Radioactive Material License (RAM) License Audit 1.0

• Inspection Conducted By: (enter name of person completing audit)

• Location: (enter facility Name and City/State of inspection)

• Date: (enter date of inspection)

  Date
• Location: (Global Positioning System (GPS) Option)
  Address

• Personnel Involved in Inspection:

• The intent of this inspection is to provide the facilitator a documented guide to pursue for compliance review the identified areas of focus outlined below. During an onsite inspection; the facilitator may observe and/or inquire about areas that are of compliance concern, but not listed within the outline of this inspection. In such an instance the facilitator shall use their industry knowledge and best judgment in deciding whether any observance of concern requires immediate action or can be listed in the comments section for follow-up. Positive recognitions are also an important portion of these types of assessments; therefore are encouraged to be listed in the comments section as well. Any item listed unsatisfactory will require follow-up actions and the Person-In-Charge (PIC) shall be prepared to acknowledge with a plan of improvement. Such items; dependent on their severity shall be identified with improvement expectation dates as well. Compliance Focus: The protection of our Personnel, affiliated Assets, the Environment and the Brand of the Organization. Safety Mindset: Unsafe Condition leads to an Unsafe Acts which can result into a Near-Misses or worse an Incident!

Section 1.0 Inspection Categories

1. License

• 1 A. License Number

• 1 B. License Effective Date

  Date

• 1 C. License Expiration Date

  Date

2. Inspection History

• 2 A. When was the last State Agency Inspection

  Date

• 2 B. Were there any violations cited?

  No Deficiencies Found

  Improvements to be Noted

• If so, were all violations corrected?

  Yes

  No

3. Management Information - Authorized Radiation Safety Officer(s)

• 3 A. Site RSO's authorized?

  Yes

  No

  N/A

• List authorized site RSO(s):

• 3 B. Personnel interviewed in support of audit:

4. RSO Duties

• 4 A. RSO Annual review of OS&E (operating, safety, emergency, and as low as reasonably achievable (ALARA) procedures):

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• 4 B. Additional Duties (TX & LA): TAC 25.289.252(f)(3) & 256(g) and LAC 33:XV:706; list all that apply:

5.0 Posting of Documents and Availability

• 5 A. TX and LA Rules available on-site?

  Yes

  No

• How can such be accessed?

• 5 B. Current License Available?

  Yes

  No

• 5 C. RAM operating procedures available?

  Yes

  No

• 5 D. Notice of Violations and/or agency orders?

  No

  Yes

• 5 E. Notice to employees posted?

  Yes

  No

6.0 Radiation Protection Program

• 6 A. Plan developed, documented and implemented?

  Yes

  No

  N/A

• Provide appropriate action and time frame required to satisfy compliance.

• 6 B. Review at interval not to exceed 12 months, documented?

  Yes

  No

  N/A

• Provide appropriate action and time frame required to satisfy compliance.

• 6 C. Entry Date?

  Date

7.0 Worker Training

• 7 A. Training conducted in accordance with; permit condition/ state regulation?

  Yes

  No

  N/A

• Provide appropriate action and time frame required to satisfy compliance.

• 7 B. Does training program meet minimum requirements?

  Yes

  No

  N/A

• Provide appropriate action and time frame required to satisfy compliance.

• 7 C. Training records available?

  Yes

  No

  N/A

• Provide appropriate action and time frame required to satisfy compliance.

8.0 Public Dose Assessment

• 8 A. Compliance with Annual Dose Limits, 100mREM/YR?

  Yes

  No

  N/A

• Provide appropriate action and time frame required to satisfy compliance.

• 8 B. Compliance with 2mREM in any one hour as shown by surveys in unrestricted areas?

  Yes

  No

  N/A

• Provide appropriate action and time frame required to satisfy compliance.

• 8 C. Records are adequate to show public dose limits were not exceeded?

  Yes

  No

  N/A

• Provide appropriate action and time frame required to satisfy compliance.

9.0 Notification of Incidents

• 9 A. Are there any recorded incidents; initial notification by phone, written follow-up, 30 days?

  Incidents Occurred

  Zero Occurrences

• Provide brief explanation supportive of each recorded incident?

10.0 Reports – Limits Exceeded

• 10 A. Reports to the agency within 30 days after learning that limits exceeded for adult occupational doses, embryo/fetus dose, dose to member of public, exceeding license condition?

  Non-Applicable

  Yes, Submitted Reports

  No, No Submission

• Provide appropriate action and time frame required to satisfy compliance.

11.0 Physical Inventory

• 11 A. At (6) month interval?

  No Deficiencies Found

  Improvements to be Noted

• 11 B. Calibration Source(s)?

  No Deficiencies Found

  Improvements to be Noted

• 11 C. NORM Meters with Check Source?

  No Deficiencies Found

  Improvements to be Noted

• 11 D. Records available?

  No Deficiencies Found

  Improvements to be Noted

• Provide appropriate action and time frame required to satisfy compliance.

12.0 Records - Receipt, Transfer, Disposal

• 12 A. Records of Receipts, authorized by licensee?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

• 12 B. Transfers; to authorized recipients?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

• 12 C. Disposal authorized?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

• 12 D. Disposed properly?

  Yes

  No

  N/A

• Provide appropriate action and time frame required to satisfy compliance

• 12 D. How?

  Select On-site Injection Off-site Landfill Off-site Injection

  • On-site Injection
  • Off-site Landfill
  • Off-site Injection

• 12 E. Records available?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

13.0 Use Area Surveys

• 13 A. Surveys performed, documented, frequency?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

• 13 B. Records available?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

14.0 Storage Area Surveys

• 14 A. Surveys performed, documented, frequency?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

• 14 B. Records available?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

15.0 Waste Storage Surveys

• 15 A. Surveys performed, documented, frequency?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

• 15 B. Records available?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

16.0 Wipe and Other Surveys

• 16 A. Surveys performed, documented, frequency?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

• 16 B. Records available?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

17.0 Air Emissions/ Monitoring

• 17 A. Air sampling performed and results documented?

  No, to both sampling & documentation - Not applicable

  Yes, to sampling and documentation

  Yes, to sampling and No, to documentation

• Provide appropriate action and time frame required to satisfy compliance.

18.0 Instrument Calibration

• 18 A. Frequency?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

• 18 B. Calibration performed by authorized persons?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

• 18 C. Records available?

  Yes

  No

  N/A

• Provide appropriate action and time frame required to satisfy compliance.

19.0 Facilities

• 19 A. Are facilitates (buildings, lab, storage, use areas) unchanged from facilities depicted drawings submitted with application?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

20.0 Use Location

• 20 A. Use at authorized locations?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

21.0 Area Posting

• 21 A. Area(s) posted as required?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

22.0 Container Marking/ Labeling

• 22 A. Are containers marked, labeled; i.e. Origin Location, Exposure Reading, DOT description Un 2910, Radioactive-LSA, Radioactive-SCO, Date?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

23.0 Security

• 23 A. Security plan in place; control of access to lab and safe access?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

24.0 Waste Storage

• 24 A. Storage in dedicated area, inventory maintained and documented, if applicable pit volume capacity adequate to application?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

25.0 Dosimetry Program – Employee & Established Areas; Fence-line & Internal

• 25 A. Are personnel monitoring devices issued to employees?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

• 25 B. Individual not monitored, are records available of the assessment made showing requirements not applicable?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

26.0 Quarterly Reports (LA & TX)

• 26 A. LA Only: Received/Shipped Log & Manifest and Remote Jobs Log

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

• 26 B. TX Only: Received Waste Log

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

27.0 Notification - Remote Job Site

• 27 A. At time of this audit; has there been any offsite temporary jobs?

  Yes

  No

  N/A

• 27 B. If yes, has written notice been provided prior to state agency for temporary offsite licensed RAM job??

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

• 27 C. Documentation available?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

28.0 Waste Generated from Remote Job / Temporary Job Site

• 28 A. Was regulated NORM Waste generated from temporary job?

  Yes

  No

  N/A

• 28 B. Was the waste disposed of or remained in generators possession?

  Disposed

  Remained in Possession

• 28 C. If left in generators possession, was notification to state agency completed and documented?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

29.0 Dosimetry Supplier/ Processor

• 29 A. Who is provider?

• 29 B. Type of Radiation and also Badges at this site?

30.0 Dosimetry Provided

• 30 A. Monitoring Methods: Frequency, Type, and Location?

• 30 B. Worn appropriately?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

• 30 C. Control Badges maintained?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

31.0 Respiratory Protection Program

• 31 A. Program is established and implemented, fit tested?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide explanation?

• 31 B. Written procedures available?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide explanation?

32.0 Dose Records / Annual Dose Notifications

• 32 A. Quarterly & Annual FORM 5 Records available?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide explanation?

• 32 B. Annual FORM 5 Records Signed/ Dated?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide explanation?

33.0 Declared Pregnancy

• 33 A. Documents and records are available and appropriate for female workers?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide explanation?

34.0 Overexposures

• 34 A. Have any Overexposures occurred?

  Incidents Occurred

  Zero Occurrences

• 34 B. If yes, notification to the appropriate agency and/or individual with the proper supporting documentation on file?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

35.0 RAM (Radioactive Material) Offered for Transport

• 35 A. Has any RAM been transported or offered for transport?

  Yes

  No

  N/A

• 35 B. Was the transport or offer of transport compliant?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

36.0 Hazmat Training

• 36 A. Received appropriate training for Hazmat employees?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

• 36 B. Received appropriate refresher training (minimum within (3) year interval?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

• 36 C. Records of training maintained and available?

  Yes

  No

  N/A

• Provide appropriate action and time frame required to satisfy compliance.

37.0 Packages

• 37 A. Labeling/ Marking Appropriate?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

• 37 B. Packages Surveyed with Documentation?

  Satistfactory

  Action Required

  Non-Applicable

  Not Assessed

• Provide appropriate action and time frame required to satisfy compliance.

38.0 Records of Shipments

• 38 A. Shipping papers maintained and available?

  Yes

  No

  N/A

• Provide explanation?

• 38 B. Emergency response information maintained and available?

  Yes

  No

  N/A

• Provide explanation?

39.0 Transport Vehicles

• 39 A. Carrier used appropriate?

  Yes

  No

  N/A

• Provide explanation?

• 39 B. Exclusive use Vehicle Surveys performed?

  Yes

  No

  N/A

• Provide explanation?

40.0 Origins outside of LA/ TX

• 40 A. Have there been any projects, jobs originating outside of Louisiana or Texas?

  Yes, outside of LA or TX

  No, Non-Applicable to either

• If yes, which State(s)?

• 40 B. Scope of work requires Ecoserv to perform work in state other than LA/ TX?

  Yes

  No; Non-Applicable

• If yes, was State notification and license reciprocity completed?

  Yes

  No

• Provide appropriate action and time frame required to satisfy compliance.

Section 2.0 Comments

• 2.1 Recommendations, Action Items and/or Observance Concerns:

• 2.2 Positive Recognition(s):

• Please assess: Overall inspection experience with regards to the safety of personnel, consideration of assets and environmental protection rated on a scale from 1-10 with (1) being the lesser value.

• Media and/ or Photographs

  Media

Section 3.0 Intercompany Program - P.A.L.S. is an acronym for (PERFORMANCE, ACCOUNTABILITY, LIFE, & SYSTEMS = Safe and Sustainable). The program influences safe behavior alignment by the use of (14) icons and written guidance that correlates to all EHS Manual programs. “Core rules are/ were determined based off constant hazards; Supplementary Rules are/ were determined based off contextual hazards”.

• Core Rules: Based on observance is compliance being achieved for all CORE Rules<br> 1. Confined Space<br>2. Heights (Working/ Ascending and Descending)<br>3. Safe Lifting Practices/ Suspended Loads (Line of Fire)<br>4. Transportation (Operator Shall-Plan Trips, Obey Laws and Cellular Usage is Prohibited)<br>5. Permitting Systems (Working and Regulating Requirements)<br>6. Energy Isolation

  No Deficiencies Found

  Improvements to be Noted

• Select the number of rule categories applicable to your recognized deficiencies and provide a positive comment as to explain how compliance achievement can be obtained:

  Select Confined Space Heights - Fall Protection Safe Lifting Practices/ Suspended Loads Transportation Permitting Systems (Working and Regulating Requirements) Energy Isolation

  • Confined Space
  • Heights - Fall Protection
  • Safe Lifting Practices/ Suspended Loads
  • Transportation
  • Permitting Systems (Working and Regulating Requirements)
  • Energy Isolation

• Compliance Achievement Comments:

• Supplementary Rules: Based on observance is compliance being achieved for all SUPPLEMENTARY Rules<br>7. Hazardous Atmospheric Exposure (Chemical/ Gas Hazards)<br>8. Working around Heavy Equipment<br>9. Dropped Objects<br>10. Safety Barriers and Equipment Guards<br>11. Severe Weather<br>12. Proper Personal Protective Equipment Practices<br>13. Fit-for-Duty (Health Management)<br>14. Stop-Work-Authority (Associated with Every Rule)

  No Deficiencies Found

  Improvements to be Noted

• Select the number of rule categories applicable to your recognized deficiencies and provide a positive comment as to explain how compliance achievement can be obtained:

  Select Hazardous Atmospheric Exposure Working around Heavy Equipment Dropped Objects Safety Barriers and Equipment Guards Severe Weather Proper Personal Protective Equipment Practices Fit-for-Duty Stop-Work-Authority (Associated with Every Rule)

  • Hazardous Atmospheric Exposure
  • Working around Heavy Equipment
  • Dropped Objects
  • Safety Barriers and Equipment Guards
  • Severe Weather
  • Proper Personal Protective Equipment Practices
  • Fit-for-Duty
  • Stop-Work-Authority (Associated with Every Rule)

• Compliance Achievement Comments:

Section 4.0 Acknowledgement Signatures

• Person-In-Charge (PIC) Signature:

  Sign

• Date and Time of Signature:

  Date

• Auditor's Signature:

  Sign

• Date and Time of Signature:

  Date