The Department uses on-the-job training to 

supplement formal, classroom training. New licensing and inspection staff members are 

assigned increasingly complex duties under the direction of the licensing or inspection 

managers, respectively. New inspectors accompany more experienced inspectors during 

increasingly complex inspections and are assigned independent inspections after demonstrating 

competence during accompaniment evaluations by their manager. The review team confirmed 

the qualifications of all staff through review of qualification journals, training records, and 

documentation of supervisory accompaniments. The review team noted that the incident 

investigation staff was not issued qualification journals similar to the inspection and licensing 

staff members. As that program has a relatively new investigator and has a vacant position, the 

review team encouraged Department managers to provide similar qualification journals to the 

incident investigation staff. 

The review team noted that Department managers encourage and support training 

opportunities, based on program needs and funding. The Department has sponsored NRC 

training courses in the past and will sponsor additional courses in the future, including the 
Texas Final Report Page 6 

Inspection Procedures course in April 2010 and the Licensing Procedures course in September 

2010. The review team concluded that the Department’s staffing and training is adequate to 

carry out its regulatory duties. 

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

that Texas’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 Department’s questionnaire response relative to this indicator, data gathered from the 

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

Manager of the Policy/Standards/Quality Assurance Group, the Inspection Radiation Branch 

supervisors, and staff members. 

The review team verified that the Department’s inspection frequencies for all types of 

radioactive materials licenses are at least the same frequency as those listed in IMC 2800, 

“Materials Inspection Program.” For licenses with multiple locations of use, inspections are 

performed at each location every inspection cycle. A separate inspection report is written for 

each location of use. 

The Radioactive Materials Inspection Group conducted a total of 1,066 inspections of Priority 1, 

2, and 3 licensees during the review period. In their response to the questionnaire, the 

Department indicated that 6 percent of the inspections were completed overdue within the 

review period and that there were no overdue inspections of those Priority 1, 2, and 3 licensees 

when the questionnaire was completed. The review team verified the Department's percent of 

overdue inspections and ascertained that no inspections were overdue at the time of the review. 

The review team also evaluated the Radioactive Materials Inspection Group’s timeliness for 

conducting initial inspections. The review team noted that the Radioactive Materials Inspection 

Group conducted 339 initial inspections during the review period. The objective is to inspect all 

new facilities within one year, in accordance with IMC 2800 guidelines; however, 16 of those 

inspections were completed overdue during the review period. The review team verified that 

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

calculated that the Department performed 6 percent of its inspections overdue during the review 

period. 

The review team evaluated the timeliness of issuance of inspection reports. The Department 

has a policy of issuing the inspection findings to licensees within 30 days from the date of the 

inspection. Inspectors are required to submit completed inspection reports to the 

Policy/Standards/Quality Assurance Group within 15 days. This Group has 15 days to complete 

their review and to convey the inspection results to the licensee. Of the 40 inspection files 

reviewed, five reports were issued beyond the 30-day goal. One inspector was responsible for 

all five late inspection reports identified by the review team. The Department was aware of the 
Texas Final Report Page 7 

late inspection reports and took appropriate corrective action to help ensure that future 

inspection reports will be issued in a timely manner. 

During the review period, the Department received requests for reciprocity from 192 licensees. 

The review team determined that the Radioactive Materials Inspection Group conducted 

reciprocity inspections of 11 percent of those licensees in 2007, 29 percent in 2008, and 28 

percent in 2009. The lower percentage of reciprocity inspections in 2007 was the result of the 

impacts of a Department office flood and significant response to hurricanes. The Department 

exceeded the NRC’s criteria of inspecting 20 percent of candidate licensees operating under 

reciprocity for the latter 2 years and is on a similar pace in 2010. 

The review team verified that Increased Controls inspections were performed concurrent with 

routine safety inspections. The inspections of Increased Controls licensees evaluated the 

pertinent aspects of the security measures. 

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

that Texas’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, and inspection field 

notes for 39 radioactive materials inspections conducted during the review period. The 

casework examined included a cross-section of inspections conducted by two former and eight 

current inspectors and covered a wide variety of inspection types. The inspection reports that 

were reviewed included academic and medical broad scope; diagnostic nuclear medicine; 

gamma knife; general license distribution; high dose-rate remote afterloaders; industrial 

radiography; instrument calibration; nuclear pharmacy; and well logging licensees. The review 

also included both initial and followup Increased Controls inspections. Appendix C lists the 

inspection casework files reviewed, with case-specific comments. 

The Radioactive Materials Inspection Group’s inspection procedures are consistent with the 

inspection guidance found in IMC 2800. Based on the evaluation of casework, the review team 

determined that inspections covered all aspects of the licensees’ radiation safety 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, and unresolved safety issues. In 

addition to paper copies that are maintained in Austin, all inspection documentation is entered 

into the Department's electronic filing system, which is accessible to all staff members. 

The Department has a policy to accompany all staff performing radioactive materials inspections 

on an annual basis. The inspector accompaniments are currently performed by a senior 

inspector. The review team encouraged the Manager of the Radioactive Materials Inspection 

Group to become involved with the accompaniment process, including annual accompaniments 

of the aforementioned senior inspector. 
Texas Final Report Page 8 

The review team determined that documents involving Increased Controls inspections were 

protected, segregated from other files (electronic and paper), and maintained in a manner to 

limit access. Inspection report files for Increased Controls were in color coded folders and kept 

separate from the routine inspection reports. If any of these records are requested by a 

member of the public, the documents are reviewed for sensitivity; marked as sensitive, as 

appropriate; and withheld from public disclosure. 

The review team verified that the Department 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 

radioactive materials inspection program are calibrated by Department staff or the 

manufacturer. 

The review team accompanied eight of the Department's inspectors between December 14, 

2009, and January 29, 2010. The inspectors conducted inspections of three medical licensees, 

two industrial radiography licensees, a well logging licensee, a nuclear pharmacy licensee, and 

a manufacturing and distribution licensee. 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 programs. The inspectors conducted interviews with appropriate personnel, 

observed licensed operations, 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. 

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

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

satisfactory. 

3.4 Technical Quality of Licensing Actions

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

managers for 29 specific licenses. 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, 

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 12 new 

licenses, 3 renewals, 20 amendments, and 3 license terminations. Files reviewed included a 

cross-section of license types, including: medical diagnostic and therapy, brachytherapy, 

gamma knife, industrial radiography, nuclear pharmacy, research and development, well 

logging, and veterinary licensees. The casework sample represented work from each of the 
Texas Final Report Page 9 

license reviewers. A listing of the licensing casework reviewed, with case-specific comments, 

can be found in Appendix D. 

All licensing actions received by the Department are assigned a log number in the Radiation 

Control LRICS computer tracking system. The licensing action is then provided to one of the 

three program leaders who assign the action to a license reviewer in their group. The licensing 

staff is responsible for reviews, deficiency letters, coordination and finalizing the licensing 

action. Deficiencies are typically communicated via formal letters addressed to the licensee. 

When a licensing action is completed, the respective program leader reviews the action for 

quality and signs the licensing action. The review team noted that the licensing actions were 

consistent with the Radiation Safety Licensing Branch Regulatory Guides, the State’s 

regulations, and good health physics practices. 

The review team verified the Department’s application of the State’s financial assurance 

requirements. The review team evaluated several licenses that met the criteria for financial 

assurance for decommissioning. The licensees had submitted the appropriate instruments, 

statement of intent, or decommissioning funding plan required under Texas regulations. The 

review team determined that the Department had appropriately identified licensees who were 

required to maintain financial assurance and had taken appropriate steps to ensure the 

licensees remain compliant with the financial assurance requirements. Financial instruments 

were appropriately protected from loss or theft. 

During the review period, the Department implemented a policy for pre-licensing reviews of all 

new applicants. The policy incorporated the essential elements of NRC’s revised pre-licensing 

guidance to verify that the applicant would use requested radioactive materials as intended. 

The Department checked applicants without a known radioactive materials license from NRC or 

another Agreement State against other types of licensure or registration, including various online search mechanisms and interagency communications, to verify the identity of individuals. 

If a pre-licensing visit was required, then the license reviewer performed the site visit. 

The review team evaluated the Department’s licensing practices regarding the Increased 

Controls and Fingerprinting requirements. The review team confirmed that the licensing staff 

evaluated new license applications and license amendments for application of the Increased 

Controls and Fingerprinting requirements, as appropriate. 

The Department does not routinely mark licenses or documents containing security-related 

information as recommended in Regulatory Issues Summary 2005-31, “Control of SecurityRelated Sensitive Unclassified Non-Safeguards Information Handled by Individuals, Firms, and 

Entities Subject to NRC Regulation of the Use of Source, Byproduct, and Special Nuclear 

Material.” If records are requested by a member of the public, the documents are reviewed for 

sensitivity; marked as sensitive, as appropriate; and withheld from public disclosure. The 

Department reviews documents requested under the Texas Open Records Acts for 

confidentiality, to determine whether the document should be withheld from public disclosure 

based on Texas Statutory Code, Section 418.178. This relatively new provision in the code 

allows documents to be withheld if the information contained in the document was more than 

likely to assist in the construction or assembly of a radiological weapon or indicated the specific 

location of radioactive material. 
Texas Final Report Page 10 

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

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

was satisfactory. 

3.5 Technical Quality of Incident and Allegation Activities

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

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

to this indicator; the Department’s incident and allegation procedures, including those for 

reporting incidents to NRC’s Headquarters Operations Center and the Nuclear Material Events 

Database (NMED); and evaluated the Department’s casework files and database for selected 

incidents and allegations. 

The review team evaluated the Department’s actions related to 11 incidents that were reported 

during the review period. A listing of the incident casework examined, with case-specific 

comments, is included as Appendix E. The review team evaluated the Department’s response 

to 12 allegations received during the review period, including eight allegations referred to the 

Department by NRC during the review period. 

The Incident Investigation Program is responsible for initial response and followup to incidents 

and allegations involving materials regulated by the Department. Allegations are referred to by 

the Department as “complaints.” At the time of the review, the Incident Investigation Program 

was composed of a manager and three incident investigators. During the review period, the 

Department processed approximately 150 incidents and approximately 60 complaints related to 

materials covered by the State’s Agreement with NRC. 

Following the previous IMPEP review, written procedures were developed by the Department 

for the receipt, processing, documenting, tracking, and reporting, incidents and allegations. At 

the time of the current IMPEP review, these procedures were under revision by the Incident 

Investigation Program to enhance their processes and procedures based on operational 

experience to provide additional guidance where necessary and clarify reporting requirements. 

Additional guidance on the conduct of investigations and investigation techniques was located in 

the Department’s Radioactive Materials Inspection Manual. 

The majority of incidents and complaints were investigated by the Incident Investigation 

Program staff. Occasionally, due to the physical location associated with an incident or 

complaint, or due to workload, the Incident Investigation Program will request that a regional 

inspector from the Radioactive Materials Inspection Group perform the onsite portion of an 

investigation. The Incident Investigation Program staff reviewed the results of the investigations 

conducted by regional inspectors. Followup actions were performed by the Incident 

Investigation Program, as necessary. The Department has a policy in place that provides a 

standard procedure for the handling of these types of shared responsibilities for incidents and 

complaints. 

All incidents and complaints were tracked by the Department in a database that was developed 

following the 2006 followup IMPEP review. The database allows for searches, queries, and 

report generation to better manage the incident response program. 
Texas Final Report Page 11 

The incidents selected for review included medical events, lost/stolen material, loss of control of 

material, contamination events, equipment failure, and damage to equipment. The review team 

found that the Department’s response to incidents was prompt, taking into consideration the 

health and safety or security significance of the event. As appropriate, incident investigators or 

inspectors were dispatched to events for an on-site response in a timely manner, often on the 

day the event was reported. On-site responses often included the performance of radiological 

surveys and measurements for fixed and removable radioactive contamination, as well as the 

collection of soil/water samples for the determination of radiological constituents. The casework 

files for incidents indicated that both on-site and in-office reviews of incidents were thorough and 

that the documentation of the investigations was generally complete. The review team did note 

a few inconsistencies and completeness issues with some of the medical event documentation. 

These comments were provided to Incident Investigation Program staff and Department 

management during the review. When appropriate, the Department issued enforcement actions 

as a result of their investigations. 

The review team performed an evaluation of the Department’s actions related to 12 complaints. 

Eight of the complaint files reviewed were those related to allegations that were referred to the 

Department by NRC during the review period. The review indicated that the Department took 

prompt and appropriate action in response to the allegers’ concerns. Of the 12 complaint 

casework files reviewed, investigations were found to be thorough and the documentation of the 

complaint resolution was generally complete. During the on-site review, discussions with the 

reviewer and investigators developed additional information regarding one of the allegations that 

NRC referred to the Department. As a result of this new information, the case file was reopened 

and the Incident Investigation Program staff initiated supplemental investigation activities. 

An Assistant General Counsel from the Department presented the review team with an overview 

of Texas statutes related to open records. Texas Government Code, Chapter 552, addresses 

Texas open government rules and the Texas Public Information Act. It specifically addresses 

written requests for information from State agencies. To implement the Texas Public 

Information Act, the Texas Attorney General has developed procedural rules, which the 

Department has adopted. The Department’s position is that allegers’ identities cannot be 

protected from release unless the alleger specifically requests that their identity be withheld or if 

the Department determines on a case-by-case basis that the alleger’s identity needs to be 

protected to encourage the reporting of information to the agency. In either situation, even if 

this request is made, the Department would need to take specific action through the Texas 

Attorney General’s office within a specified time frame to block the release of the information. In 

some cases, the release of the alleger’s identity cannot be blocked even through legal action. 

As a result, when allegers are made aware that their identities potentially could, and likely would 

be, released through an open records request, they sometimes refuse to provide their 

identification and contact information. This precludes the Department from providing the 

allegers with feedback regarding the resolution of their concerns. Other times, Department staff 

have discouraged allegers from providing their identity and contact information, which again 

precludes feedback regarding resolution of concerns. The Department has a Complaint 

Process Improvement Team in place that has been looking into these issues and trying to 

develop means through which feedback can be provided to allegers even if they choose to 

remain anonymous. When allegers did provide their identification and contact information, the 

Department provided feedback regarding their concerns either verbally or in writing. 
Texas Final Report Page 12 

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

that Texas’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 the State of Texas relinquishes regulatory authority for all programs covered by 

the four non-common performance indicators. 

4.1 Compatibility Requirements

Texas became an Agreement State in 1963. In assessing Texas’s compatibility requirements, 

the review team examined the Department’s and Commission’s responses to the questionnaire 

relative to this indicator, reviewed the State Regulation Status Data Sheets (SRS) for the 

Department and the Commission, and conducted interviews with managers responsible for this 

program area. 

4.1.1 Legislation 

Both the Department and the Commission are granted legal authority through the Texas 

Radiation Control Act, Chapter 401 of the Texas Health and Safety Code. Chapter 401 outlines 

that the Department is the Texas Radiation Control Agency. It further outlines the jurisdictional 

authorities of the two agencies. For simplicity’s sake, the Department has jurisdiction over 

activities related to radiation and radioactive materials except for those activities that are under 

the jurisdiction of the Commission. The Commission has the jurisdiction to license and regulate 

the disposal of radioactive materials, the recovery and processing of source material, the 

processing of tailings or waste produced by or resulting from the extraction or concentration of 

uranium or thorium from ore (11e.(2) byproduct material as defined in the Atomic Energy Act, as 

amended), the commercial processing or storage of radioactive waste, and sites for the disposal 

of low-level radioactive waste and byproduct material. The Commission is also affected by the 

Texas Low-level Radioactive Waste Disposal Compact, Chapter 403 of the Texas Health and 

Safety Code. Each agency was indirectly affected by many other Texas rules and legislation. 

The jurisdictional areas noted above are different than those noted during the last IMPEP 

review. The changes were the result of Texas Senate Bill 1604, which was passed in the Texas 

80th Legislature in 2007. This bill amended the Texas Radiation Control Act and transferred 

licensing and regulatory jurisdiction from the Department to the Commission for the recovery 

and processing of source material, 11e.(2) byproduct material disposal, and commercial 

processing or storage of radioactive waste. As a result of these changes, certain sections of the 

Department’s regulations in 25 Texas Administrative Code Chapter 289 were repealed and 

these matters were primarily incorporated into the Commission’s regulations in 30 Texas 

Administrative Code Chapter 336. 

The Department and the Commission (as the former Texas Natural Resource Conservation 

Commission) developed and implemented a Memorandum of Understanding (MOU) in 1996, 
Texas Final Report Page 13 

which was revised in 1998. The MOU specified the respective responsibilities of the two 

agencies and stated that the Department and Commission agreed to work together to ensure 

that complete regulation is maintained for sources, uses, and users of radiation. The MOU also 

addressed certain operational functions of the two agencies, such as emergency preparedness, 

instrument calibration, and mutual assistance. The review team noted that the MOU was 

outdated and did not reflect the current jurisdictions or responsibilities of the two agencies. 

References to the MOU were retracted from the Commission’s regulations although the MOU is 

still in statute in the Department’s regulations under 25 Texas Administrative Code 289.101. 

The review team encouraged the two agencies to work together to revise the MOU. Such an 

effort would increase communication between the two agencies with respect to matters related 

to radiation in the State. 

All Texas agencies are subject to sunset review by the Texas Sunset Commission. The 

Department was last reviewed in 2000 and the Commission was reviewed in 2001. The next 

sunset review for the Department is anticipated to be within the next year. The sunset review 

for the Commission was underway at the time of the IMPEP review and was anticipated to 

continue through 2011. The Radioactive Materials Division is one of the specific programs 

within the Commission that will be reviewed during the current sunset review. To support this 

effort, the Commission performed a self-assessment and provided the results to the Texas 

Sunset Commission. 

Additionally, State agencies are required to perform a review of each rule 4 years from the last 

effective date of the rule. The purpose of the review is to assess whether the reasons for 

adopting the rule continue to exist; whether the rule reflects current legal considerations, policy 

considerations, and current agency procedures; or whether the rule is obsolete. 

4.1.2 Program Elements Required for Compatibility 

The review team examined the procedures used in the Department’s and the Commission’s 

regulatory processes. Both the Department and the Commission receive recommendations on 

proposed rulemaking from the Texas Radiation Advisory Board. The Department also 

coordinates its rulemaking through the State Health Services Counsel. At the time of the 

review, the Department was in the process of standardizing its policies and procedures for 

rulemaking for all programs within the Department. Some rulemakings involve public meetings 

and both agencies’ rulemaking processes provide an opportunity for public/stakeholder 

comment on proposed regulations. The Department and the Commission provide NRC any 

proposed rules for a compatibility review. 

The Department’s rulemaking process often proposes and adopts rules in regulatory packages 

that are different than NRC’s Review Summary Sheets for Regulation Amendments (also known 

as RATS Identification). This results in individual portions of RATS Identification sheets being 

promulgated and adopted by the Department at different times. In addition, the Department 

often combines portions of RATS Identification sheets into one rulemaking package. 

During 2007, the Department’s facility was impacted by a flood that inadvertently prevented 

some final rule packages from being submitted to NRC for review. These final packages were 

sent to NRC for review and returned to the Department on January 10, 2010. Some of the rules 

were returned with comments. The Department had also previously sent proposed rules to 
Texas Final Report Page 14 

NRC, several of which were returned to the Department with comments. Additionally, the 

Department’s reconciliation of NRC comments related to other rules is currently in the 

rulemaking process. The reconciliation includes all or portions of the following regulation 

amendments: 

• “Medical Use of Byproduct Material,” 10 CFR Parts 20, 32, and 35 amendment (67 FR 

20249), that was due for Agreement State adoption on October 24, 2005. 

• “Medical Use of Byproduct Material – Recognition of Specialty Boards,” 10 CFR Part 35 

amendment (70 FR 16336), that was due for Agreement State adoption on 

April 29, 2008. 

• “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 Department does not have any proposed regulations that are overdue for adoption that 

have not already been addressed. The review team reminded the Department that there is one 

pending regulatory package that is due for State adoption during 2010. The Department needs 

to address the following amendment: 

• “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. 

During the review period, the Commission sent several final rule packages to NRC for review 

and comment. Several of these packages were submitted to NRC for review as a result of the 

transfer of jurisdictional authority over of certain activities from the Department. All but one of 

the final packages was returned by NRC without comments. The one final regulatory package 

returned by NRC with comments was: 

• “Radiological Criteria for License Termination of Uranium Recovery Facilities,” 10 CFR 

Part 40 amendment (64 FR 17506), that was due for Agreement State adoption on June 

11, 2002. 

The Commission has one regulatory package that is overdue. The RATS Identification for the 

regulatory package addresses rules that pertain to both the Department and the Commission. 

The Department has submitted their rules to NRC and they were returned to the Department 

with comments. The Commission still needs to address the rules that pertain to the 

Commission. The Commission representatives indicated that they will be processing a 

rulemaking package beginning in fall 2010. This rulemaking will address other pending rules 

and will also address any changes to the rules necessary as part of the overdue regulatory 

package. The Commission expects the rulemaking to be completed in 2011. The overdue 

regulatory package is: 

• “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. 
Texas Final Report Page 15 

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

that Texas’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 

Department’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 Texas 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 team also evaluated SS&D 

staff training records, certain reported incidents involving products authorized in Texas SS&D 

sheets, 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 distributed amongst the license review staff. The staff is 

divided between industrial SS&D evaluations (Industrial Unit) and medical SS&D evaluations 

(Medical Unit). The lesser experienced staff member signs evaluations with a more 

experienced staff member signing in concurrence. 

The Department has six reviewers who are qualified to perform safety evaluations of SS&D 

applications. All have science degrees and have attended NRC’s SS&D Workshop. 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 SS&D staffing level and education qualifications for the current staff 

were evaluated and were found adequate. 

4.2.2 Technical Quality of the Product Evaluation Program

The review team evaluated 15 of the 57 SS&D evaluation amendments, inactivations, and new 

registrations, which included custom evaluations issued by the Department during the review 

period, representing the work of eight SS&D reviewers (six active reviewers and two former 

reviewers). The Industrial Unit conducted seven new evaluations, issued 24 amendments to an 

existing registration and inactivated 18 registrations since the last review. The Medical Unit 

conducted three new evaluations, issued four amendments and inactivated one registration 

since the last review. The review team noted that the Department completed two SS&D actions 

involving naturally occurring and accelerator-produced radioactive material on behalf of the 

State of Wisconsin. These registries were transferred to NRC’s jurisdiction during this review as 

appropriate following the expansion of NRC’s regulatory authority granted in the Energy Policy 

Act of 2005. There were no emerging technology evaluations completed during the review 

period. The cases selected for review were representative of the Department’s licensees and 

SS&D reviewers throughout the reporting period. The Department stated that they currently 
Texas Final Report Page 16 

manage 297 active SS&D registrations. A list of SS&D casework examined, with the casespecific comments, can be found in Appendix F. 

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

information contained in the Department’s response to the IMPEP questionnaire for this 

indicator and interviewed program staff and managers. The review team confirmed that the 

Department follows the recommended guidance from NRC’s SS&D Workshop, NUREG-1556 

Series guidance, applicable and pertinent American National Standards Institute standards, 

ISO-9001, and Texas Regulatory Guides. The review team verified that these documents were 

available and used appropriately in performing SS&D reviews. 

The Department performed evaluations based on sound conservative assumptions to ensure 

public health and safety was adequately protected. The Department also sought the input from 

other licensing jurisdictions that have experience with similar products. Deficiency letters clearly 

stated regulatory positions and all health and safety issues were addressed. The review team 

determined that product evaluations were thorough, complete, consistent, and adequately 

addressed the integrity of the products during use and in the event of accidents. 

4.2.3 Evaluation of Defects and Incidents Regarding SS&Ds

Two incidents related to SS&D defects involving sources or devices registered by the State of 

Texas were reported during the review period. The review team found that the Department’s 

response to incidents was prompt, taking into consideration the health and safety or security 

significance of the event. Incident procedures are in place should an SS&D-related incident 

occur. Department managers were aware of the need to look at such incidents as potentially 

generic in nature with possible wide-ranging effects. 

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

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

Program, was satisfactory. 

4.3 Low-level Radioactive Waste Disposal Program

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

performance regarding the low-level radioactive waste (LLRW) disposal program. These 

subelements were: (1) Technical Staffing and Training, (2) Status of Low-level Radioactive 

Waste Disposal Inspection, (3) Technical Quality of Inspections, (4) Technical Quality of 

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

The regulatory responsibility for LLRW disposal resides with the Commission. Since the 2005 

IMPEP review, the Commission’s Radioactive Material Licensing team has issued two Technical 

Notices of Deficiencies in response to Waste Control Specialists, LLC (WCS) license application 

and the initial radioactive materials license to receive, handle, process, store, and dispose of 

LLRW at a site near Andrews, Texas. The Texas Legislature established the process and 

timelines for receiving license applications and their review, ending with the issuance of a 

disposal site license after two rounds of interrogatories. 

 
Texas Final Report Page 17 

4.3.1 Technical Staffing and Training

The LLRW program team currently has nine full-time and/or part-time staff members with a 

staffing effort of 4.9 FTE. The FTE total includes support by the Uranium Technical Assessment 

program. Staff supporting the LLRW program include: the Division Director, Radioactive 

Materials Licensing Manager, Health Physicists, engineers, geologists, and an administrative 

assistant. 

Five primary contractors were also utilized for technical support during the review period. 

Contractors provided assistance in health physics, nuclear engineering, hydrogeology, geology, 

geotechnical engineering, financial assurance, ecology, land/mineral rights, law, and civil 

engineering. 

The program shifted from the Department to the Commission in 2007. Several Department staff 

transferred with the program. Four staff associated with the LLRW program left the program 

during the review period. The Commission hired eight new staff since the program moved. Two 

of the newly-hired personnel are health physicists that will serve as resident inspectors at the 

low-level radioactive waste disposal facility. The newly hired inspectors have Bachelor’s 

degrees in technical fields and health physics backgrounds. 

Within the Commission, the licensing group is segregated from the inspectors. Licensing occurs 

within Office of Permitting & Registration, Radioactive Materials Division, Radioactive Material 

Licensing Section. The inspectors are located in the Office of Compliance and Enforcement, 

Homeland Security Program. As identified in earlier sections of this report, organizing by 

functional groups rather than by program, requires significant emphasis on communication 

between licensing and inspection staffs to achieve an effective regulatory program. 

The review team examined the training records of the staff and found them up to date and 

complete, although the Commission does not have a documented training and qualification 

program for staff performing LLRW licensing or inspections. Section managers use professional 

judgment to certify when staff is “qualified.” The review team spoke to the Commission 

managers about the benefits to the program and staff for a well-documented training program 

including training journals and sign-off sheets. 

The review team determined that the current staff has the right mix of technical expertise and is 

adequate to maintain the quality and performance of the LLRW program. Through interviews 

with the professional staff and program managers, combined with an evaluation of training and 

experience, the review team concluded that the Commission staff is qualified to carry out 

regulatory duties for licensing and inspecting of the LLRW site. Managers are attempting to 

build depth in their programs. At the time of the review, only one of the four LLRW inspectors 

was qualified to inspect all aspects of a LLRW facility. All inspectors had partial qualifications to 

review certain aspects of a LLRW facility. 

4.3.2 Status of Low-level Radioactive Waste Disposal Inspection

Due to the pre-construction status of the disposal site, no license-specific health and safety 

inspections have taken place since the issuance of the license on September 10, 2009. 
Texas Final Report Page 18 

LLRW program staff visited the disposal site several times before and since the license was 

issued. Staff performed pre- and post-licensing soil and water sampling and environmental TLD 

monitoring. In addition, when health physics investigators inspected the co-located processing 

and storage facility, they routinely observed activities at the planned LLRW disposal site. 

4.3.3 Technical Quality of Inspections

Due to the current status of the LLRW program, the review team had only limited activities to 

review for this subelement. Inspection modules for use at the LLRW disposal site have not 

been developed. 

On January 13, 2009, two review team members accompanied two Commission inspectors at 

the WCS facility, as indicated in Appendix C. The inspectors were well prepared and thorough 

during their limited review of the LLRW disposal site. Under the LLRW license, site security, 

pre-operational environmental monitoring, and facility posting were observed. Inspectors 

conducted proper entrance and exit interviews with licensee managers and safety staff. 

Inspectors also conducted interviews with non-supervisory site personnel during the course of 

the inspection to ascertain perspective on licensee commitment to safety and training. During 

the accompaniments, the inspectors demonstrated appropriate performance-based inspection 

techniques and knowledge of the regulations. The inspections were adequate to assess the 

safety and radiological hazards at the LLRW disposal facility. 

Based on the pre-construction status, the review team did not have any radioactive shipment 

receipt inspection activities to review for this subelement. 

4.3.4 Technical Quality of Licensing Actions

Since the conclusion of the 2005 IMPEP review, staff in the Commission’s Radioactive Materials 

Division have completed a technical review of the WCS license application for receipt of lowlevel radioactive waste and issued a license to WCS for receipt of low-level radioactive waste 

limited to Compact waste and Federal Facility waste. The WCS facility holds three licenses 

from the Commission and one from the Department. A listing of the LLRW licensing casework 

reviewed by the review team may be found in Appendix D. 

Following the completion of the technical review, the Commission conducted a public meeting in 

Andrews, Texas, and opened a 30-day period to receive public comments and requests for a 

public hearing on the application. Based on the results of the technical review and public 

comments, the Commission issued radioactive materials license number R04100 to Waste 

Control Specialists, LLC on September 10, 2009. The review team concluded that the license 

conditions were clearly stated and inspectable. 

The review team also evaluated Commission staff technical reviews associated with the 

responses to several pre-construction license conditions submitted by the licensee prior to 

issuance of the license. At the time of this review, the Commission staff had reviewed several 

of the licensee’s responses to license conditions, and is planning to issue a single response to 

the licensee’s submittals. 
Texas Final Report Page 19 

The review team examined the financial surety proposed for the facility. Per license condition, 

discrete financial surety amounts for several categories (e.g., decommissioning, closure, and 

post-closure) are stated. To evaluate the licensee’s proposal, the Commission sought outside 

assistance from a private contractor, as well as another State agency. Discussions continue 

with the licensee on this topic. The review team determined that the Commission adequately 

addressed the financial surety component of the license. 

The review team concluded that the Commission’s licensing process was thorough, complete, 

consistent, and of acceptable quality. 

4.3.5 Technical Quality of Incident and Allegation Activities

The review team found that the Commission had procedures in place for handling incidents and 

allegations. The procedures for handling incidents include information on what constitutes an 

incident, appropriate documentation of the incident, reference to NRC abnormal occurrence 

criteria, and incident tracking. The procedures for handling allegations include information on 

protecting the identity of the alleger, documentation of the allegation, and allegation tracking. 

During the review period, there were no incidents or allegations pertaining to the LLRW 

program. 

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

that Texas’s performance with respect to the indicator, Low-level Radioactive Waste Disposal 

Program, was satisfactory. 

4.4 Uranium Recovery Program

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

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

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

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

and Allegation Activities. 

The Texas uranium recovery program has undergone inter-agency jurisdictional changes since 

the 2005 IMPEP review. In 2005, the Department had jurisdiction for the licensing, inspection, 

and enforcement actions for the above ground processes at licensed sites, including the review 

of the design, construction, operation, record keeping, maintenance, decommissioning, 

decontamination, and surface reclamation. The Commission had jurisdiction on the permitting, 

inspection, and enforcement actions for wells permitted by the underground injection control 

(UIC) program, including wellhead assemblies and groundwater monitoring requirements. Both 

agencies were responsible for the review, permitting, licensing, inspection, and enforcement 

activities for fluid holding ponds. 

As of July 1, 2007, the regulatory jurisdiction of the uranium recovery program was transferred 

to the Radioactive Material Division in the Commission. In 2008, the Commission codified rules 

for radiological materials licensing, and the Department redacted it rules. In 2009, the 

Commission further reorganized such that (a) inspections for uranium recovery program 

licenses and UIC permits were performed by personnel in the Homeland Security Program 
Texas Final Report Page 20 

(under a separate office at the Commission) and (b) the UIC Permits team was moved from 

another section within the Office of Permitting & Registration to the Radioactive Material 

Division. 

At the time of this IMPEP review, the Texas uranium recovery program consists of three 

conventional mill licenses (three sites currently under decommissioning and currently 

undergoing groundwater assessments), five in-site recovery licenses (two licensees in 

decommissioning status, one licensee in “standby” status, one licensee in active production, 

and one licensee newly approved but not in operation), three in-situ recovery applications for 

new facilities, and one “reclamation” licensee to administer cleanup of vicinity properties 

abutting an in-situ recovery licensee that had been revoked by the Department. 

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. 

The duties and responsibilities for the Texas uranium recovery program are assigned to staff in 

two sections within the Radioactive Materials Division and one section in the Homeland Security 

Program. Radioactive Materials Division staff members are responsible for licensing actions 

associated with source material licenses and for permitting of the injection wells, requirements 

for exempt aquifers, and groundwater restoration. Homeland Security Program staff members 

are responsible for routine inspections of facilities that have a uranium recovery program 

license. 

The Radioactive Materials Division staffing level is currently at 30 persons with various degrees 

of involvement in the uranium recovery program. Staffing levels have remained consistent, with 

only three staff members involved in the uranium recovery program leaving the Division during 

the review period. The staff has expertise in various technical disciplines including health 

physics, geology, hydrology, and engineering. A majority of the staff has a professional 

registration and/or an advanced degree. 

The staffing levels in the Homeland Security Program dedicated to the uranium recovery 

program consist of three persons (including the manager); only one staff member is fully 

qualified for inspections under the program. The staffing levels and their duties at the 

Homeland Security Program have been consistent throughout the IMPEP review period. The 

staff has the experience, education, and training to adequately perform uranium recovery 

inspections. 

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

regarding training efforts. Training for the staff is hampered somewhat by the agency-wide 

restriction on out-of-state travel. This restriction is mitigated by staff attending NRC-sponsored 

classes and the Commission providing in-house training by outside experts. During 2009, the 

Commission has provided nine in-house training courses and is proposing to send 12 personnel 

to NRC-sponsored training courses during the upcoming fiscal year. 

The review team determined that the staffing levels, staff qualifications, and training levels for 

the uranium recovery program are adequate. 
Texas Final Report Page 21 

4.4.2 Status of Uranium Recovery Inspection Program

In reviewing this subelement, the review team evaluated the inspection frequency for uranium 

recovery licensees and the timeliness of inspection finding communications to the licensees. 

The review team's evaluation is based on Texas’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, the Commission performed 48 license inspections at 7 active licenses: 

3 conventional mills in decommissioning, 2 in-situ recovery licenses in decommissioning, 

1 active but non-production in-situ recovery license, and 1 active in-situ recovery license. 

Inspections were performed in accordance with IMC 2801, “Uranium Mill and 11e.(2) Byproduct 

Material Disposal Site and Facility Inspection Program,” requirements. 

The Texas procedures require that the inspection findings be communicated to a licensee 

during exit meeting at the end of an inspection. A written inspection report is generated for each 

inspection and placed in the appropriate licensee’s file. The written inspection report is not 

submitted to the licensee, unless the licensee specifically requests a copy. 

4.4.3 Technical Quality of Inspections

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

conducted by the Commission during the review period and accompanied inspectors on 

inspections at two licensed facilities. The cases selected for review represented a range of 

uranium recovery licensing 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 uranium recovery 

program inspection files evaluated by the review team are listed in Appendix C. 

The inspector accompaniments and casework reviews confirmed that Commission inspections 

were thorough, included operational and record reviews, and violations were communicated by 

the inspector to the licensee during the inspection and exit interviews. The inspectors focused 

on interviews with licensee personnel to ensure that the work force was adequately trained and 

knowledgeable of the existing safety procedures, that the procedures were being followed, and 

that the worker’s and public health and safety were properly monitored. The record review 

concentrated on worker’s health and health physics monitoring; however environmental 

monitoring record review was not as in-depth. Appropriate enforcement actions were taken 

given the scope of violations noted in the inspection reports. 

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. 

For the conventional mills, the licensing actions during the review period consisted of license 

renewal, annual financial assurance updates, compliance monitoring, and post-
Texas Final Report Page 22 

decommissioning monitoring for groundwater compliance. For in-situ recovery facilities, the 

licensing actions during the review period consisted of reviews of new applications, license 

renewals, license amendments, annual financial updates, decommissioning plans, and project 

area authorizations. Based on the casework evaluated, the review team concluded that the 

licensing actions were of high quality and consistent with Commission procedures, State 

regulations, and good health physics practices. 

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 Commission’s response to two incidents and three allegations 

(complaints) regarding the uranium recovery program. A listing of the incident casework 

examined can be found in Appendix E. 

The State’s investigations were thorough and results of the allegation investigations were 

discussed with the originating complainant. Appropriate enforcement actions were taken given 

the scope of the violations noted. The review team discussed with Commission staff the 

importance of documentation of all investigations. The Commission is developing a database 

designed for agency-wide tracking of incidents, complaints, and enforcement actions. 

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

that Texas’s performance with respect to the indicator, Uranium Recovery Program, was 

satisfactory. 

5.0 SUMMARY 

As noted in Sections 3.0 and 4.0, Texas’s performance was found satisfactory for all nine 

performance indicators. The review team made no recommendations regarding program 

performance by the State. Overall, the review team recommended, and the MRB agreed, that 

the Texas 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. 
LIST OF APPENDIXES AND ATTACHMENTS 

Appendix A IMPEP Review Team Members 

Appendix B Texas Organization Charts 

Appendix C Inspection Casework Reviews 

Appendix D License Casework Reviews 

Appendix E Incident Casework Reviews 

Appendix F Sealed Source and Device Casework Reviews 

Attachments April 14, 2010 Letter from Kathryn Perkins 

Texas Department of State Health Services’ 

Response to the Draft Report 

April 14, 2010 Letter from Mark Vickery 

Texas Commission on Environmental Quality’s 

Response to the Draft Report 
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

James Lynch, Region III Team Leader 

 Technical Staffing and Training 

 Inspector Accompaniments 

Janine Katanic, FSME Team Leader-in-Training 

 Technical Quality of Incident and Allegation 

 Activities 

 Compatibility Requirements 

 Inspector Accompaniments 

George Johns, Minnesota Status of Materials Inspection Program 

 Technical Quality of Inspections 

Rachel Browder, Region IV Technical Quality of Licensing Actions 

 Compatibility Requirements 

Sandra Kessinger, Illinois Sealed Source and Device Evaluation Program 

Earl Fordham, Washington Low-level Radioactive Waste Disposal Program 

 Inspector Accompaniments 

Christopher Grossman, FSME Low-level Radioactive Waste Disposal Program 

John Saxton, FSME Uranium Recovery Program 

 Inspector Accompaniments 
APPENDIX B 

TEXAS ORGANIZATION CHARTS 

ADAMS ACCESSION NO.: ML100670214 
APPENDIX C 

INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

Texas Department of State Health Services

File No.: 1 

Licensee: Scott & White Memorial Hospital License No.: L00331 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 6/1/09 Inspector: LC 

File No.: 2 

Licensee: Scott & White Memorial Hospital License No.: L00331 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 6/2/09 Inspector: LC 

File No.: 3 

Licensee: Scott & White Memorial Hospital License No.: L00331 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 6/11/09 Inspector: LC 

File No.: 4 

Licensee: Scott & White Memorial Hospital License No.: L00331 

Inspection Type: Special, Announced Priority: 2 

Inspection Date: 6/11/09 Inspector: LC 

Comment: 

The Department conducted the initial special inspection 259 days overdue. 

File No.: 5 

Licensee: Southwestern Foundation License No.: L00468 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 7/9/09 Inspector: RW 

Comment: 

The Department conducted the inspection 289 days overdue. 

File No.: 6 

Licensee: Memorial Hermann Hospital System, LLC License No.: L00650 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 8/19/08 Inspector: LC 

Comment: 

The Department conducted the inspection 144 days overdue. 
Texas Final Report Page C.2 

Inspection Casework Reviews 

File No.: 7 

Licensee: Memorial Hermann Hospital System, LLC License No.: L00650 

Inspection Type: Initial Special, Announced Priority: 2 

Inspection Date: 9/15/08 Inspector: LC 

File No.: 8 

Licensee: Baptist St. Anthony’s Health System License No.: L01259 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 2/6/07 Inspector: ERS 

Comment: 

The Department conducted the inspection 101 days overdue. 

File No.: 9 

Licensee: Baptist St. Anthony’s Health System License No.: L01259 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 6/10/09 Inspector: ERS 

File No.: 10 

Licensee: The University of Texas Health Science License No.: L01279 

 Center at San Antonio 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 3/28/08 Inspector: RW 

Comment: 

The Department issued the inspection report 110 days overdue. 

File No.: 11 

Licensee: The University of Texas Health Science License No.: L01279 

 Center at San Antonio 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 3/26/08 Inspector: RW 

File No.: 12 

Licensee: The University of Texas Health Science License No.: L01279 

 Center at San Antonio 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 3/25/08 Inspector: RW 

File No.: 13 

Licensee: The University of Texas Health Science License No.: L01279 

 Center at San Antonio 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 3/25/08 Inspector: RW 
Texas Final Report Page C.3 

Inspection Casework Reviews 

File No.: 14 

Licensee: The University of Texas Health Science License No.: L01279 

 Center at San Antonio 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 3/27/08 Inspector: RW 

Comment: 

The Department issued the inspection report 84 days overdue. 

File No.: 15 

Licensee: The University of Texas Health Science License No.: L01279 

 Center at San Antonio 

Inspection Type: Special, Announced Priority: 2 

Inspection Date: 3/28/08 Inspector: RW 

Comment: 

The Department issued the inspection report 91 days overdue. 

File No.: 16 

Licensee: The University of Texas Health Science License No.: L01279 

 Center at San Antonio 

Inspection Type: Special, Announced Priority: 2 

Inspection Date: 3/26/08 Inspector: RW 

Comment: 

The Department issued the inspection report 24 days overdue. 

File No.: 17 

Licensee: The University of Texas Health Science License No.: L01279 

 Center at San Antonio 

Inspection Type: Special, Announced Priority: 2 

Inspection Date: 3/25/08 Inspector: RW 

File No.: 18 

Licensee: The University of Texas Health Science License No.: L01279 

 Center at San Antonio 

Inspection Type: Special, Announced Priority: 2 

Inspection Date: 3/27/08 Inspector: RW 

Comment: 

The Department issued the inspection report 44 days overdue. 

File No.: 19 

Licensee: Austin Texas Radiation Oncology Group, PA License No.: L01761 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 7/15/09 Inspector: LC 
Texas Final Report Page C.4 

Inspection Casework Reviews 

File No.: 20 

Licensee: Austin Texas Radiation Oncology Group, PA License No.: L01761 

Inspection Type: Special, Announced Priority: 2 

Inspection Date: 7/1509 Inspector: LC 

File No.: 21 

Licensee: Austin Texas Radiation Oncology Group, PA License No.: L01761 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 7/15/09 Inspector: LC 

File No.: 22 

Licensee: Texas Tech University Health Sciences Center License No.: L01869 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 8/5/08 Inspector: WK 

Comment: 

The Department conducted the inspection 370 days overdue. 

File No.: 23 

Licensee: Northwest Texas Healthcare System, Inc. License No.: L02054 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 6/11/09 Inspector: ERS 

Comment: 

The Department conducted the inspection 129 days overdue. 

File No.: 24 

Licensee: Gray Wireline Services License No.: L03541 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 12/28/10 Inspector: ERS 

File No.: 25 

Licensee: Cardinal Health License No.: L04043 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 8/14/07 Inspector: SF 

Comment: 

The Department conducted the inspection 82 days overdue. 

File No.: 26 

Licensee: Titan Specialties License No.: L04920 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 12/2/08 Inspector: ES 

Comment: 

The Department issued the inspection report 669 days overdue. 
Texas Final Report Page C.5 

Inspection Casework Reviews 

File No.: 27 

Licensee: TAPCO International, Inc. License No.: L04990 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 12/14/09 Inspector: JS 

File No.: 28 

Licensee: TAPCO International, Inc. License No.: L04990 

Inspection Type: Special, Announced Priority: 2 

Inspection Date: 12/14/09 Inspector: JS 

File No.: 29 

Licensee: ROSA of the South Plains License No.: L05484 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 1/12/10 Inspector: ES 

File No.: 30 

Licensee: University of Texas Southwestern License No.: L05947 

 Medical Center at Dallas 

Inspection Type: Initial, Announced Priority: 2 

Inspection Date: 2/22/07 Inspector: SF 

Comment: 

The Department conducted the inspection 117 days overdue. 

File No.: 31 

Licensee: University of Texas Southwestern License No.: L05947 

 Medical Center at Dallas 

Inspection Type: Initial, Announced Priority: 2 

Inspection Date: 4/24/09 Inspector: SF 

File No.: 32 

Licensee: Garland Cardiac Imaging License No.: L05948 

Inspection Type: Initial, Announced Priority: 5 

Inspection Date: 1/12/07 Inspector: SP 

Comment: 

The Department conducted the inspection 65 days overdue. 

File No.: 33 

Licensee: Texas Coast Cardiovascular, LLC License No.: L05983 

Inspection Type: Routine, Announced Priority: 5 

Inspection Date: 1/14/08 Inspector: HD 

Comment: 

The Department conducted the inspection 68 days overdue. 
Texas Final Report Page C.6 

Inspection Casework Reviews 

File No.: 34 

Licensee: Grace Clinic of Lubbock License No.: L06040 

Inspection Type: Routine, Announced Priority: 5 

Inspection Date: 1/12/07 Inspector: SP 

Comment: 

The Department conducted the inspection 45 days overdue. 

File No.: 35 

Licensee: Waste Control Specialists License No.: L06153 

Inspection Type: Initial, Announced Priority: 5 

Inspection Date: 7/18/08 Inspectors: WK 

File No.: 36 

Licensee: Waste Control Specialists License No.: L06153 

Inspection Type: Initial Special, Announced Priority: 5 

Inspection Date: 7/18/08 Inspector: WK 

File No.: 37 

Licensee: Texas Department of State Health Services License No.: L05865 

Inspection Type: Routine, Announced Priority: 5 

Inspection Date: 6/1/09 Inspector: JH 

File No.: 38 

Licensee: Texas Department of State Health Services License No.: L05865 

Inspection Type: Special, Announced Priority: 5 

Inspection Date: 6/2/09 Inspector: JH 

File No.: 39 

Licensee: National Oilwell Varco, LP License No.: L06094 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 7/30/08 Inspector: JH 

File No.: 40 

Licensee: Rio Grande Resources Corporation License No.: L02402 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 8/20/09 Inspector: MA 

Texas Commission on Environmental Quality

File No.: 41 

Licensee: Mesteña Uranium, LLC License No.: R05360 

(UIC Permit UR03060) 

Type of Action: UIC Annual Inspection Priority: 1 

Date of Action: 5/14/06 Reviewer: MA 
Texas Final Report Page C.7 

Inspection Casework Reviews 

File No.: 42 

Licensee: Mesteña Uranium, LLC License No.: R05360 

(UIC Permit UR03060) 

Type of Action: UIC Annual Inspection Priority: 1 

Date of Action: 4/19/07 Reviewer: MA 

File No.: 43 

Licensee: Mesteña Uranium, LLC License No.: R05360 

(UIC Permit UR03060) 

Type of Action: UIC Annual Inspection Priority: 1 

Date of Action: 4/3/08 Reviewer: MA 

File No.: 44 

Licensee: Mesteña Uranium, LLC License No.: R05360 

(UIC Permit UR03060) 

Type of Action: UIC Annual Inspection Priority: 1 

Date of Action: 3/11/09 Reviewer: MA 

File No.: 45 

Licensee: Mesteña Uranium, LLC License No.: R05360 

Type of Action: Annual Inspection Priority: 1 

Date of Action: 8/28/08 Reviewer: SS 

INSPECTOR ACCOMPANIMENTS 

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

Texas Department of State Health Services

Accompaniment No.: 1 

Licensee: TAPCO International, Inc. License No.: L04990 

Inspection Type: Special, Announced Priority: 1 

Inspection Date: 12/14/09 Inspector: JS 

Comment: 

The inspector did not review the inspection findings from the previous special inspection. 

Accompaniment No.: 2 

Licensee: South Texas Nuclear Pharmacy License No.: L05304 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 12/15/09 Inspector: KD 

Accompaniment No.: 3 

Licensee: Gray Wireline Service, Inc. License No.: L03541 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 12/28/09 Inspector: ERS 

Accompaniment No.: 4 
Texas Final Report Page C.8 

Inspection Casework Reviews 

Licensee: St. David’s Healthcare Partnership License No.: L05856 

Inspection Type: Special, Announced Priority: 2 

Inspection Date: 12/29/09 Inspector: ENS 

Accompaniment No.: 5 

Licensee: Spectro Analytical Instruments, Inc. License No.: L02788 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 12/30/09 Inspector: LC 

Accompaniment No.: 6 

Licensee: Shannon Medical Center License No.: L02174 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 1/11/10 Inspector: WK 

Accompaniment No.: 7 

Licensee: ROSA of the South Plains, LLP License No.: L05484 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 1/12/10 Inspector: ES 

Comment: 

The inspector reviewed only one patient therapy file. 

Accompaniment No.: 8 

Licensee: IRIS NDT, Inc. License No.: L04769 

Inspection Type: Special, Announced Priority: 1 

Inspection Date: 1/29/10 Inspector: HA 

Texas Commission on Environmental Quality

Accompaniment No.: 9 

Licensee: Rio Grande Resources Corporation License No.: L02402 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 1/25/10 Inspectors: MA, SS 

Accompaniment No.: 10 

Licensee: Waste Control Specialists, LLC License Nos.: R04100, R04971, R05807 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 1/13/10 Inspectors: MA, SS 

Accompaniment No.: 11 

Licensee: Mesteña Uranium, LLC License No.: R05360 

Inspection Type: Routine, Announced Priority: N/A 

Inspection Dates: 1/26-28/10 Inspectors: MA, SS 

Comment: 

The inspector performed only a limited review of environmental monitoring records 

associated with the site.
APPENDIX D 

LICENSE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

Texas Department of State Health Services

File No.: 1 

Licensee: Solutia, Inc. License No.: L00219 

Type of Action: Renewal Amendment No.: 84 

Date Issued: 9/9/08 License Reviewer: DG 

File No.: 2 

Licensee: Southwest Research Institute License No.: L00775 

Type of Action: Amendment Amendment No.: 79 

Date Issued: 5/14/09 License Reviewer: DF 

File No.: 3 

Licensee: National Oil Well Varco, LP License No.: L06094 

Type of Action: New Amendment No.: 00 

Date Issued: 7/23/07 License Reviewer: DF 

File No.: 4 

Licensee: Supply Chain Solutions, LTD License No.: L06253 

Type of Action: New Amendment No.: 00 

Date Issued: 7/30/09 License Reviewer: DF 

File No.: 5 

Licensee: Supply Chain Solutions, LTD License No.: L06253 

Type of Action: Amendment Amendment No.: 01 

Date Issued: 9/28/09 License Reviewer: DF 

File No.: 6 

Licensee: Memorial Hermann Hospital System, Inc. License No.: L00650 

Type of Action: Renewal Amendment No.: 81 

Date Issued: 2/27/07 License Reviewer: HW 

File No.: 7 

Licensee: Sabia, Inc. License No.: L06141 

Type of Action: New Amendment No.: 00 

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

File No.: 8 

Licensee: Sabia, Inc. License No.: L06141 

Type of Action: Termination Amendment No.: 02 

Date Issued: 10/15/09 License Reviewer: DF 
Texas Final Report Page D.2 

License Casework Reviews

File No.: 9 

Licensee: BetaBatt, Inc. License No.: L05961 

Type of Action: New Amendment No.: 00 

Date Issued: 4/27/06 License Reviewer: DF 

File No.: 10 

Licensee: BetaBatt, Inc. License No.: L05961 

Type of Action: Amendment Amendment No.: 03 

Date Issued: 8/25/08 License Reviewer: DF 

File No.: 11 

Licensee: Advanced Inspection Technologies License No.: L06228 

Type of Action: New Amendment No.: 00 

Date Issued: 4/1/09 License Reviewer: RF 

File No.: 12 

Licensee: Eagle NDT, LLC License No.: L06176 

Type of Action: New Amendment No.: 00 

Date Issued: 7/3/08 License Reviewer: JK 

File No.: 13 

Licensee: Eagle NDT, LLC License No.: L06176 

Type of Action: Termination Site Amendment No.: 13 

Date Issued: 2/14/09 License Reviewer: KS 

File No.: 14 

Licensee: University of Texas, MD Anderson License No.: L06227 

 Cancer Center 

Type of Action: Amendment Amendment No.: 10 

Date Issued: 1/28/10 License Reviewer: JS 

File No.: 15 

Licensee: University of Texas, MD Anderson License No.: L06227 

 Cancer Center 

Type of Action: Renewal Amendment No.: 116 

Date Issued: 4/15/09 License Reviewer: JK 

File No.: 16 

Licensee: Texas Oncology License No.: L06206 

Type of Action: New Amendment No.: 00 

Date Issued: 12/19/08 License Reviewer: FT 

Comment: 

 The license reviewer authorized an individual on the license who was not qualified for 

one of the two approved modalities. 
Texas Final Report Page D.3 

License Casework Reviews

File No.: 17 

Licensee: Medi-Physics dba GE Healthcare License No.: L04764 

Type of Action: Amendment Amendment No.: 34 

Date Issued: 9/19/07 License Reviewer: SU 

File No.: 18 

Licensee: El-Paso Animal Emergency Center License No.: L06263 

Type of Action: New Amendment No.: 00 

Date Issued: 9/11/09 License Reviewer: PS 

File No.: 19 

Licensee: Cardinal Health 200, Inc. License No.: L02407 

Type of Action: Amendment Amendment No.: 31 

Date Issued: 2/13/07 License Reviewer: DF 

File No.: 20 

Licensee: University of North Texas Risk License No.: L00101 

 Management Services 

Type of Action: Amendment Amendment No.: 83 

Date Issued: 8/20/08 License Reviewer: FT 

File No.: 21 

Licensee: University of North Texas Risk License No.: L00101 

 Management Services 

Type of Action: Amendment Amendment No.: 86 

Date Issued: 2/9/10 License Reviewer: FT 

File No.: 22 

Licensee: Marco Inspection Services LLC License No.: L06027 

Type of Action: Amendment Amendment No.: 25 

Date Issued: 10/21/09 License Reviewer: KS 

File No.: 23 

Licensee: Marco Inspection Services LLC License No.: L06027 

Type of Action: Amendment Amendment No.: 18 

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

File No.: 24 

Licensee: Memorial Hermann License No.: L00439 

Type of Action: Amendment Amendment No.: 149 

Date Issued: 2/11/10 License Reviewer: JS 
Texas Final Report Page D.4 

License Casework Reviews

File No.: 25 

Licensee: Memorial Hermann License No.: L00439 

Type of Action: Amendment Amendment No.: 143 

Date Issued: 7/3/09 License Reviewer: FT 

Comments: 

a) The license reviewer did not authorize a medical physicist on the license. 

b) The license reviewer failed to require the physical presence of an authorized user during 

IVB procedures. 

File No.: 26 

Licensee: Nuclear Scanning Services, Inc. License No.: L04339 

Type of Action: Amendment Amendment No.: 22 

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

File No.: 27 

Licensee: Houston Northwest Operating Company, LLC License No.: L06190 

Type of Action: Amendment Amendment No.: 05 

Date Issued: 1/14/10 License Reviewer: TC 

File No.: 28 

Licensee: Dialog Wireline Services LLC License No.: L06104 

Type of Action: Amendment Amendment No.: 04 

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

File No.: 29 

Licensee: Dialog Wireline Services LLC License No.: L06104 

Type of Action: New Amendment No.: 00 

Date Issued: 10/4/07 License Reviewer: AG 

File No.: 30 

Licensee: Kakivik Asset Management License No.: L06211 

Type of Action: New Amendment No.: 00 

Date Issued: 1/21/09 License Reviewers: KS, JK 

File No.: 31 

Licensee: Waste Control Specialists, LLC License No.: L06153 

Type of Action: Amendment Amendment No.: 03 

Date Issued: 11/24/09 License Reviewer: KS 

File No.: 32 

Licensee: Waste Control Specialists, LLC License No.: L06153 

Type of Action: Amendment Amendment No.: 01 

Date Issued: 5/6/08 License Reviewer: AG 
Texas Final Report Page D.5 

License Casework Reviews

File No.: 33 

Licensee: Iso Tex Diagnostics, Inc. License No.: L02999 

Type of Action: Amendment Amendment No.: 46 

Date Issued: 6/1/09 License Reviewer: SU 

File No.: 34 

Licensee: Frac Tech Services LTD License No.: L06188 

Type of Action: New Amendment No.: 00 

Date Issued: 3/26/09 License Reviewer: JK 

File No.: 35 

Licensee: Integrated Production Services, Inc. License No.: L06051 

Type of Action: New Amendment No.: 00 

Date Issued: 1/4/07 License Reviewer: MD 

File No.: 36 

Licensee: Express Energy Services License No.: L06111 

Type of Action: Termination Amendment No.: 04 

Date Issued: 11/24/09 License Reviewer: SG 

File No.: 37 

Licensee: University of Houston License No.: L01886 

Type of Action: Amendment Amendment No.: 63 

Date Issued: 1/22/10 License Reviewer: FT 

File No.: 38 

Licensee: Memorial Hermann Hospital License No.: L03772 

 System, The Woodlands 

Type of Action: Amendment Amendment No.: 75 

Date Issued: 1/26/10 License Reviewer: FT 

Texas Commission on Environmental Quality

File No.: 39 

Licensee: Waste Control Specialists, LLC License No.: R04100 

Type of Action: New Amendment No.: 0 

Date Issued: 9/10/09 License Reviewers: RMD Team 

File No.: 40 

Licensee: Waste Control Specialists, LLC License No.: R04100 

Type of Action: Amendment Amendment No.: 1 

Date Issued: 1/19/10 License Reviewer: BB 
Texas Final Report Page D.6 

License Casework Reviews

File No.: 41 

Licensee: Waste Control Specialists, LLC License No.: R04100 

Type of Action: Response to Condition License Condition No.: 50A 

Date Issued: N/A License Reviewer: AP 

File No.: 42 

Licensee: Waste Control Specialists, LLC License No.: R04100 

Type of Action: Response to Condition License Condition No.: 53D 

Date Issued: N/A License Reviewer: PL 

File No.: 43 

Licensee: Waste Control Specialists, LLC License No.: R04100 

Type of Action: Response to Condition License Condition No.: 50B 

Date Issued: N/A License Reviewers: BB, WS 

File No.: 44 

Licensee: Rio Grande Resources Corporation License No.: L02402 

Type of Action: Routine Monitoring Report Amendment No.: N/A 

Date of Action: 1/29/10 License Reviewers: CM, KT 

File No.: 45 

Licensee: Rio Grande Resources Corporation License No.: L02402 

Type of Action: Routine Monitoring Report Amendment No.: N/A 

Date of Action: 12/23/09 License Reviewers: CM, KT 

File No.: 46 

Licensee: Rio Grande Resources Corporation License No.: L02402 

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

Date of Action: 12/22/09 License Reviewer: LG 

File No.: 47 

Licensee: Everest Exploration, Inc. License No.: L03626 

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

Date of Action: 4/2/09 License Reviewer: PS 

File No.: 48 

Licensee: Everest Exploration, Inc. License No.: L03626 

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

Date of Action: 8/11/08 License Reviewer: LG 

File No.: 49 

Licensee: Mesteña Uranium, LLC License No.: R05360 

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

Date of Action: 11/25/08 License Reviewers: LG, BB 
Texas Final Report Page D.7 

License Casework Reviews

File No.: 50 

Licensee: Mesteña Uranium, LLC License No.: R05360 (UIC Permit UR03060) 

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

Date of Action: 6/5/07 License Reviewer: JS 

Comment: 

The license reviewer did not fully document the technical review that was performed. 

File No.: 51 

Licensee: South Texas Mining Venture, LLP License No.: R06062 

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

Date of Action: 10/14/09 License Reviewers: Team 
APPENDIX E 

INCIDENT CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

Texas Department of State Health Services

File No.: 1 

Licensee: Ludlum Measurements, Inc. License No.: L01963 

Date of Incident: 11/13/08 NMED No.: 080792 

Investigation Date: 11/13/08 Type of Incident: Contamination 

Type of Investigation: Site 

File No.: 2 

Licensee: QC Laboratories, Inc./Top Dollar Pawn Shop License No.: L04750 

Dates of Incident: 6/15/06, 11/15/06 NMED No.: 060401 

Investigation Dates: 6/15/06, 11/15/06 Type of Incident: Lost/stolen material 

Type of Investigation: Site 

Comment: 

The incident investigation involved the loss/theft of the material and the recovery of the 

material. 

File No.: 3 

Licensee: Texas DSHS Community Preparedness Section License No.: L05865 

Date of Incident: 11/28/06 NMED No.: 060757 

Investigation Date: 11/28/06 Type of Incident: Lost/stolen material 

Type of Investigation: Telephone/e-mail 

File No.: 4 

Licensee: Nuclear Sources and Services, Inc. License No.: L02991 

Date of Incident: 8/20/09 NMED No.: 090696 

Investigation Date: 8/28/09 Type of Incident: Contamination 

Type of Investigation: Site 

File No.: 5 

Licensee: Christus Santa Rosa Surgery Center License No.: L05805 

Date of Incidents: 1/4/06 -8/14/06 NMED No.: 070092 

Investigation Date: 2/13/07 Type of Incidents: Medical 

Type of Investigation: Site 

File No.: 6 

Licensee: Desert Industrial X-Ray License No.: L04590 

Date of Incident: 3/5/09 NMED No.: 090388 

Investigation Date: 3/5/09 Type of Incident: Equipment failure 

Type of Investigation: Site 
Texas Final Report Page E.2 

Incident Casework Reviews

File No.: 7 

Licensee: Rone Engineering Services License No.: L02356 

Date of Incident: 7/30/08 NMED No.: 080442 

Investigation Date: 7/30/08 Type of Incident: Lost/stolen material 

Type of Investigation: Telephone/e-mail 

File No.: 8 

Licensee: James Hardie Building Products, Inc. License No.: G02040 

Date of Incident: 10/29/07 NMED No.: 070735 

Investigation Date: 11/26/07 Type of Incident: Equipment failure 

Type of Investigation: Telephone/e-mail 

File No.: 9 

Licensee: Cardinal Health 200, Inc. License No.: L02407 

Date of Incident: 3/11/07 NMED No.: 070236 

Investigation Date: 3/12/07 Type of Incident: Equipment failure 

Type of Investigation: Telephone/e-mail 

File No.: 10 

Licensee: Petrochem Inspection Services License No.: L04460 

Date of Incident: 5/20/07 NMED No.: 090438 

Investigation Date: 6/4/07 Type of Incident: Damaged equipment 

Type of Investigation: Telephone/e-mail 

File No.: 11 

Licensee: Physician Reliance, LP License No.: L05545 

Date of Incident: 8/19/08 NMED No.: 080490 

Investigation Date: 8/19/08 Type of Incident: Medical 

Type of Investigation: Telephone/e-mail 

File No.: 12 

Licensee: Delek Refining, Ltd. License No.: L02289 

Date of Incident: 10/28/08 NMED Log No.: 090001 

Investigation Date: 12/30/08 Type of Incident: Equipment failure 

 Type of Investigation: Site 

File No.: 13 

Licensee: Delek Refining, Ltd. License No.: L02289 

Date of Incident: 11/26/08 NMED Log No.: 080722 

Investigation Date: 12/30/08 Type of Incident: Equipment failure 

 Type of Investigation: Site 

 
Texas Final Report Page E.3 

Incident Casework Reviews

Texas Commission on Environmental Quality

File No.: 14 

Licensee: URI, Inc. License No.: L03653 

Date of Incident: 11/6/07 NMED No.: 080140 

Investigation Date: 11/6/07 Type of Incident: Contamination 

Type of Investigation: Site 

File No.: 15 

Licensee: Mesteña Uranium, LLC License No.: R05360 

Date of Incident: 8/14/09 NMED No.: N/A 

Investigation Date: 8/14/09 Type of Incident: Contamination 

 Type of Investigation: Site 
APPENDIX F 

SEALED SOURCE & DEVICE (SS&D) CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Registry No.: TX-634-S-109-S SS&D Type: (H) General Neutron 

Source Applications 

Applicant Name: Thermo Fisher Scientific Type of Action: Amendment 

Date Issued: 7/20/07 Reviewers: DF, PM 

File No.: 2 

Registry No.: TX-634-S-109-S SS&D Type: (H) General Neutron 

Source Applications 

Applicant Name: Thermo Fisher Scientific Type of Action: Amendment 

Date Issued: 2/10/10 Reviewers: JK, RF 

Comments: 

a) The reviewers authorized an open-ended provision which could allow unregistered 

sources to be included in the registry. 

b) The reviewers did not ensure that all sources met the useful life identified in the registry. 

c) The reviewers authorized a capsule model on the source registry that does not exist. 

d) The reviewers required sources to be special form but two of the added sources were 

not identified as special form. 

File No.: 3 

Registry No.: TX-634-D-176-B SS&D Type: (H) General Neutron 

Source Applications 

Applicant Name: Thermo Fisher Scientific Type of Action: New 

Date Issued: 7/23/07 Reviewers: DF, MD 

File No.: 4 

Registry No.: TX-634-D-176-B SS&D Type: (H) General Neutron 

Source Applications 

Applicant Name: Thermo Fisher Scientific Type of Action: Amendment 

Date Issued: 11/6/09 Reviewers: JK, DF 

Comment: 

The reviewers did not amend the device registry to include the lower ANSI rating that the 

source registry required. 

 
Texas Final Report Page F.2 

SS&D Casework Reviews 

File No.: 5 

Registry No.: TX-634-D-174-B SS&D Type: (H) General Neutron 

Source Applications 

Applicant Name: Thermo Fisher Scientific Type of Action: Amendment 

Date Issued: 7/23/07 Reviewers: DF, PM 

Comment: 

The reviewers did not amend the device registry to include the lower ANSI rating that the 

source registry required. 

File No.: 6 

Registry No.: TX-1300-D-101-S SS&D Type: (D) Gamma Gauge 

Applicant Name: GeoTek Limited Type of Action: New 

Date Issued: 4/2/08 Reviewers: DF, MD 

Comment: 

The reviewers did not ensure that the foreign manufacturer/distributor had a U.S. 

radioactive materials license, per Texas regulations, or an import/export license. 

File No.: 7 

Registry No.: TX-227-D-801 through 810-B SS&D Type: (U) X-Ray Fluorescence 

Applicant Name: Columbia Scientific Industries, Corp. Type of Action: Inactivation 

Date Issued: 10/17/05 Reviewers: DF, PM 

Comment: 

Registrations TX-227-D-801-B through TX-227-D-810-B are not listed in the NRC 

database. 

File No.: 8 

Registry No.: TX-634-D-858-B SS&D Type: (U) X-Ray Fluorescence 

Applicant Name: Thermo MeasureTech Type of Action: Inactivation 

Date Issued: 7/7/06 Reviewers: DF, PM 

File No.: 9 

Registry No.: TX-1032-D-103-S SS&D Type: (X) Medical Reference Sources 

Applicant Name: GE Medical Systems Type of Action: Amendment 

Date Issued: 11/17/06 Reviewers: SK, DF 

File No.: 10 

Registry No.: TX-1032-D-104-S SS&D Type: (X) Medical Reference Sources 

Applicant Name: GE Medical Systems Type of Action: New 

Date Issued: 8/1/08 Reviewers: SK, DF 

 
Texas Final Report Page F.3 

SS&D Casework Reviews 

File No.: 11 

Registry No.: TX-1176-D-101-B SS&D Type: (D) Gamma Gauge 

Applicant Name: Roxar, Inc. Type of Action: Amendment 

Date Issued: 1/22/10 Reviewers: DF, MD 

File No.: 12 

Registry No.: TX-634-D-858-B SS&D Type: (U) X-Ray Fluorescence 

Applicant Name: Thermo MeasureTech Type of Action: Inactivation 

Date Issued: 7/10/06 Reviewers: DF, PM 

File No.: 13 

Registry No.: TX-586-S-110-S SS&D Type: (F) Well Logging 

Applicant Name: Schlumberger Technology Corp. Type of Action: Amendment 

Date Issued: 9/17/09 Reviewers: JK, RF 

File No.: 14 

Registry No.: TX-1297-D-101-S SS&D Type: (F) Well Logging 

Applicant Name: Hotwell, US, Ltd. Type of Action: Amendment 

Date Issued: 8/25/09 Reviewers: SG, RF 

File No.: 15 

Registry No.: TX-734-D-101-S SS&D Type: (D) Gamma Gauge 

Applicant Name: Tracerco Type of Action: Amendment 

Date Issued: 7/28/09 Reviewers: SG, RF
ATTACHMENTS 

April 14, 2010 Letter from Kathryn Perkins 

Texas Department of State Health Services’ 

Response to the Draft Report 

ADAMS Accession No.: ML101160054 

April 14, 2010 Letter from Mark Vickery 

Texas Commission on Environmental Quality’s 

Response to the Draft Report 

ADAMS Accession No.: ML101100576