ML13329A756
| ML13329A756 | |
| Person / Time | |
|---|---|
| Site: | San Onofre  |
| Issue date: | 03/20/1992 |
| From: | Krieger R SOUTHERN CALIFORNIA EDISON CO. |
| To: | Martin J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| References | |
| NUDOCS 9203250050 | |
| Download: ML13329A756 (66) | |
Text
ENCLOSURE 1 LIST OF INITIAL LICENSE APPLICANTS
INITIAL SENIOR REACTOR OPERATOR LICENSE APPLICANTS CARRILLO, JULIAN CHANG, PO CORTOPASSI, LOUIS GOODWIN, DEAN JANKE, JASON RODRIGUEZ, GILBERT WOOD, KEVIN INITIAL REACTOR OPERATOR LICENSE APPLICANTS BARRIE, DOUGLAS COTTON, BREWSTER FOLTZ, GEORGE FORD, DAVID GUERRERO, AUGUST HOWARD, ROBERT HUFFMAN, GARY JOHNSON, MICHAEL JOHNSTON, MICHAEL JOZWIAK, CHET McGAULEY, MICHAEL POORE, MARK SCANLON, PATRICK SCHOTT, STEVEN
ENCLOSURE 2 CANDIDATE'S NON-CERTIFIED NRC 396 & 398 FORMS
NRC FORM 398 (FACSIMILE)
U.S. NUCLEAR REGULATORY Ct-1MISSION APPROVED BY CMB NO. 3150-0090 DATE RECEIVED jl-O)5 3
5.5 EXPIRES
1-39 (Io be completed by NRC)
(10-90)5 EXPIRES:,1-31-92 55.47, an 5.
5 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITS THIS INFORMATION COLLECTION REQUEST: 2.0 HRS. FORWARD COMENTS REGARDING BURDEN ESTIMATE TO THE INFOR MATION AND RECORDS MANAGEMENT BRANCH PERSONAL QUALIFICATION STATM LICENSEE (MNBB 7714) U.S.NUCLEAR REGULATORY COM MISSION WASHINGTON DC 20555 AND TO THE PAPtRWORK REDUCtION PROJEfT (3150 0090) OFFICE OF MANAGEMENT AND BUDGET, TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED WASH INGTON, DC, 20503
- 1. APPLICANT'S FULL NAME (Last, First, Middle) AND ADDRES 4.TYPE OF APPLICATION (Check applicable boxes)
OCO (include ZIP Code)
- a. NW WAIVER REQUESTED CARRILLO, JULIAN JR.
X
- c. UPGRADE 134 Ave Aragon Apt "B" 2OPERATING (Category)
San Clemente, CA 92672-4622 INCUDE ADDITINAL U NIT 3-ELIGIBILITY
- e. REAPPLICATION 1-FIRST4-MEDICAL
- 2. CITIZSSIP
- 3. BIRT DATE 2-SECOND Se lok1-*gD TERSE EEI X
- a. UNITED STATES MONTS DAY YEAR 3-THIRD AE EX-RIY INTO ECTO
- b. OTHER (Specify) 0 6
3 0
5 7
IFAPiC
- 5. TYPE OF LICENSE APPLIED FOR 6.-
PREVIOUIS LICERSE(S) HELD
- a. OPERATOR E.
DAE X. EIO OEATRa.-DOCKET NUMBER RD SRO b. LICENSE NMER MONT EXIATI DAE d.FACILITY DOCKET NUMBER X
- b.
SENOR OPERAOR.tDUPGDAYDYE
- c. LIMITED SRO 55-50167 X
P050097-02 0
3 0
6 9
5 50206 (e.g., Fuel Handler) 7.NANE AND ADDRESS (Include ZIP Code) OF APPLICANT'S EPI.OYER
- 10. CURRENT POSITION AT FACILITY
- a. PLANT SUPERINTENDENT I
- i. AUXILIARY UNIT OPERATOR/
3LTRAINEETURBINE BUILD S..outer Caiori2Ei8
- b. ASSISTANT PLANT SUPERINTENDENT INGj EU PMNT OPERATOR Pe.OREAPPLICATION San Clemente, California 92674-0128
- c. SHIFT SUPERVISOR (NO CENSED OPERATOR)
- d. STAFF ENGINEERE
- 8. NAmE OF APPLICATS FACILITY FACILITY DOCKET NJMER
- a. SHIFT TECHNICAL ADVISOR/ L~
T Seiy SHIFT ENGINEER San Onofre Unit 1 50-206
- f. INSTRUCTOR
- 9. ADDITICK3 FACILITY DOCKETS (Multi-unit Licenses)
- g.
SENIOR CONTROL R O OPERATOR X
- h. CONTROL ROCM OPERATOR a.OPERATORc.EXPN11.
EDUCATION X Gb SCHOOL
- c. MAJOR AREA(S) OF NUMBER HIGHEST DEGREE CODES
- d. VOCATIONAL NUMBER CERTIFICATE STUDY OF YEARS DEGREE To be used for TECHNICAL
-~OF RECEIVED X GRADUATE ENGINEERING (FIELDS)
(Use Codes)
APInIEd)
TYPLOYER 1
C E
T NNTHS POS O
a.PLAN SUPERINTEN ENT
- i.
AU YES NO GED EQUIVALENCY 0 -
NONE Nuclear Power School 6
X 1 - CERTIFICATER(
S A
NO OTHER 2-ASSOCIATE Nuclear Prototype 6
X
___________~~
3BACHELOR
- b. NUMBER OF A
MASTER YEARS OF 5
-DOCTORAL COLLEGE 0
- 12. TRAINING (SINCE LAST APPLICATION FSEE INSTRUCTIONS)
- 13.
SPERIENCE (DO NOT DOUBLE COUNT SEE INSTRUCTIONS)
- a. ADANTH AND YEAR b. NUMBER ae)NTH AND YEAR b NUMBER FROM TO CT ROOMNAVY FRERATO 1-NUCLEAR POWER PL1ANT FUNDAMENTALS (Classroom) 1 - RO 2-PLANT SYSTEMS 2
- EOW/PPch CLASSROOM OBSERVATION O
- b. NMBE OF4
- MASTER W
3-OPERATING PRACTICE L ERIECET CONTROL ROOM OPERATIONS ON SHIFT 5 -
OTHER (Specify) Electrical SIMULATOR OPERATING Operator (Includes Classroom)
FOSSIL SIMULATOR NAMES 6 -
OPERATOR
- a.
Ii II ll ilId111I i!II~BI~I PRIO IiiiIIuIIII~lIII~ilI~lIIII~fiuIi 8 -
PLANT STAFF CERTIFIED STARTUP YE NOifIf"____________________
PROGRAM COMPLETED f9-OHR(pcy NO.
OF REACTIVITY MANIPULATIONS PL..AN fhIII~i'flI!I!IIIIIICp1W"Ej9 AI NUCEAR ( Including Re earch/
PLANT SIMULATOR Test Reacto See Block 17 10- REACTOR OPERATOR (Licensed) 4-SRO INSTRUCTION 11 - SENIOR OPERATOR (Licensed) 5-EXTRA PERSON ON SHIFT IN CONTROL 12 - SHIFT SUPERVISOR (Licensed)
ROOM (13-WEEK MINIMUM)
- a.
IM ONSHFTABOE 0213
- STAFF/SHIFT ENGINEER (Licensed)
TIME~~~
-N SUPERVISOR%
OWE (6-WEEK MINIMUM)____
14 - AUX/EQUIP. OPER. (Nonlicensed)
UALIFICATION 15 - PLANT STAFF HER (Specify) 16 -
OTHER (Specify)
NRC FORM 398 (10-90)
- 14.
FACILITY OPERATOR TRAINING PROGRAM
- a. GRADUATE OF INPO ACCREDITED OPERATOR
- b. CERTIFIED ON NRC FORM 474 ("SIMULATION TRAINING PROGRAM THAT IS BASED UPON X
YES NO FACILITY CERTIFICATION")
OR NRC APPROVED X
YES NO A SYSTEMS APPROACH TO TRAINING SIMULATION FACILITY IS USED IN THE OPERATOR TRAINING PROGRAM
- 15.
FOR RENEWALS ONLY
- b. DATE AND RESULT OF MOVST DATE
- RESULT, HOURS OPERATED FACILITY RECENT NRC ADMINISTERED REQUALIFICATION EXAMINATION PASS FAIL
- 16. EXPERIENCE DETAILS
- a. POSITION TITLE FROM TO
- b. FACILITY
- c. DUTIES
- 17. COMMENTS (Specify the item number to which you are elaborating. Attach additional sheets as necessary.)
4.g. Mr. Carrillo held a RO license prior to the.existence of the Generic Fundamentals Examination. Mr. Carrillo should be exempt from the Generic Fundamentals Examination based on Generic Letter 89-17, dated September 6, 1989.
12.3.b. Certified Reactor Startup and Number of Reactivity Manipulations are not required for SRO upgrades.
- 18. NBC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE, IS ATTACED ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
19a.
I certify under penalty of eerjury that the information in this document and attachments is true and correct.
I further X b.ye o
n a
e certify that I have notified my current emlyeof (1) all peius employers; (2) any instance where-I have been tested by a Health and Human Services (HIES)Certiie DrgTsingLaboratory or a Licensee's testing facilit fo alcohol or a controlled substancadtetsreutexeedhectf levels establ~shed rsuant to 10 CRPart 216 ( J any instance where I have been arrested for theegale, use or fssion of a ntolWsusac described in16CRPr2; and (4) any reasons for removal or revecation of unescor d acco s at auclear facility, I also authorize the NRC to submit the results of examinations to m'pemplyrr use in repari g retra ing programs, as necessary.
SIGNATURE -
APPLICANT ATI DATE C1E APPLICABL.E
- b. I cer that the above named individuamlsas suce u
M plted the facility licensees requirements to be licensed as ane raorSeio Operator pusan-oTil A Cod of Federal Regulations, Part 55' and thatlthe individual has
- a eed~ora pertorSenor pertorlicense to p-hi/e asged duties and thaL the facility will be made available for examination.
I also certf unebeat fpruyta the information in this document and attachments is true and correct.
- c. RENEWAL ONLY - I certify that the above named individual meets the ap proved requalification program,(withc exceptions noted in Item 17) as required by asaction 50.54 (1-1o 0CR5,an hth/b a dahra i/e licensed responsibilities competently and safely. I also certify under penalty of perj ury tai the information In this document and attachments is true and correct.
PRINTED OR TYPED NTA EDRobert Y CDENIED PRINTED OR BY SITE
________________________________________S.
E. MRA SIGNATURE JDATE SIGNATURE NO SIGNATURE REQUIRED JDAT
~i-L~.-A' ~11-~7NON-CERTIFIED APPLICATION T
FONRC USE WAIVER (Check or complete items, as applicable)
IMEETS REQUIREMENTS DOES NOT MEET REQUIREMNTS(Explain below)
CATEGORY GRANTED BY DENIED BY HEADQUARTERS REGION' HEADQUARTERS REGION TTEN TING ELIGIBILITY MEDICAL SIGNATURE
- REVIEWER DATE OTHER NRC FORM 398 (10-90)
';C V S '.LZ.
-SF ECULATCRY C, tYiSick V'i-!y CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSE E
-X
-A Carrillo, Julian AC ZL17Y FACILITY OCKET N 5
San Onofre Nuclear Generating Station, Unit 1 50-206 A. MEDICAL EXAMINATION CERTIFICATION I: %
7 ~ ~ ~
E N A'D !
L A N AFt CN A T. c C RI L~T I : E
' S E N BA E E y AC "
StAE AND LICENSE NUMBER EXA':NATICN DATE Steven Rosen, M.D.
.Calif.
G24823 Nov.14, 1991 EASED ON THE RESULTSCF ThE EXAMINATION. INCLUDING INFFATION FURNSH BY THE APPLICANT. THE PHYSIC!AN HAS DET INED THAT THE APPLICANT'S PHYSICAL CONDITION AND GENERAL HEALTH A^E N^DT SUCH THAT IT
.IGHT CAUSE OPERATIONAL ERRORS ENDANGERI'iDG PLIC HEA TH AND SAFETY, I CERTIFY THAT IN REACHING THIS DETERVINATION. THE GUIDANCE CONTAINED IN ANS/ANS3.1983.0R ANSI 1NG PUSLIC HAL FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW SY NRC.
1ANS 15.4.197 (N80) WA ON THE EASIS OF THE RECOMMENDATION OF THE PHYSICIAN. I RECOMMEND THAT THE APPLICANTS OPERATOR LICENSE BE CONDITIONED AS FOLLO'vS:
- 1. NO RESTRICTIONS
- 2. CORRECTIVE LENSES EE WORN WHEN PERFORMING LICENSED DUTIES
- 3. HEARING AID EE WORN WHEN PERFORMING LICENSED DUTIES
- 4.
RESTRICTED LICENSE OR EXCEPTION-Pevide de:eils o
a4 r..ach sup;oring meiial evidenoe for NRC review.
S. RESTRICTION CIANGE FROM PREVIOUS SUEMIT AL-Prese deanits befew and at1c:ah se:>;oni-.; meicI rdeide for NRCreview.
PROPOSED WCRDING OF RESTRICTION Slock 4acji)
Corrective lenses be worn when performing licensed duties.
RE LATIONSHIP OF REST RICT ION TO DISOLALIFYING CONDITION Srkfly idcare how rric-ion will crre-m :he di&g lifyin condition)
RE*ARKS FOR RESTRICTION CHANGE (Block S8beJ
- 9. NONMEDICAL CERTIFICATION HIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DUTY REQUIREMENTSOF THIS FACILITY F
E LICENSED OPERATORSE ANY FAL!E STA7EME%T OR OMISSION IN T~RSDOCUWENT. INCLUDING ACm.4EN1S.MAY 9E S EJSJCT TO CIVIL AND GFUMIN&L SANCTION.1 CERTIFY UNZER PENALTY OF TNET TJE ;rCAMATIC IN TWIS DDCUM&ANT AND ATTACHWENTS IS RUE AND COAPECT.
PRINTED NAME AND SIGNATURE (Senor m
Rperseastijj onrl TITLEDAT No Signature Required, Non-Certified H. E MoganAppicaionVice President & Site Manager H. E. MorganAplcto In acorace with 10 CFR S5.5.Ccrnrrj*orl.
is form iI bf W lhe NRCM 10I1cw:
BY MAILADDREED TO:
Re-;or.al Acmiratoior, Re Io I
-. 2;or.aI Acrrara U.S. Nuclear Rejuatiory Cor.*nisision U.S. Nw:Icar rc-piory Corn uon U.S. Nuclsar Re7.#lciory Com m
475 Allenlet Read 101 Vareina 51mg?. Suite 3100 7?9 Rozw~rel Road King of Presa. PA 51406 Atlanta. GA X223 Glen Ellyn. IL 60137
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nm ;oon U.S. N.car Rogalalory Comr;u;or ar Q'uality Evaluation AII Plan Pa. D 1. S76,1 1J50 W a,4 Lar.,. Suite 210 Anm: Opvstor Licensing B**nc0 ArlI-%.cn. TX 76011 Watan Ceir, CA 14SS8 U.S. Nelesar Rtpalsiory Comm ts;on Washing DC 20SS5 p FPRIVACY ACT STAT-EPENT.
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-I
IC FES 398 (FACSIMILE)
U.S.
NUCLEAR REGULATORY COMISSION APPROVED BY OMB: NO. 3150-0090 DATE R=IVED (10-90)
EXPIRES: 1-31-92 (To be completed by NRC) 0 CFR 5531 55.35, ESTIMATED SBURDEN PER RESPONSE TO COMPLY 55.47, and 5t.57 WITH THIS INFORMATION COLLECTION MUST: 2.0 ERS.
FORWARD COMMENTS B ARDING BURDEN ESTIMATE TO THE INFOR MATION AND RECORDS MANAGEMENT BRANCH PERSORAL QUALIFICATIC STATEMENT - LICE MNBB 7714SUS.UCLEAR REGULATORY COM MISIONtWASHiNGTON DC 20555 AND TO THE PAPRORK REDUCtION PROJEfT (3150 0090) OFFICE OF MANAGEMENT AND BUDGET, TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED WASHINGTON, DC, 20503
- 1. APPLICANTS FULLe AME (Last, First, Middle) AND ADDRES 4.TTPE OF AFPLICATICN (Check applicable boxes)X BOT I
CO (include ZIP Code)
X
- a. NEW WAIVER REQUESTED Justif on Reverse)
CHANG, PO KUEN
- b. RENEWAL 1WRITEN 3695 Cameo Drive
- c. UPGRADE 2-OPERATING (Category)
Oceanside, CA 92056
- d. MULTI-UNIT (AMND To INCLUDE ADDITIONAL UNIT)
- e. REAPPLICATION X1-FITDTA4-MEDICAL b.FRS OTE (Specify
- 2. CITINSHIP
- 3. BIRT DATE 2-SECOND X.DATE PASSED GENERIC-T
- a. UNITED STATES MONT.
DAY YEAR 3-THIRD FUNDMENTALS EXAM-FM YY 0INATION SECTION b.OTH(0 8
13 (IF APPLICABLE) 0 6 90
- 6. PREVIOUS LITN(S)
MnD eOPERATOR
- c. EXPIRATION DATE a*a.
DOCKET NUMBER RO SOb. LICENSE NUMBER d.FACILITY DOCKET NUMBE
- b. SENIOR OPERATOR MONTE DAY YEARE 4LIMITED SRE 55-D (e.g., Fuel Handler) 7.INE AND ADDRSS (Include ZIP Code) OF APPLICANT'S EPLOYER
- 10. CIRRT.POSITION A FACILITY
- a. PLANT SUPERINTENDENT OFi.
AUXILIARY UNIT OPE ATR/
Southern California Edison L-RINEITUBN BUILD P.O0. Box 128 RIE UBK L
San Clemente, CA
- b. ASSISTANT PL.ANT SUPERINTENDENT INGgU PMNT OPERATOR 92674-0128
- c. SHIFT SUPERVISOR (NOCENSED OPERATOR) 8 b.E SNOR OPPEANTOR Fa.ITY DOKTUBE O.
FACILITY DOCKET NUMBERESAFFENGNEE (Specify) 7.AME AND ADDRESS InCL IP FAPLI CT EMER
- e. SHIFT TECHNICAL ADVISPOR/
San Onotre Unit 1 50-206 SHIFT ENGINEER CF
- f.
INSTRUCTOR
- 9. ADDITIONAL FACILITY DOCETS (Multi-unit Licenses)
- g. SENIOR CONTROL ROOM OPERATOR
- h. CONTROL ROOM OPERATOR
- 11. EDUCATION GB SCHOOL
- c. MAJOR AREA(S)
OF NUMBER HIGHEST DEGREE CODES
- d. VOCATIONAL /
NUMBER CERTIFICATE STUDY OF YEARS DEGREE To be used for TECHNICAL OF RECEIVED X
GRADUATE ENGINEERING (FIELDS)
(Use.Codes) obieT TYPE OF TRAINING HNTSYES NO GED EQUIVALENCY Chem. Engineering 4
3 0 - NONE Nuclear Power School 6
X 1 - CERTIFICATE NO OTHER 2 - ASSOCIATE Nuclear Prototype 6
X 3
BACHELOR
- b. NUMBER OF 4 - MASTER YEARS OF 5 - DOCTORAL COLLEGE 4
- 12. TRAINIG (SINCE LAST APPLICATION - SEE INSTRUCTIONS)
- 13.
EXPERIENCE (DO NOT DOUBLE COUNT SEE INSTRUCTIONS)
- a. MONTH AND YEAR b.
NUMBER a.MONTH AND YEAR b. NUMBER OIF WEEKS OF MONTHS FROMI TO NAVY
-FROM4 TO 1-NUCLEAR POWER PLANT FUNDAMENTALS FOE WF N
(Classroom) 1--
RO 2-PLANT SYSTEMS 2 -
EOOW/PPWO CLASSROOM OBSERVATION 3 -
EWS/PPWS 4 - ERS/CRW 3-OPERATING PRACTICE 4___ERS/CRW CONTROL ROOM OPERATIONS ON SHIFT 5 - OTHER (Specify)
SIMULATOR OPERATING (Includes Classroom)
FOSSIL SIMULATOR NAME~S 6
OPERATOR.--.
- a. Unit 1Il I
DhflINflhJIfhlu~ifll~lfi~flI~lujI~iIlIIM7~
S UPERVISOR CERTIFIED STARTUP X YES NO mw immmmn IBmMUMiwlianiuiLlilF PROGRAM COMPLETED IIITlEli (llSilpHleIilcluillli ilflllil)l 1881ffhIlllfIi tiii:iImflIIIImIIinnifflli lfiit NO. OF REACTIVITY MANIPULATIONS PLANT SIMI..TO COMMERIAL NUCLEAR (Including Research/
PLANT SIMULATOR lillli~lIl~l111111111111IlI~l Illl fluil DuhIIIII~wIII~uwIiliflI~
u~uflhItW i
nIiitilluillhiIinIiest Reactor) 10 - REACTOR OPERATOR (Licensed) 4-SR0 INSTRUCTION 11 -
SENIOR OPERATOR (Licensed) 5-EXTRA PERSON ON SHIFT IN CONTROL 12 - SHIFT SUPERVISOR (Licensed)
ROk (13-WEEK MINIMUM) 1 TF/HF NIER(iesd TIME ON SHIFT ABOVE 20Z 13PSTF/HITENIERELcesd (6-WEEK.MINIMUMI)
____14
- AUX./EQUIP.
OPER. (Nonlicensed)
UA CATION 15 -
PLANT STAFF
-9THER (Specify) 16 - OTHER (Specify)
NRC ORM 398 (10-90)
- 14.
FACILITY OPERATR TRAINING PROGRAM
- a. GRADUATE OF INPO ACCREDITED OPERATOR
- b. CERTIFIED ON NRC FORM 474 ("SIMULATION TRAINING PROGRAM TEAT IS BASED UPON X
YES NO FACILITY CERTIFICATION")
OR NRC APPROVED X
YES NO A SYSTEMS APPROACH TO TRAINING SIMULATION FACILITY IS USED IN THE OPERATOR TRAINING PROGRAM
- 15. FR REEALS CNIT BOURS OPERATED FACILITY
- b. DATE AND RESULT OF MOST DATE RESULT HOUR OPEATEDFACIITYRECENT NRC ADMINISTERED
- 16.
EXPERIENCE DETAILS
- a. POSITION TITLE FRCH TO
- b. FACILITY
- c. DUTIES
- 17..CHIENTS (Specify the item number to which you are elaborating. Attach additional sheets as necessary.)
- 18.
-RC F4M 396, CETIFICATIOR OF MEDICAL EACMHAIIo By FACILITY LIES, IS ATTACHED ANY FALSE STATEMENT OR OMISSION IN TBIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
19a. I certify under penalty of perjury that the information in this document and attachments is true and correct.
I further certi aat I have note my current emplo er of: T1) all previous employers; (2),any instance where I have been tested by a alth and Human Services (HES) Certilied Drug Teating Laboratory or a Liese' testing facility for alcohol or a controlled substance, and the test results exceeded the cu off levels establishe suant to 10 CFR rt 26* 3 any instance where I have been arrested for the sale, use or possession of a controlle ubstance described in 16 Y Part 26; and (4) any reasons for removal or revocation of unescorted access at a nuclear facility, I also authorize the NRC to submit the results of examinations to my employers for use in preparing retraining programs, as necessary.
SIGNATURE - APPLICANT DATE CHEC AFLICABLE Bt X
- b. I certify that the above named individual has successfully completed the facility licensees requirements to be licensed as an erator/Senior Operator pursuant to Title 10, Code of Federal Regulations, Part 55* and that the individual has a need Tor an Operator/Senior Operator license to perform his/her assigned duties and that the facility will be made avaiaben for examination.
I aso certify under penalty of perjury that the information in this document and attachments is true and correct.
- c.
RENEWAL ONLY - I certify that the above named individual meets the ap roved re alification program (with exceptions noted in Item 17) as required by section 50.54 (i-1 o? 10 CFR 0, and that he/s e has dischar ad his/her licensed responsibilities competently and safelY. I alsoce y under penalty of perjury the the information in this document and attachments is true an corect.
TRAINING CXEDIATOR SENIM MANAGEMENT EEFRESENTAIV 0N SITE PRINTED OR TYPED NAME PRINTED OR TYPED NAME Robert Clement I.
E. MORGAN SIGNATURE 1DATE SIGNATURE NO SIGNATURE REQUIRED DATE
( aL, rj Q-NON-CERTIFIED APPLICATION FOR HBC USE WAIVER (Check or complete items, as applicable)
MEETS REQUIREMNTS DOES NOT MEET REQUIREMENTS(Explain below)
CATEGORY GRANTED BY DENIED BY HEADQUARTERS REGION HEADQUARTERS REGION ITTEN PERATING ELIGIBILITY MEDICAL SIGNATURE - REVIEWER DATE OTEER NRC FORM 398 (10-90)
U S.
RE OULATCRY CC'Y!sSIZ%
.E r I<
n B
CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE A.A -,-A
- o=
- -D.
AO LN Drr
- Chang, Po
- A Z; L 17 Y
~~FAC ILIT Y :
T NhS E A
- San Onofre Nuclear Generating Station, Unit 1
50-206 A. MEDICAL EXAMINATION CERTIFICATION 5
S7z FY T-S0\\
N.'
LIAT F
AN FEF. ACR;.ENICR C
R ATCR LICSE Zs.
X A
C.
tevn_
- Rs:
MS.AD.
AND LICENSE NU6.BER EXA.:
iCN E
Steven'Rosen, M.D.
Calif. G24823 11-18-91 ASED ON THE RESULTSCF THE EXAMINATION. INCLUD!NG INFCV.YATION FURN:SHED BY THE APPLICANT. THE PHYSIC!AN HAS DET.'MI.wO THAT THE APPLICANTS PHYSICAL CONDITION AND GENERAL HEALTH ARE NOT SUCH THAT IT VIGHT CAUSE CEP.ATIONAL ERACPS ENAGE PLLICHEAL AND SAFETY. I CERTIFY THAT IN REACHING.THIS DETERMINATION.THE GUIDANCE CONTAINED IN ANSI!ANS 3.4-19F3.OR ANSI,'ANS: 5.4.1577 N.nH AS FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY NRC.
ON THE BEASIS OF THE RECOMMENDATION OF THE PHYSICIAN. I RECOMMEND THAT THE APPLICANT'S OPERATOR LICENSE EE CONDITIONED AS FOLLOWS:
- 1. NO RESTRICTIONS
- 2. CORRECTIVE LENSES SE WORN WHEN PERFORMING LICENSED DUTIES
- 3. HEARING AID SE WORN WHEN PERFORMING LICENSED DUTIES
- 4. RESTRICTED LICENSE OR EXCEPTION-Prcv;de detaIs below a-4 rach svp;iorin; medial evietn for NRC rev rw.
- 5. RESTRICTION CHANGE FROM PREVIOUS SUEMIIAL-Pe,, e de:ails dtow ard ;ta:ah spor.i; reicl e.via e - for NbRC tr;ew FRCPOSED WOROING CF RESTRICTION (Bocks 4 Corrective lenses be worn when performing licensed duties.
RELATIONSHIP OF RESTRICTION TO DISOUALIFYING CONDITION Br;tdyinin:, how rriction willcrn-.t the dislfi; condition REMARKS FOR RESTRICTION CHANGE (Block Sab5o*v)
- 9. NONMEDICAL CERTIFICATION
-H!S CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DUTY REQUIREMENTS OF TH:S FACILITY FR LICENSED OPERATORS.
A-r FALSE ST&TEW! T OR CWI!SICN IN THIS DOCuk. ENT, NCLUDING AT7ACNWlENTSD1AY EE SVEJECT TO CIVIL AND CRIMINAL SANCIONS.
ICERTIFY U'ER FENALTY OF PRINTED NAME AND SIGNATURE Inor Manjement reprr~ri on Srrj TITLE DATE No Signature Required, Non-Certified H. E. Morgan Application Vice President & Site Manager Im S ~oreance with. 0 CFR ES.S. Com mncona this form shall be submine ts the NRC as follows: BY MAIL ADDRESSED 70:
A..Vor'.sI lC~ai.S. P Comm issin TAmristrator, Regon II
.p
- oral Admitrsimrr.r. PR.gion III U.5 AleUS.,,;e-r Sri-pasoat Cornramorn U.S. Nuclear Rei. atoy Commisson 475? Allerdjat ACI 101 V-rr-a SI'tr. Sui-te 31003 7?9 Rol~.a~th Road King of Prus
- a. PA 1 S'cS Alsan:s. GA 3C323 Gln EI'yn, IL 60127 Re;oreal Adrn
,anrator, Re.on IV
- oral AdmInrator, Rtgiort V-Durecuor. D;iv;sin of L;cerse, Perform?.arnce U.S. N.cltar P tJ!atory Ce mrarm
- ,orn U.S. Nvcter R9gulatory Cornmiu;on.
ard Ovality E alition 611 Pyarn P!a:a Dr,, S:!
1000
- 1.,
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- 6
- 11 WaInA C-M,. CA ;4596 U S. N:Itwar Repjlu.cory Comm;sa;orn Wuibing1.on. DC 2C!55 FRIVACY ACT STA EVENT P4'.o 5 U.S.C. 162al
)(3). t l a -;rre
'I-by scon 3 of te Pr;.cy Act of ROUTINE USES: Tof ;
.o.uon r4y L d:ido..
to am a:ropa~a F.._,.I o,
174 (P *I;C La...53-579).
tie folloi-ng r.a tr-.ent it 'urn &hod 0 ;
a 1s who locl "ncy n 114 r, the fr,.aicon r.4.cara. a of or tl:aI v;oIa;on of !..
i.4 Wy,rfor.&t.on to 1.t US. N.clear Pn lory Comm u;oM on NFC Form 62S. ad ;nl14
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WHETHER DISCLOSUPE IS W.ANA7CR'? OR VOLUNTARY AN~D EFF ECT CN PR CIPAL P.RK LEIS)
-st. on are.'d.on lhs focm s u e c on-;r.e INDIVIDUAL OF N T PACVIDINS
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NRC FTRM 398. (FACSINKLE)
U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0090 DATE RECEIVED (10-90)
EXPIRES: 1-31-92 (To be completed by NRC) 1CFR 55,31 55.35, ESTIMATED BURDEN PER RESPONSE TO COMPLY a
5.57 WITH THIS INFORMATION COLLECTION.
REQUEST: 2.0 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE INFOR MATION AND RECORDS MANAGEMENT BRANCH PERSONAL QUALIFICATION STATEMENT - LICENSEE (MNBB 7714) U.S.NUCLEAR REGULATORY COM MISSION WASHINGTON DC 20555 AND TO THE PAPtRWOR REDUCtION FROJEfT (3150 0090) OFFICE OF MANAGEMENT AND BUDGET, TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED WASH INGTON, DC, 20503
- 1. APPLICANT'S FULL IAME (Last, First, Middle) AND ADDRESS 4.TYPE OF APPLICATION (Check applicaole boxe)
O CLD (include ZIP Code)
IC LD
- a. NEW
- f. WAIVER REQUESTED b.Justif on Reverse CORTOPASSI, LOUIS PAUL i
- c. UPGRADE 40017 Whiteleaf Lane TO 2-OPERATING (Category)
- Murrieta, CA 92562 INCLUDE ADDITIONAL UNIT) 3-ELIGIBILITY
- e. REAPPLICATION 1-FIRST 4-MEDICAL 5-0TE
- 2. CITIZENSHIP
- 3. BIRTH DATE 2-SECOND See block 17
.DATE PASSED GENERIC X
- a. UNITED STATES MONTH DAY YEAR 3-THIRD FUNDAMENTALS EXAM-tM YY INATION SECTION b.OTER(Specify) 0 6
2 0
6 4
(IF.APPLICABLE)
- 5.
TYPE OF LICENSE APPLIED FOR.
- 6. PREVIOUS LICENSE(S)
ELD
- a. OPERATOR
- c. EXPIRATION DATE
- b. SENIOR OPERATOR ONTH01 DAY YEAR
- c. LIMITED SRO 55-50388 X
OP-50257-00 8
3 1
9 3
50-206 (e.g.,
Fuel Handler) 7.HAME AND ADDRESS (Include ZIP Code) OF APPLICANTS EDPLOYER
- 10. CURRENT POSITION AT FACILITY
- a. -PLANT SUPERINTENDENT
- i. AUXILIARY UNIT OERATOR/
TiBRAINE /MUBIEB I
Southern California Edison
- b. ASSISTANT PLANT SUPERINTENDENT INGEEU NT OPERATOR
.P.O.
Box 128 (IC+/-
EN OPERATOR San Clemente, California 92674-0128
- c.
SHIFT SUPERVISOR (No CENsED OPERATOR)
- d. STAFF ENGINEER O
( c
- 8.
RAME OF APPLICANT'S FACILITY FACILITY DOCKET NUMBER SHIFT TECHNICAL ADVISOR/(Specify)
-- SIFT ENGINEE San Onofre Unit 1 50-206
- f. INSTRUCTOR
- 9. ADDITIONAL FACILITY DOCKETS (Multi-unit Licenses)
- g. SENIOR CONTROL ROOM OPERATOR X
- h. CONTROL ROOM OPERATOR
- 11. EDUCATION IGB SCHOOL
- c. MAJOR AREA(S) OF NUMBER HIGHEST DEGREE CODES
- d. VOCATIONAL /
NUMBER CERTIFICATE STUDY OF YEARS DEGREE (To be used for TECHNICAL OF RECEIVED
'HIGHEST DEGREE" HONTHS X
GRADUATE ENGINEERING (FIELDS)
(Use Codes) obtained)
TYPE OF TRAINING YES NO GED EQUIVALENCY Math, Science 2
0 0 -
NONE 1 - CERTIFICATE NO OTHER 2 -
ASSOCIATE 3 -
BACHELOR
- b.
NUMBER OF 4 - MASTER YEARS OF 5 - DOCTORAL COLLEGE 2
- 12. TRAINING (SINCE LAST APPLICATION - SEE INSTRUCTIONS)
- 13.
ERIEKCE (DO NOT DOUBLE COUNT - SEE INSTRUCTIONS)
- a. MONTH AND YEAR b NUMBER a.MONTH AND YEAR b NUMBER O
WEEKS Of MONTHS FROM' TO NAVY FROM4 TO (Classroom) 1 RO 2-PLANT SYSTEMS 2 -
EDOW/PPWO CLASSROOM 3____
3 -
EWS/PFWS OBSERVATION 4
4 - ERS/CRW 3-OPERATING PRACTICE CONTROL ROOHA OPERATIONS ON SHIFT 5 -
OTHER (Specify) Electrical SIMULATOR OPERATING
.Operator (Includes Classroom)
FOSSIL SIMULATOR NAMES I
6-OPERATOR
- b.
Hilitanni m 0i19a11 M11u n
SUPERVISOR CERTIFIED STARTUP YES NO 8_-_LANT STAFF FROMMi COMPLETED MEwrI 9I -uwinunlm OTE (Specify)
NO.
OF REACTIVITY MANIPULATIONS I
E ncd eec PLANT SCOMMERCIAL NUCLEAR (Including Research/
PLANT SIMULATOR m
Test Reactor)
See Block 17 10 - REACTOR OPERATOR (Licensed) 4-SRO INSTRUCTION 11 -
SENIOR OPERATOR (Licensed) 5-EXTRA PERSON ON SHIFT IN CONTROL 12 -
SHIFT SUPERVISOR (Licensed)
ROOM~ (13WEEK MINIMUM)
TIME ON SHIFT ABOVE 20% POWER 13 -
STAFF/SHIFT ENGINEER (Licensed)
(6-WEEK MINIMUM) 14 - AUX./EQUIP.
OPER.
(Nonlicensed)
QUALIFICATION 15 -
PLANT STAFF I-OTER.(Specify) 16 - OTHER (Specify)
NRC FORM 398 (10-90).
- 14. FACILITY OPERATOR TRAINING PROGRAM
- a. GRADUATE OF INFO ACCREDITED OPERATOR
- b. CERTIFIED ON NRC FORM 474 I"SIMULATION TRAINING PROGRAM THAT IS BASED UPON X
YES NO FACILITY CERTIFICATION")
OR NRC APPROVED X
YES NO A SYSTEMS APPROACH TO TRAINING SIMULATION FACILITY IS USED IN TEE OPERATOR TRAINING PROGRAM
- 15. FOR RENEHALS ONLY 1.DATE AND RESULT OF MOST DATE RESULT OURS OPERATED FACILITY RECENT NRC ADMINISTERED DE REQUALIFICATION EXAMINATION PASS FAIL
- 16.
EXPERIEHC DETAILS
- a. POSITION TITLE FROM TO
- b. FACILITY
- c. DUTIES
- 17. CR9SENTS (Specify the item number to which you are elaborating. Attach additional sheets as necessary.)
4.g Mr. Cortopassi held a RO license prior to the existence of the Generic Fundamentals Examination.
Mr. Cortopassi should be exempt from the Generic Fundamentals Examination based on Generic Letter 89-17, dated September 6, 1989.
12.3.b Certified Reactor Startup and Number.of Reactivity Manipulations are not required for SRO upgrades.
- 18. NBC FORM 396, CERTIFICATION OF MEDICAL AMINATION BY FACILITY LICEN, IS ATITACHE ANY FALSE STATEMENT OR CHISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
19a. I certify under penalty of perjury that the information in this document and attachments is true and correct.
I further certify that I have notifie8 my current employer of: (1) all previous employers; (2) any instance where I have been tested by a realth and Human Services (BBS) Certified Drug Testin Laoratory or a Licensee's testing facility for alcohol or a controlled substance, and the test results exceeded the cutoff levels established pursuant to 10 CFR Part 26* (3 any instance where I have been arrested for the sale, use or possession of a controllea substance described in 16 CF Part 26*
and (4) any reasons for removal or revocation of unescorted access at a nuclear facility, I also authorize the NRC to submit the results of examinations to my employers for use in preparing retraining programs, as necessary.
SIGNATURE - APPLICANT DATE CHECK APPLICABLE BOE X
- b. I certify that the above named individual has successfully completed the facility licensees requirements to be licensed as an Operator/Senior Operator pursuant to Title 10, Code of Federal Regulations, Part 55* and that the individual has a need or an Operator/Senior Operator license to perform his/her assigned duties and that the facility will be made available for examinat on.
I also certify under penalty of perjury that the information in this document and attachments is true and correct.
- c. RENEWAL ONLY - I certify that the above named individual meets the a roved reaualification pro ram (with exceptions noted in Item 17) as required by section 50.54 (i-1) o 10 CFR 50, and that he/s a has dischar ed his/her licensed resonsibilities competently and safely. I so certify under penalty of perjury the the information in this document and attachments is true and correct.
TRAINING COCEDIATCR SEICR MANAGEMENT RESNTATIVE 08 SITE PRINTED OR TYPED NAME PRINTED OR TYPED NAME Robert Clement B. E. MRGAN SIGNATURE DATE SIGNATURE NO SIGNATURE REOUIRED DATE (LA L.
wI NON-CERTIFIED UPPLICATIO F(R C USE WAIVER (Check or complete items, as applicable)
MEETS REQUIREMENTS
- DOES NOT MEET REQUIREMENTS(Explain below)
GRANTED BY DENIED BY CATEGORY HEADQUARTERS REGION HEADQUARTERS REGION TTEN TING ELIGIBILITY MEDICAL SIGNATURE - REVIEWER DATE OTHER NRC FORM 398 (10-90)
c.
.'.*L R
-ULALCRYC tYYSSIC CERTIFICATION OF MEDICAL EXA IINATION BY FACILITY LICENSEE s
-'-t UAI.AB46*-
T Ar-a Dr S
.2 N
Cortopassi, Louis P.
A' 1 L Y
~FACI 1.17CLITY DOCKET NUER San Onofre Nuclear Generating Station, Unit 1
.50-206 A. MEDICAL EXAMINATION CERTIFICATION RINTED
.N.'.
s:.4-STAT AND LICENSE NUMBER E
E C.. Rolbin,MD CA A019523 11-14-91 BASED ON THE RESULTS OF THE EXA.INATION.NCLUD!NG INFCR.ATION FURNISHED,Y THE APPLICANT, THE PHYSICAN HS DE ERMINED THAT HE APPLICANT'S FYSICAL CONDITION AND GENERAL HEALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPERATIONAL ERRORS ENDANGERING PUBLIC HEAL-I AND SAFETY, ICERTIFY THAT IN REACHING THIS DETERMINAT1ON.THE GUIDANCE CONTAINED IN ANSI/ANS14-1983.OR AESRANSA15.4.1;6 INCI0 H.AS FOLLOWED AND THAT DOCUMENTATIC IS AVAILABLE FOR REVIEW BY NRC.
ON LTHE B
OF THE RECOMMENDATION OF THE PHYSICIAN, I RECOMMEND THAT THE APPLICANTS OPERATOR LICENSE SE CONDITIONED AS FOLLO34 NO RESTRICTIONS p
- 2. CORRECTIVE LENSES EE WORN WHEN PERFORMING LICENSED DUTIES
- 3. HEARING AID BE WORN WHEN PERFORMING LICENSED DUTIES
- 4.
RESTRICTED LICENSE OR EXCEFTICN-Prvide detsils biew a*d ric:h sup-orming med ical evidn:x for NRC review.
S. RESTRICTION ChIANGE FROM PREVIOUS SUBMITTAL-Prev,* de ails beoIw and st:.m£ a
me nicaI r;denct for NRC rye PROPOSED WORDING OF RESTRICTION (irk 4 abc)
CORRECTIVE LENSES BE WORN WHEN PERFORMING LICENSED DUTIES.
RELATIONSHIP OF RESTRICTION TO DISOUALIFYING CONDITION:3rilyW ir'tiesshowa rriwionwillirrc rthe disqualisho cofii1onJ REM.ARKS FOR RESTRICTION CHANGE (SBlock Sao).
- 9. NONMEDICAL CERTIFICATION TH!S CERTIFIESOTAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DUTY REQUIREMENTSOF THIS FACILITY FPR LICENSED OPERATORS.REURMNSOTHSFCLY ANir FAL!E STA 0T OR 0 ASSION INTKIS DOCUMCENT.1ICLUDIN ACm AEENTSIE E S.JECT TO CIVIL AND CRIMINAL SANC7ION& I CERTIFY UNDER FENALTY OF FEJURAy THAT TrE IINFOPMATION IN THIS DOCUIAENT AND A=-ACWmEKTS ISTAUE AND COArECT.
FRINTED NAME AND SIGNATURE ISeniorMa agerment RperrSetsf:u onS Vi TITLE DATE No Signature Required, Non-Certified H. E. Mor an Application Vice President & Site Manager In accordnce wtit IOCFR 55.5. Cormwni cjon, this form shall be Ibni-edI tothe NRC a follows: BY MAILADDRESSED T0:
U.S. lo ~ qr mIi ator, Ro n r
A m straor, Reg;on IIR P
U.S. Nucin r Rpusory Commission U.S. N,:!ear Reg7 latory Comm;uon 475 Allends~t Read 101 Var~r-a Surrt. Suite 31>3 U..-Wla tJ10 o
m lo Kin; of Pr,.. 1:, PA iS'16 AtIanta, GA 3C323 Glr EIyn. I c" Reg;onal Admintrmstor. Region IV Rn.o-.af Mminnator, A t Re P...,or VD
- om ef L46mirs Pirform..,c.
U.S. Nvctar Patoy Commi:s;on U.S. N.o'tkr Re-p9atory C mm;u;on and O.aI-y EvIw;om 611 Ryan P!sm Driv, Sui,,t 1C003 1450 M4,4 Larne, Sui,.t 210 Ai:O ao 4os ArG-%.om TX 76,I11*
WmI'n C-k. CA U.S. NleIlar PRplor#cry CommIsson%
WjN,~n DC 2C!SS 5 U..C.'-511.I 1(3) 1 I'r d
y C.
RIVACY ACT STAT Em.ENT
- h 10 U.S.C.
by ~on 3 of i.e PXOrcy Aco of DOUTIvE USES: Ths infrm on m io n o Licae F ora.e.
o 1974 IP~bI;C b.
S3.$79
. I o[IL F-r.1" t'.3it
- S lumih d 10 SOC31' "Nh0 in J 1 I4 the inforrii~;hd
- =
a ;oir;Cn ot por1:b o;:1on~ oi It.
Affy *'1'.al; n 10 the U.S. NT CXm PtWal C mm:u:o t on N C Fe r 2 5 &Cd U*rI1 1 V'I'n 114,vlg1Tr,J1of ird r S. '.
-taIo r Th:t
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- d.
the c ofw ir rai r
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AU7HCRITY Sc ;
IC.7.,d 161b) cf %to Atom;c E' ;y Aci 0f 4* as ras t.-&ay ue Im at NRC Cecvhn abtoq yi.e (R42CIA U.SOC.SE 5
ETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON I..CPAL P:RPSEvI s ); Inforal on eme' Ihi r
- d.
o e y"nIrm-re INDIVIDUAL CF NOT FROVIDING IaFCF.I/ATION.
D:
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I=CM 398 (FACSIMILE)
U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO.
3150-0090 DATE R IVED (1-90)
EXPIRES: 1-31-92 (To be cocpJeted by NRC) 0 CFR 55.31 55.35, ESTIMATED BURDEN PER RESPONSE TO COMPLY 55.47, ana 5t.57 WITS THIS INFORMATION COLLECTION RE0UEST: 2.0 ERS.
FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE INFOR MATION AND RECORDS MANAGEMENT BRANCH PERSCRAL QUALIFICAION STAmDEWT -
LICSKE MNBE 7714) U.S.NJCLEAR REGULATORY COM MISSION WASHINGTON DC 20555 AND TO THE PAPtRWORK REDUCtION PROJE6T (3150 0090) OFFICE OF MANAGEMENT AND BUET, TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED WASHINGTON, DC, 20503
- 1.
APPLICANT'S FULL KAHE (Last, First, Middle). AND ADDRESS 4.TYPE OF APPLICATIC (Check applicable bozes) X HOT COLD (include ZIP Code)
X
- a. NEW
- f. WAIVER REQUESTED (Justify on.Reverse)
GOODWIN, DEAN RUSSELL
- b. RENEWAL.-
ITTE (Category) 24331 Taxco Drive
- c.
UPGRADE 2-OPERATING (Category)
Dana Point, CA 92629
- d. MULTI-UNIT (AMEND TO INCLUDE ADD ITIONAL UNIT) 3-ELIGIBILITY
- e. REAPPLICATION 4-MEDICAL 1-FIRST 5-OTHER
- 2. CITIZSESHIP
- 3. BIRTE DATE 2-SECOND X g.DATE PASSED GENERIC X
- a. UNITED STATES MONTE DAY YEAR 3-TBIRD FUNDAMENTALS EXAM-MM YY INATION SECTION
- b. OTHER (Specify) 0 3
11 0 5
8 (IF APPLICABLE) 10 90
- 5.
TYPE OF LICENSE APPLIED FOR
- 6.
PEVIOUS LICENSE(S)
- a. OPERATOR
- c. EXPIRATION DATE ba.
DOCKET NUMBER RO SRO b. LICENSE NUMBER d.FACILITY DOCKET NUMBER X
- b. SENIOR OPERATOR MONTH DAY YA
- c. LIMITED SRO 55-50 (e.g., Fuel Handler) 7.RAME AND ADDRESS (Include ZIP Code) OF APPLICANT'S EMPLOYER
- 10. CRENT POSITIOB AT FACILITY
- a. PLANT SUPERINTENDENT
- i. AUXILIARY UNIT OPERATOR/
Southern California Edison TRAINEE /TURBINE BUILD P. 0. Box 128
- b. ASSISTANT PLANT SUPERINTENDENT ING/EQUIPENT OPERATOR San Clemente, CA (NONLICENSED OPERATOR) 92674-0128
- c. SHIFT SUPERVISOR X1 d. STAFF ENGINEER
- 8. NAME OF APPLICANT'S FACILITY FACILITY DOCKET NUMBER
- e. SHIFT TECHNICAL ADVISOR/
-J.
OTHER (Specify)
San Onofre Unit 1 50-206 SHIFT ENGINEER
- f. INSTRUCTOR
- 9. ADDITIORAL FACILITY DOCKETS (Multi-unit Licenses)
- g. SENIOR CONTROL ROOM OPERATOR
- h. CONTROL ROOM OPERATOR
- 11.
EDUCATIO0 GB SCHOOL
- c. MAJOR AREA(S)
OF NUMBER HIGHEST DEGREE CODES
- d. VOCATIONAL /
NUMBER CERTIFICATE STUDY OF YEARS DEGREE STo be used for TECHNICAL OF RECEIVED HIGHEST DEGREE" MONTHS X
GRADUATE ENGINEERING (FIELDS)
(Use Codes) obtained)
TYPE OF TRAINING YES NO GED EQUIVALENCY Mechanical & Nuclear 4
3 0 - NONE 1 -
CERTIFICATE NO OTHER 2
ASSOCIATE 3
BACHELOR
- b. NUMBER OF 4 -
MASTER YEARS OF 5 -DOCTORAL COLLEGE 4
- 12. TRAIIKG (SINCE LAST APPLICATION -
SEE INSTRUCTIONS)
- 13. EXPERIENCE (DO NOT DOUBLE COUNT - SEE INSTRUCTIONS)
- a. MONTS AND YEAR b.
NUMBER a.MONTH AND YEAR b. NUMBER OF WEEKS
'OF MONTHS 1-NUCLEAR POWER PLANT FUNDAMENTALS FROM TO O
EK R
FROM TO (Classroom) 1 - RO 2-PLANT SYSTEMS 2 - EDOr/PFWO CLASSROOM OBSERVATION 3 - EWS/PPWS 4 -
ERS/CRW 3-OPERATING PRACTICE________
CONTROL ROOM OPERATIONS ON SHIFT 5 - OTR (Specify)
SIMULATOR OPERATING (Includes Classroom)
FOSSIL SIMULATOR NAMES 6 -OPERATOR
- a. Unit 1 IB In lilin I
mi 1l
- b.
m mafInuIllWianI IInunuInin 7 -SUPERVISOR CERTIFIED STARTUP X YES NO 8-0 STAFF PROGRAM COMPLETED 9-OTHER (Specify)
NO.
OF REACTIVITY MANIPULATIONS I11M 11l PLANT COMMERCIAL NUCLEAR (Including Research/
SIMULATOR
.Itum an am mm laf Test Reactor) 5 10 - REACTOR OPERATOR (Licensed) 4-SRO INSTRUCTION 11 - SENIOR OPERATOR (Licensed) 5-EXTRA PERSON ON SHIFT IN CONTROL 12 - SHIFT SUPERVISOR (Licensed)
ROOM (13-WEEK MINIMU.M) 13__
-_____IT NIEE Lcesd TIME ON SHIFT ABOVE 20%
13 - STAFF/SHIFT ENGINEER (Licensed)
(6-WEEK MINIMUM) 14 - AUX./EQUIP. OPER. (Nonlicensed)
UALIFICATION 15 -
PLANT STAFF 7-OTR (Specify) 16 -
OTHER (Specify)
NRC FORM 398 (10-90)
- 14. FACILITY OPERATMR TRINING PROGRAM
- a. GRADUATE OF INPO ACCREDITED OPERATOR
- b. CERTIFIED ON NRC FORM 474 ("SIMULATION TRAINING PROGRAM TEAT IS BASED UPON X
YES NO FACILITY CERTIFICATION" OR NRC APPROVED X
YES NO A SYSTEMS APPROACS TO TRAINING SIMULATION FACILITY IS USED IN THE OPERATOR TRAINING PROGRAM
- 15. F(R RENEALS ONLY 1b. DATE ADRSULT OF MOST DATE RESULT HOURS OPERATED FACILITY b
RECEN NRC ADMINISTERED RSULT REQUALIFICATION EXAMINATION PASS FAIL
- 16.
EXPERIENCE DETAILS
- a. POSITION TITLE FROM -TO
- b. FACILITY
- c.
DUTIES
- 17. COMENTS (Specify the item number to which you are elaborating. Attach additional sheets as necessary.)
- 18.
HRC FORM 396, CERTIFICATION OF MEDICAL EMINATIO BY FACILITY LICSEE, IS ATTACHED ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
19a. I certify under penalty of perjury that the information in this document and attachments is true and correct. I further c ertf htIhv oidm cur n
lorer of: (1) all previous employers; (2) any instance where I have been tested by a alth and Human Services (HHS) Certi i Dr Testin Loratory or a Licensee's testing facility for alcohol or a controlled substance, and the test results exceeds the cu off levels established ursuant to 10 CFR Part 26*
3 instance where I have been arrested for the sale, use or possession of a controlle substance described in 16 FR t 26; and (4) any reasons for removal or revocation of unescorted access at a nuclear facility, I also authorize the NRC to submit the results of examinans to my paployers for use in preparing retraining programs, as necessary.
SIGNATURE - APPLICANT
.DATE CEC APPLICAE BOX X
- b. I certi that the above named individual hag successfully completed the facility licensees requirements to be licensed as an erator/Senior Oerator pursuant to Title 10, Code of Federal Regulations, Part 55-and that the individual has a need or an operator/Senior Operator license to perform his/her assigned duties and that the facility will be made vaibeN for examination.r also certify under penalty of perjury th the information in this document and attacmets is true and correct.
- c. RENEWAL ONLY - I certify that the above named individual meets the ap roved re alification program (with exceptions noted in Item 17) as required by section 50.54 (i-1 oi 10 CFR 0, and that he/s e has discharged his/her licensed responsibilities compet ly and safely. I also certify under penalty of perjury the the information in this document and attachments is true and correct.
TRAINIMG COODIEATO SENI MANAGEMENT REPRESENTATIVE ON SITE PRINTED OR TYPED NAME PRINTED OR TYPED NAME Robert Clement B. E. MORGAN SIGNATURE DATE SIGNATURE NO SIGNATURE RE URED DATE
-~\\) q.NON-CERTIFIEDAPLCTO FOR NRC USE WAIVER (Check or complete items, as applicable)
MEETS REQUIREMENTS DOES NOT MEET REQUIREMENTS(Explain below)
CATEGORY GRANTED BY DENIED BY HEADQUARTERS REGION HEADQUARTERS REGION TTEN TING ELIGIBILITY MEDICAL SIGNATURE - REVIEWER DATE OTEE N OTHER NRC FORM 398 (10-90)
".R;C
-z2 6
U S.
- L~~
EUL ~RY COy~y!SIC CERTIFICATION OF MEDICAL EXAMrINATION ESLI k E S7.
BY FACILITY LICENSEE O".:s A
-. r _ADIY:
W 4-
,,:N Goodwin.
Dean R.
San Onofre Nuclear Gene ILt.Y DOCKET enraig Station,. Unit 1 NU0-206 A
MEDI
-06 A. FEICAL EXAMINATION CETIFICATIAN O HES SIS OF TH RO NAT E O F - A%.'4I APLICANT F AN :OE THAT E
RAT O
.... L.. ENS E C Y RRTC EE TV',=
LA SEBWRNHN 3.I HEN AD AE WON HE PRORIN LCNSDUTE
- 4.
REST.ICT.
LICE..
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dD Iails beA CN DAE PROPSEDOHRING OF RESTITO E Ba Xr hw ur v
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of REATOSHP FRETRCIO T
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s EL N T T HEPH Y S L TCO F EI T IO N NL HAR E
NK SR N IS H E D E Y T H E A P P C H N T P H Y S ICA N H A S D E T E R M IN E AISNOT SUCH THAT IT MIGHT CAUSE OERATIONAL ERRORS ENDANGERING PUBLIC HEALTH AND SAFETY I CERTIFY THAT IN REACHING THIS DETERMINATION THE GU IDANCE CONTAINEDIN ANSUANS 3.4QIR NSIOANS FACII FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FO R REVIEW BY NRCR S3.TO R UND ENLTY OF ON THE BASIS OF THE, RECOMMENDATION OF THE PHYSICIAN. I RECOMMEND THAT THE APPLICANT'S OPERATOR LICENSE BE CONDITIONED A FO LLOWS:
- 1. NO RESTRICTIONS A
No. RECTIVE LENSES BE WORN WHEN PERFOsRMING LICENSED DUTIES
- 3. HEARING AID EWORN WHEN PERFORMING LICENSED DUTIES
- 4. RESTRICTED LICENSE OR EXCEPTION&Provie da below subid t rtJh S acrin w
S dYnm for NRC revEw S. REST RICTION CHANG FROM PREVIOUS SUBMf1ALProvin, Su.
itsb wm I r1 a I
'e for NRC r torw C
ROPOSEbD WORDING OF RESTRICTION (Bok4 460.11 Corrective lenses be WOre wEyen performing RE LATIONSHIP 0 RESTRICTION TO DisauAI'N CNIIN(rilyidcthc erinil thdali.gcodio)
U. Nu la R eaor o miso RUN-TION M iint or, Rqd I on VetLro ~ c~r=Tocrq aiyn in6,in emARIK5 FOR RESTRICTION CHANGE (Blockl 5aboaqj US NNNMEDICAL CiR I FICATION bus a tt 5 UIIE.C A
5 2TE3)
PPivacy WamsharonFUND TO MDC20E555EUA FOR LICENSED OPERATORS.......
AFU4S (ND 579),
FOR Dmo REQUIREMENTS t THIS FACILITY ANY FALSE STATEMEST OR OMII S SIN 11IN ITI'S 0'1OCU'1 'IM E7 N ICL U 011ING A 1TTA IC' M ENTS1 5' M A,Y BE1 SJECT '70 CII N RMNLS NI ICRIYUDRIE ATY O PERJURY T HAT T HE INFCAMATION IN THIS DOCUMENTN Aho VTA E'TS IS TRUE ND ORC PRINTED NAME AND SIGNATURE f.Snior V~frp;mem RfP, 1.9~;- on SrtJ TITLELI "EA 1 No Signature Required, Non-Certified H: E. Mo"U an DATE S
n.oa ai re Rn m
ecrsdeeq.
e Ap*plitecatite oraoonr c e a vorto o otna voe~o o a ApplicatontVice President & Site Manager Ia corda ei t 10 F R:::.
) 4*
-of this torm Ehall be o
t4.
Ns foore.: BY
.A L A DDcErED TO:
CR M o *6 S. mRregion l r Ato r tIrc IioF. Reg io* 11 A A~ onal Af min;.taor. Rr.g0 III Nuclear Regulator;' Commision U.S. Nuclear PrW lort Commuon U.S. Nuclear Re.lsory Commission
- 475 Allenadale Road
.101 )/arieI~ S1.1tot. Suif. 31D0 7?3Rcr9 hRa i
n g o f P n n I a P A 1 9 c1 A la n a G A 3 0 2 3 G e l y. I 0 3 Regonal Arn~;ngrator.
Ppon IV RH ar~rtr.Rpo
- vI D,&o fL~i efr ac U.S. Nuclear RagVI~ Commits;on R..;-~
Nula Reultoyomu;om
. Oualrily Evaluation 611 Ryan Plaza Dive, Svue DD 1450 U.S.
a NUclea B~lto' C2mmujo Da.or
.. isin fLcramPtorla AdT.T 61 antC,"** CA ;45918 U S. NcorRepIIory orll 5w by PR~IVACY ACT STAEMENWahno.C 05 Pwituant 1o 5 USCQ SI24(f)I3). @~~,&I int !a*yscion 3 of the Pri;a.cy Act of ROUTINE USES: The information, meay b4 dc,.d to an aporoyav F.le*
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VOLUINTARY A4 FETG
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NRC FORM 398 (FACSIELE)
U.S.
NUCLEAR REGULATORY COMMISSION APPROVED BY M: NO. 3150-0090 DATE RECEIVED 10-90) 10R5531053 EXPIRES: 1-31-92 (To be completed by NRC) 10 ESTIMATED BURDEN PER RESPONSE TO CPLY 55.47, and 5.57 WITH THIS INFORMATION COLLECTION REOUEST: 2.0 ERS. FORWARD COMMENTS SARDING BURDEN ESTIMATE TO THE INFOR MATION AND RECORDS MANAGEMENT BRANCH PESONAL QUALIFICATION STAEMENT - LI(MNBB 7714) U.S.NUCLEAR REGULATORY COM MISSION WAHINGTON DC 20555 AND TO THE PAPRORK REDUCtION PROJECT (3150 0090 OFFICE OF MANAGEMENT AND BUDGET, TO RFMAIN VALID, THIS FORM MUST NOT BE ALTERED WHINGTON, DC, 20503
- 1. APPLICANT'S FULL NAME (Last, First, Middle) AND ADDRESS 4.TYPE OF APPLICATION (Check applicable boxes)
HOT COLD (include ZIP Code) e X
- a. NEW L
- f. WAIVER REQUESTED
- b. RENEWAL i-WRITTIN (Caeers JANKE, JASON BRIAN X
- c. UPGRADE 4794 Via Escala d MULTIUNT TO 2-OPERATING (Category)
Oceanside, CA 92056 INCLUDE ADDITIONAL UNIT)
X a. UNITED STATES MONTH DAY YEAR 3TIDEPF AFTL
- b. OTHER (Specify) 0 8
1 17 6-4 ITONSCIr
- 5.
PREAPPLICATION
- 2. CITIAI
- 3.
EXIIATIO DAE2-EONATHE R
Sealok1
- gDNEPSSDGWEI
- b. SENIOR OPERATOR INTH VDAY RYEAR
- c. LIMITED SRO 55-50385 X
OP-50258-00 0
3 1 9 M
-3 50-206 (e.g., Fuel Handler) 7.RAME AND ADDRESS (Include ZIP Code) OF APPLICANT'S EPL.OYER
- 10. CMMNT POSITION AT FACILITY a.-PLANT SUPERINTENDENT
- i.
AUXILIARY UNIT OPERATOR/
L-i TRAINEE/TURBINE BUILD Southern California Edison
- b. ASSISTANT PLANT SUPERINTENDENT ING/EU PMENT.OPERATOR P.O. Box 128 NL San Clement, California 92674-0128
- c. SHIFT SUPERVISORN Ce OR)
Id.
STAFF ENGINEER W i OTHER (Seiy
- 8. NAE OF APPLICANTS FSHIFT TECHNICAL ADVISOR/E
)
5.TPELITYLICENEAAPIICKTORE
- e.
E SHIFT ENGINEER San Onofre Unit 1 50-206
- f. INSTRUCTOR
- 9. ADDITIORAL FACILITY DO aTS (Multi-unit Licenses)
- g. SENIOR CONTROL RO DAY OPERATOR cX
.3.
CONTROL RO8 OPERATOR
- 11. E10PATION HIGH SCHOOL
- c. MAJOR AREA(S)OF aNUMBER HIGHEST DEGREE CODES
- d. VOCATIONAL NUMBER CERTIFICATE STUDY OF YEARS DEGREE CTo be used for TENDEAT T/0 RECBRATD SHIGHEST DEGREE" TEISRICNLICNSE ECEIVED GRADUATE ENGINEERING (FIELDS)
(Use Codes) obtained)
TYPE OF TRAINING ED EQUIVALENCY 0EI NONE
.X b CNTROL OOMOPEATO NO OTHER 2 -ASSOCIATE General 2
U0 3BACHELOR
- b. NUMBER OF 4
NGMASTER YEARS OF 5
YDDOCTORAL COLLEGE 2
- 12. RAINI (SINCE LAST APPLICATION (SEE INSTRUCTIONS)
- 13.
)LERI E (DO NOT DOUBLE COUNT SEE INSTRUCTIONS)
- a. MONTE AND YEAR b. NUMBER a.MONTE AND YEAR b. NUMBER GEDFQUIALECYS OFONETH 1-NUCLEAR POWER PLANT FUNDAMENTALS FRM T
OFWES NVFOM O
OFOTH (Classroom) 1 - RO 2-PLANT SYST ES 2 -
EOOW/PPW CLASSROOM.___
OBSrlVATION.
3 -
EWS/PPWS b BER O4 3-OPERATING PRACTICE4-R/W ECONTROL RO OPERATIONS ON SHIFT 5 - OTHER (Specify) Electrical 1-NULATR PERA PLTN DAETL FROpTORaTFRoT (Includes Classroom) 2-PLA O
S MES 2 - EOPPO 7 - SERSR b..
UPRIO CERTIFIED STARTUP YES NO 8 -
PLANT STAFF PROGRAM COMPLETED In 01IHInfufufifflfilH101I1 0
9 - OTHER (Specify)
NO. OF REACTIVITY MANIPULATIONS PLANT SIMULATOR 1Il 1
I 00HHERCIAL NUCLEAR (Including Research/
PLANTSIMUL Rl iI II Test Reactor)
See Block 17 10 - REACTOR OPERATOR (Licensed) 14-SRO INSTRUCTION 11 - SENIOR OPERATOR (Licensed) 5-EXTRA PERSON ON SHIFT IN CONTROL 12 - SHIFT SUPERVISOR (Licensed)
- a. TIME ON SHIFT ABOVE 20%
13 - STAFF/SHIFT ENGINEER (Licensed)
(6-WEEK MINIMUM) 14 - AUX./EQUIP. OPER. (Nonlicensed)
QUALIFICATION 15 -
PLANT STAFF OTHER (Specify) 16 -
OTHER (Specify)
NRC FORM 398 (10-90)
- 14.
FACILITY OPERATOR TRAININ PROGRAM
- a. GRADUATE OF INPO ACCREDITED OPERATOR
- b.
CERTIFIED ON NRC FORM 474 ("SIMULATION TRAINING PROGRAM THAT IS BASED UPON X
YES NO FACILITY CERTIFICATION")
CR FRC AFFROVED X
YES NO A SYSTEMS APPROACH TO TRAINING SIMULATION FACILITY IS USED IN THE OPERATOR TRAINING PROGRAM
- 15. FOR RENDALS OHLY
- b.
DATE AND RESULT OF MOST DATE RESULT HOURS OPERATED FACILITY 1
.RECENT NRC ADMINISTEREDDAEEST REQUALIFICATION EXAMINATION PASS FIL
.16.
EXFERIENCE DETAIIS
- a. POSITION TITLE FROM TO
- b. FACILITY
- c. DUTIES
- 17. 00HMENTS (Specify the item number to which you are elaborating. Attach additional sheets as necessary.)
4.g. Mr. Janke held.a RO license prior to.the Generic Fundamentals Examination. Mr. Janke should be exempt from the Generic Fundamentals Examination based on Generic Letter 89-17, date September 6, 1989.
12.3.b. Certified Reactor Startup and Number of Reactivity Manipulations are not required for SRO upgrades.
- 18. IEC FORM 396, CERTIFICATION OF MEDICAL EXAMIRION BY FACILITY LICENE, IS ATTACEE ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
19a. I certif under penalt of perjury that the information in this document and attachments is true and correct. I further certif ytbat I have notife vemy current emiloyer of: (1i all previous employers; (2) any instance where I have been tested by a Health and Human Services (H)
Criie Dru Testing Laboratory or a Licensee's testing facility for alcohol, or a controlled substance, and the test results exceeded the cu off levels established rsuant to 10 CFR Part 26 3
any instance where I have been arrested for the sale, use or possession of a controlle usubstance described in li F
Part 26; and (4) any reasons for removal or revocation of unescorted access at a nuclear facility, I also authorize the NRC to submit the results of exam ations to myemployers for use in preparing retraining programs, as necessary.
SIGNATURE - APPLICANT JDATE.
C EC APPLICABLE fc X
- b. I certi that e above named individual has successfully completed the facility licensees requirements to be licensed as an Operator/Senior 0 erator pursuant to Title 10, Code of Federal Regulations, Part 55* and that the individual has a need or an perator/senior Oerator license toperform his/her assigned duties and that the facility will be made tavailae for examination.
I also certify under penalty of perjury that the information in this document and attachments is true and corre ct.
- c.
RENEWAL ONLY -.I certify that the above named individual meets the ap roved requalification pro ram (with exceptions noted iin Item 17) as required by section 50.54 (i1oY0CF 0 and that bt/sge has discharged his/her licensed respons bilities competently and safely.
so certify under penalty of perjury thr the information in this document and attachments is true and c orect.
TRAINING CDIRATM SEIOR MAGEMENT RERESENTAIVE 06 SITE PRINTED OR TYPED NAME Robert Clement H. E. MORGAN SIGNATURE t L
DATE SIGNATURE NO SIGNATURE REQUIRED JDATE klp7 3 V)C NON-CERTIFIED APPLICATION FOR NRC USE WAIVER (Check or complete items, as applicable)
MEETS REQUIREMENTS DOES NOT MEET REQUIREMENTS(Explain below)
CATEGORY GRANTED BY DENIED BY HEADQUARTERS REGION HEADQUARTERS REGION ITTEN ERATING ELIGIBILITY MEDICAL SIGNATURE REVIEWER DATE OTHER NRC FORM 398 (10-90)
- r CERTIFICATION OF.EDICAL EXMINATION t* Z.-s I=>.nE S s-- -E :
-o BY FACILITY LICENS==
L" o a.ZEu-r s
Janke, Jason FACILITY
-CET N,*MBER San Onofre Nuclear Generating Station, Unit 1 0-206 A. MEDICAL EXAMINATION CERTIFICATION
-":INTED
!:.'zr:.i STATE AND LICENSE NUMjER EXAM:NATIO ATE S. Rosen, MD CA G24823 Nov. 25 1991 S
D ON THE.ESULTSOF T-E EXAMINATION.
INCLUDING INFCORATION FURN:SHED BY THE APPLICANT, THE PHYSICIAN HAS DETR.;iED TATTH APPLICANT S PHYSICAL CONiTION AND GENERAL HEALTH ARE NOT SUCH THAT IT MIGHT CAL-E OFERATIONAL ERRCRS EN:ANGERING PLIC HEALT AND SAFETY I CERTIFY THAT IN REACHING THIS DETErMINATION. THE GUIDANCE CONTAINED IN ANSI/ANS 3.4153,CR ANSI/ANS 15.4.1S77 IC3$3) WAS FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FCR REVIEW BY NRC.
ON THE BASIS OF THE RECOMMENDATION CF THE PHYSICIAN. I RECOYMEND THAT THE APPLICANT'S OPERATOR LICENSE BE CONDITIONED AS FOLLCWS:
- 1. NO RESTRICTIONS
- 2. COF.RECTIVE LENSES.^ E WORN WHEN PERFORMING LICENSED DUTIES
- 3. HEARING AID BE WCRN WHEN PERFORMING LICENSED DUTIES
.4. RESTRICTED LICENSE OR EXCEFTION-Prov;de tils beow ad reich supprtim I
eiers for NRC review.
S. RESTRICTION CHANGE FROM PREVIOUS SUBMI, AL-Prce dta belu ow andiAj
- s.
rineiu; r for NRC reevdee PROPOSED WOROING OF RESTRICTION (Bixk 41 ]
CORRECTIVE LENSES BE WORN WHEN PERFORMING LICENSED DUTIES.
RELATIONSHIP OF REStRICTION TO DISOLALIFYING CONDITION (Sritely i how will cora the dis ulifyin; con'ition)
EM.ARKS FOR RESTRICTION CHANGE (Block Sasokvj
- 3. NONMEDICAL CERTIFICATION THIS CERTIFIES THATTHE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DUTY REOUIREMENTSOF THIS FACILITY FCR LICENSED OPERATORS.
E-NSO HSFCLT ANY' FALE STAT!ME%. OR CAISION INTMIS DOCUMENT INCLUDING ATTACMCNIS.
MAY IE STJECT TO CIVIL AND CRIMINAL SANCIOkL I CERTIFY UNTER FENALTY OF I' PE;.JLRY TNL&T Tw INCRMA~s.-,
IN ?awrS 0OCI,JENT AND AT'TACHM.EN--
IS TRUE, AND CORRECT.
PRINTED NAME AND SIGNATURE ISeior Margemet ieprwatsth ore TITLE DATE No Signature Required, Non-Certified H E Morgan Application Vice President & Site Manager Ia acordtnce with 10 CFR 55.5 Commun cjon, this form shall !e subeninte to the NRC s follows: BY MAIL ADDRESSED TO:
Re.-.;0t.a: AxmA4iatr Rej.a~or F i1r
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.~r R.Fr II;o I~~oa Mmrrinrur.r-o Fq.or III tU.S. Ncltat RepjIllory C sU.
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£7S AIItndslt Rea 101 V/arrna Sitt. Suhit 3*t3 729 F;,.aa4,h Rood Kin; of Prussha.
PA 14GB Ailana. GA C323 Glen Eyn IL 037 ReforaiAd mratr,~ R rIV
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D ctor, Division of LCne e Perforrr.ance U.S. Nuctsar RPP9.41tr Cor-.mi-ssona U.S. Nvcdear Repwratory Commlulom Arms Ovality E-alwation 611 R an P!&:
3 O,;,, sw*,; 1:03 1 40 WAr LAr-e. Si'.
210 Arn: Operator L;cr.i;, Samc.h ArlIr;-on. Tx
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- t.
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tI U.S C. 2.7 p WHETH-ER DISCLOSURE IS MANDATORY OR VOLLI2TARY AND EFFECT ON F rINCIPAL s*rC
- In h in on 10,m t or ; u-2 t
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- -I f 0CI y t
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NRC FORM 398 (FACSIMILE)
U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY MB: NO. 3150-0090 DATE RECEIVED 10-90)
EXPIRES: 1-31-92 (To be completed by NRC) 0 CFR 55.31 55.35, ESTIMATED BURDEN PER RESPONSE TO COMPLY 55.47, anfd 5.57 WITH THIS INFORMATION COLLECTION REQUEST: 2.0 ERS.
FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE INFOR MATION AND RECORDS MANAGEMENT BRANCH PERSONAL QUALIFICATION STATEMENT - LICENSEE (2NBB 7714) U.S.NUCLEAR REGULATORY COM MISSION WAHINGTON BC 20555 AND TO THE PAPtRWORK REDUCtION PROJECT (3150 0090 OFFICE OF MANAGEMENT AND BUDGET, TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED WASSINGTON, DC, 20503
- 1. APPLICANT'S FULL NAME (Last, First, Middle) AND ADDRESS 4.TYPE OF APPLICATION (Check applicable boxes)
HOT COLD (include ZIP Code)
- a. NEW
- f. WAIVER REQUESTED RODRIGUEZ, GILBERT
- b. RENEWALCeeos X
- c. UPGRADE 5241 Heatherwood Dr.
2-OPERATING (Category)
- d. MULTI-UNIT (AMEND TO Oceanside, CA 92056 INCLUDE ADD TIONAL UNIT) 3-ELIGIBILITY
- e. REAPPLICATION 1-FIRST 4-MEDICAL
- 2. CITIZESIP
- 3. BIRTH DATE 2-SECOND See Block 17 g.DATE PASSED GENERIC X
- a. UNITED STATES MONTB DAY YEAR 3-THIRD FUNDAMENTALS EXAM-MM YY INATION SECTION
- b. OTHER (Specify) 0 5
1 6
5 6
(IF APPLICABLE)
- 5. TYPE OF LICENSE APPLIED.FOR
- 6. PREVIOUS LICENSE(S) HELD
- a. OPERATOR
- c. EXPIRATION DATE
- a.
DOCKET NUMBER RO SRO b. LICENSE NUMBER d.FACILITY DOCKET NUMBER X
- b. SENIOR OPERATOR MONTH DAY YEAR
- c. LIMITED SRO 55-50178 X
OP-50122-01 0
8 0
7 9
3 50-206 (e.g., Fuel Handler) 7.NAME AND ADDRESS (Include ZIP Code) OF APPLICANT'S DEPLOYER
- 10. CURRENT POSITION AT FACILITY
- a.
PLANT SUPERINTENDENT
- i.
AUXILIARY UNIT OPERATOR/
TRAINEE/TURBINE BUILD Southern California Edison
- b. ASSISTANT PLANT SUPERINTENDENT ING/EOUIPMENT OPERATOR P.O. Box 128 L
San Clemente, California 92674-0128
- c.
SHIFT SUPERVISOR (NOEICENSED OPERATOR)
- d.
STAFF ENGINEER
- 8.
AME OF APPLICANT'S FACILITY I
FACILITY DOCKET NUMBER
- e. SHIFT TECHNICAL ADVISOR/
Lj3. OTHER (Specify)
SHIFT ENGINEER San Onofre Unit 1 50-206
- f. INSTRUCTOR
- 9. ADDITIONAL FACILITY DOCKETS (Multi-unit Licenses)
- g. SENIOR CONTROL ROOM OPERATOR X
- h. CONTROL ROOM OPERATOR
- 11.
EDUCATION IGH SCHOOL
- c. MAJOR AREA(S)
OF NUMBER HIGHEST DEGREE CODES
- d. VOCATIONAL /
NUMBER CERTIFICATE STUDY OF YEARS DEGREE cTo be used for TECHNICAL OF RECEIVED HIGHEST DEGREE" MONTHS--I X
GRADUATE ENGINEERING (FIELDS)
(Use Codes) obtained)
TYPE OF TRAINING YES NO GED EQUIVALENCY 0
NONE Nuclear Power School 6
X 1
CERTIFICATE NO OTHER 2
ASSOCIATE Nuclear Prototype 6
X
- 73 BACHELOR
- b. NUMBER OF 4
MASTER YEARS OF 5-DOCTORAL COLLEGE 0
- 12. TRAINING (SINCE LAST APPLICATION -
SEE INSTRUCTIONS)
- 13.
EnPERIENCE (DO NOT DOUBLE COUNT - SEE INSTRUCTIONS)
- a. MONTH AND YEAR b. NUMBER a.MONTH AND YEAR b. NUMBER FROMI To O
-0.F WEK AYFROM TO OFMNH 1-NUCLEAR POWER PLANT FUNDAMENTALS FM Ou.RM (Classroom) 1 - RO 2-PLANT SYSTEMS 2 - EOO/PPWO CLASSROOMI OBSERVATION 3 - EWS/PPWS OBSERATIO 3-OPERATING PRACTICE 4-ESCW_______
CONTROL ROMA OPERATIONS ON SHIFT 5 - OTER (Specify) Electrical SIMULATOR OPERATING Operator (Includes Classroom)
FOSSIL SIMULATOR NAMES i
6 - OPERATOR b.
Witufllullo Illmiillh in lhMi n a n 8111j9997 - SUPERVISOR PR~AM
~ffETE S
O8 PL.ANT STAFF CERTIFIED STARTUP I YES1 NO Uuulmiianinn LN TF FROGRAM COMPLETED 9 - OTHER (Specify)
NO.
OF REACTIVITY MANIPULATIONS PLANT SIMULATOR COMMERCIAL NUCLEAR (Including Research/
SltMUitiIlsTest Reactor)
See Block 17 n
10 -
REACTOR OPERATOR (Licensed) 4-SRO INSTRUCTION 11 -
SENIOR OPERATOR (Licensed) 5-EXTRA PERSON ON SHIFT IN CONTROL 12 -
SHIFT SUPERVISOR (Licensed)
RCt 1-EEK MINIMUM)
-TIM ON SHIFT ABOVE 20%
13 -
STAFF/SHIFT ENGINEER (Licensed)
(6-WEEK MINIMUM) 14 - AUX./EQUIP.
OPER.
(Nonlicensed)
QUALIFICATION 15 - PLANT STAFF 7-OTHER (Specify) 16 - OTHER (Specify)
NRC FORM 398 (10-90)
- 14. FACILITY OPERATOR TRAINING PROGRAM
- a. GRADUATE OF INPO ACCREDITED OPERATOR
- b. CERTIFIED ON NRC FORM 474X ("SIMULATION TRAINING PROGRAM THAT IS BASED UPON X
YES NO FACILITY CERTIFICATION")
OR NRC APPROVED X
YES NO A SYSTEMS APPROACS TO TRAINING SIMULATION FACILITY IS USED IN TEE OPERATOR TRAINING PROGRAM
- 15. FOR RENEWALS OELY
- b. DATE AND RESULT OF MDST DATE RESULT HOURS OPERATED FACILITY RECENT NRC ADMINISTERED REQUALIFICATION EXAMINATION PASS FAIL
- 16. ECPERIENCE DETAILS
- a. POSITION TITLE FROM TO
- b. FACILITY
- c. DUTIES
- 17. CMENTS (Specify the item number to which you are elaborating. Attach additional sheets as necessary.)
4.g. Mr. Rodriguez held a RO license prior to the existence of the Generic Fundamentals Examination.
Mr Rodriguez should be exempt from the Generic Fundamentals Examination based on Generic Letter 89-17, dated September 6, 1989.
12.3.b. Certified Reactor Startup and Number of Reactivity Manipulations are not required for SRO Upgrades.
- 18. NRC FORM 396, CERTIFICATION OF MEDICAL EAMINATION BY FACILITY LICENSEE, IS ATTACHED ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
19a. I certify under penalty of gerjury that the information in this document and attachments is true and correct.
I further.
certif that I have notified my. current employer of: (1) all previous employers; (2) any instance where I have been tested baHealth and Human Services (EES) Certifi ed DrugTsigLbrtyoraicnestsig facility for alcohol or a controlled substance, and the test results exceeded the cutoff levels established ursuant to 10 CFR Par 26 (3)any instance where I have been arrested for the sale, use or possession of a controlled substance described in 1 Prt 26; and (4) any reaso for removal or revocation of unescorted access at a nuclear facility, I also authorize the NRC to submit the results of e am n ioq o my employers for use in preparing retraining programs, as necessary.
SIGNATURE -
APPLICANT
,DATE CHEC AFPLICABLE BOX X
- b. I certify that the above n ned md vidual had successfully completed the facility licensees requirements to be licensed as anOperator/Senior Operator pursuant to Title 10, Code of Federal Regulations, Part 55i and that the individual has a need for an Operator/Senior Op~erator license to perform his/her assigned duties and that the facility will be made available for examination. I also certify under penalty of perjury that the information in this document and attachments is' true and correct.
- c. RENEWAL ONLY - I certify that the above named individual meets thea roved re alification pro ram (with exceptions noted In Item 17) as required by section 50.54 (i-11 ON 10 CFR 5O-and that he/s 9 has discharged his/her licens d resonsibilitiea competently andsafely.
also certify under penalty of perjury tha the information in this document and attachments is true and correct.
TRAININ COCIRDINATC SENIOR MAAGEMENT EPRESENTATIVE 0N SITE PRINTED OR TYPED NAME PRINTED OR TYPED NAME Robert Clement H. E. MORGAN SIGNATURE DATE SIGNATURE NO SIGNATURE RE UIRED
- DATE Qc) Ckt,% J NON-CERTIFIED APPICTION FR NBC DSE WAIVER (Check or complete items, as applicable)
MEETS REQUIREMENTS DOES NOT MEET REQUIREMENTS(Explain below)
GRANTED BY DENIED BY CATEGORY HEADQUARTERS REGION HEADQUARTERS REGION TTEN TING ELIGIBILITY MEDICAL SIGNATURE -
REVIEWER DATE OTHER NRC FORM 398 (10-90)
NRC rcU 396 U.S. NUCLEAR REGULATORY COMMISSION APP'E3 r' C'4.C 5
EXP.S 1.1 IJ !:7. 5 S57ES-IMATM BURDEN PER RESPONSE w-O w i S CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEENY C B
- 31.
AND TO -DE PENOAX REuCON Pc:OJECT YCW'= >
OFICE O ANGMENT AND BUDET (AS N-t0Ad DC 2S.c3 NAME OF APPLICANT FACILITY FACIL TY DOCKET NUMBER So 5 S UNTso A. MEDICAL EXAMINATION CERTIFICATION TH:S iS TO CERTIFY THAT THE ABOVE NAMED APPLICANT FOR AN OPERATOR/SENIOR OPERATOR LICENSE HAS BEEN EXAMINED BY A PHYSICIAN.
PRINTED NAME TUMBER
.EXAMINA O.ATE BASED ON THE RESULTS OF THE EXAMINATION. INCLUDING INFORMATION FURNISHED BY THE APPLICANT. THE PHYSICIAN HAS DETEWMI.ED HAT THE APPLICANT'S PHYSICAL CONDITION AND GENERAL HEALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPERATIONAL ERRORS ENDANGERING PUBLIC HEALTH AND SAFETY. I CERTIFY-THAT IN REACHING THIS DETERMINATION. THE GUIDANCE CONTAINED IN ANSI/ANS 3.4-1983. OR ANSI/ANS 15.4-1977 (N380) WAS FOLLOWED AN HAT DOCUMENTATION IS AVAILABLE FOR REVIEW-BY NRC.
ON THE BA OF THE RECOMMENDATION OF THE PHYSICIAN. I RECOMMEND THAT THE APPLICANT'S OPERATOR LICENSE BE CONDITIONED AS FOLLOW NO RESTRICTIONS.
1
- 2. CORRECTIVE LENSES BE WORN WHEN PERFORMING LICENSED DUTIES
- 3. HEARING AID BE WORN WHEN PERFORMING LICENSED DUTIES
- 4. RESTRICTED LICENSE OR EXCEPTION-Provide details below and attach supporting medical evidence for NRC review.
- 5. RESTRICTION CHANGE FROM PREVIOUS SUBMITTAL-Provide details below and attach supporting medical evidence for NRC rev.
PROPOSED WORDING OF RESTRICTION (Block 4above)
Corrective lenses be worn when performing licensed duties.
RELATIONSHIP OF RESTRICTION TO DISQUALIFYING CONDITION (Briefly indicate how restriction willcorrWcthe disqualifyin condition)
REMARKS FOR RESTRICTION CHANGE (Block 5above)
B. NONMEDICAL CERTIFICATION THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DUTY REOUIREMENTS OF THIS FACILITY FOR LICENSED OPERATORS.-
ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT. INCLUDING ATTACHMENTS MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS. I CERTIFY UNDER PENALTY OF PERJURY THAT THE INFORMATION IN THIS DOCUMENT AND ATTACHMIENTS IS TRUE AND CORRECT.
PRINTED NAME AND SIGNATURE (Senior Maragement Representerim on Sire)
TITLE DATE No Signature Required, Non-Certified H. E. Morgan Application Vice President & Site Manager In accordance with 10 CFR 55.5. Communications. this form shall be submitted to the NRC as follow: BY MAIL ADDRESSED TO:
Regional Administrator. Region I Regional Administrator, Region 1 Regional Adminirisor. Region III U.S. Nuclear Regulatory Commission U.S. Nuclear Regulatory Commission U.S. Nuclear Regulatory Commission 475 Allendale Road 101 'Mariens Stret. Suite 3100 799 Roosevelt Road King of Prussia. PA 19406 Atlanta, GA 30323 Glen Ellyn. IL 60137 Regional Administrator, Region IV Regional Administrator, Region V Direcor. Division of LiceIsIe Performance UUS. Nuclear Regulatory Commission US. Nuclear Regulatory Commiuion and Quality Evaluation 611 Ryan Plaza Drive. Suite 1000 1450 Maria Lane. Suite 210 Attn: Operator Licensing Branch Arlington TX 76011 Walnut Creek, CA 94596 U.S. Nuclear Regulatory Commission Wseinglon. C 20555 PRIVACY ACT STATEMENT-Pursuant to U.S.C. 552a(t 3. egror d ito Ia. by section 3 of the Pri nscy Act of ROUTINE USES: The information may be disclosed to an opfroiet Federal. State, or 1974 (Public Law 931579), the following raemerrnt is %rnished to indivduall who local agency in the event the information indicnts a Violin-on or polortal violation of lt.
suppy information o thR UeS. Nucuur legvratory Commission on NRC Form 396.
and in the ven the information indicats a violation or oltai voanton of law and in This inforration is maintained -in a sy10r0 of rords designated aa NRC-16 and the couse of an dministrative or judicial proceedring In addition. tis information may be AIcrito a. fTX A.7r1 33Waint Creek A949.
U.transferred to an apSropriate Federal, State. and local agency to e setent releant ano AUTHORITY: Sections 107 and 16t) f the Atomic Energy Act of 1954. as necessary for an NfCdecisionabru you.
arnended (42 USCS 2137 and 2201tfill.
WHETHER DISCLOSURE IS MANDATORY OR VOLUNTA-RY AND EFFECT ON PRINCIPAL PURPOSEbS)l Information enaemed on this form is ued to determine INDIVIDUAL OF NOT PROVIDING INFORMATION. Dw~chco.t-91-161Y. If the whether the Physcal condiion and get*ea! ktalh of the a;pficant are such that they requenned formation i not provided, however, the applicalaon fCr a mmiIsino NAFeormr' will nfat cause operalional errors enda.nerrg pOic healh and siaeety. Th rforms-or senior operyrorrs locer.s may be ddneed.
pon may beused by the NRC rTOf RITcY:e~en:r f the indivdwal meets the e-quire-SYSTEM MANAGERIS) AND ADDRESS: Cadef O161(i), L;of ts Atoa'Cm. Eecgy A o1 mani of t CF R 55 to tike ortarron to o
tot issued on operators Icense.
Nuclear Reactor Regulieon US. Nclear Rrm:ate NRC FORM 3AT 0.SE)
NRC FORM 398 (FACSIMILE)
U.S. NUCLEAR REGULATORY COMISSION APPROVED BY CMB: NO. 3150-0090 DATE RECEIVED (10-90)
EXPIRES: 1-31 (To be completed by NRC) 10 CFR 55 31 55.35, ESTIMATED BURDEN PER RESPONSE TO COMPLY 55.47, and 5t.57 WITH THIS INFORMATION COLLECTION REOUS: 2.0 ERS. FORWARD COMMENTS.
REGARDING BURDEN ESTIMATE TO "HE INFOR MATION AND.RECORDS MANAGEIENT BRANCH PERSONAL QUALIFICATION STATIMENT - LICENSEE (MNBB 7714) U.S.NUCLEAR REGULATORY COM MISSION WASHINGTON DC 20555 AND TO THE PAPtRHORK REDUCtION PROJECT (3150 0090) OFFICE OF MANAGEMENT AND BUDGET, TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED WASHINGTON, DC, 20503
- 1. APPLICANT'S FULL NAME(Last, First, Middle) AND ADDRESS 4.TYPE OF APPLICATION (Check applicable boxes)
OT COLD (include ZIP Code)
X
- a. NEW
. WAIVER REQUESTED
- WOOD, KEVIN CRAIG
- b. RENEWAL I
(onCRegr 1122 Las Poses
- c.
UPGRADE 2-OPERATING (Category)
San Clemente, CA 92672
- d. MULTI-UNIT (AMEND TO INCLUDE ADDITIONAL UNIT) 3-ELIGIBILITY
- e. REAPPLICATION 4-MEDICAL 1-FIRST 5-OTHER
- 2.
CITIZENSHIP
- 3. BIRTH DATE 2-SECOND X g.DATE PASSED GENERIC X
- a. UNITED STATES MONTH DAY YEAR 3-THIRD
-FUNDAMENTALS EXAM-YY INATION SECTION
- b. OTE (Specify) 1 1
1 1 5
9 (IF APPLICABLE) 10 90
- 5. TYPE OF LISE APPLIED FOR
- 6. PEVIOUS LICENSE(S) HFL.D
- a. OPERATOR
- c. EXPIRATION DATE
- b. SENIOR OPERATOR NTB DAY YEAR
- c. LIMITED SRO 55-50 (e.g., Fuel Handler) 7.NAME AND ADDRESS (Include ZIP Code) OF APPLICANT'S EMPLOYER
- 10. CUERENT POSITION AT FACILITY
- a. PLANT SUPERINTENDENT
- i. AUXILIARY UNIT OPERATOR/
Southern California Edison TRAINEE/ TURBINE BUILD P. 0. Box 128
- b. ASSISTANT PLANT SUPERINTENDENT ING/EU PMENT OPERATOR San Clemente, CA (NONLICENSED OPERATOR) 92674-0128
- c. SHIFT SUPERVISOR
- d. STAFF ENGINEER
- 8.
NAME OF APPLICANTS FACILITY FACILITY DOCKET NUMBER X
- e. SHIFT TECHNICAL ADVISOR/
3Jj.
OTEE (Specify)
San Onofre Unit 1 50-206 SHIFT ENGINEER
- f.
INSTRUCTOR
- 9. ADDITIONAL FACILITY DOCKTS (Multi-unit Licenses)
- g. SENIOR CONTROL ROOM OPERATOR
- h. CONTROL ROMC OPERATOR
- 11.
EDUCATIC0 IGH SCHOOL
- c. MAJOR AREA(S)
OF NUMBER HIGHEST DEGREE CODES
- d. VOCATIONAL /
NUMBER CERTIFICATE STUDY OF YEARS DEGREE To be used for TECHNICAL OF RECEIVED HIGHEST DEGREE" MONTHS X
GRADUATE ENGINEERING (FIELDS)
(Use Codes) obtained)
TYPE OF TRAINING YES NO GED EQUIVALENCY Mechanical 4
3 0 -
NONE 1 - CERTIFICATE NO OTHER 2 -
ASSOCIATE General 2
0 3 -
BACHELOR
- b. NUMBER OF 4 -
MASTER YEARS OF 5 - DOCTORAL COLLEGE 6
- 12. TRAINING (SINCE LAST APPLICATION - SEE INSTRUCTIONS)
- 13. EUPEIECE (DO NOT DOUBLE COUNT -
SEE INSTRUCTIONS)
- a. MONTH AND YEAR b. NUMBER a.MONTH AND YEAR b NUMBER OF WEEKS 6 MNTHS 1-NUCLEAR POWER PLANT FUNDAMENTALS FROM TO OFAE FROM TO.
(Classroom) 1 -
RO 2-PLANT SYSTEMS 2 - EOOW/PPWO CLASSROOM OBSERVATION 3 - EWS/FFWS 4 - ERS/CRW 3-OPERATING PRACTICE CONTROL ROOM OPERATIONS ON SHIFT 5 - OTHER (Specify)
SIMULATOR OPERATING (Includes Classroom)
FOSSIL SIMULATOR NAMES
- IRE, 6 -
OPERATOR b.7 SUPERVISOR CERTIFIED STARTUP 1n1
.1 NO 8 -
PLANT STAFF PO n OMLETy 9
r OTIIHII I
imiuiui (Specify)
NO.
OF REACTIVITY MANIPULATIONS____________
PLANTIMULAOR Iiwll~lillnuliIlIaIliriJil UCLEAR (Including Research/
II111111111111mwi 1i li it 11 Test Reactor) l-
!l ll 10 -
REACTOR OPERATOR (Licensed) 4-SRO INSTRUCTION 11 - SENIOR OPERATOR (Licensed) 5-EXTRA PERSON ON SHIFT IN CONTROL 12 - SHIFT SUPERVISOR (Licensed)
ROOM (13-WEEK MINIMUM)
TIME ON SHIFT ABOVE 20% POWER 13 -
STAFF/SHIFT ENGINEER (Licensed)
(6-WEEK MINIMUM) 14 - AUX./EQUIP.
OPER.
(Nonlicensed)
QUALIFICATION 15 - PLANT STAFF 7-OTHER (Specify) 16 - OTHER (Specify)
NRC FORM 398 (10-90)
- 14. FACILITY OPERATIR TERAINING PROGRAM a, GRADUATE OF INPO ACCREDITED OPERATOR
- b. CERTIFIED ON NRC FORM 474 ("SIMULATION TRAINING PROGRAM THAT IS BASED UPON X
YES NO FACILITY CERTIFICATION")OR NRC APPROVED NO A SYSTEMS APPROACH TO TRAINING SIMULATION FACILITY IS USED IN THE OPERATOR TRAINING PROGRAM (AMW
- 15.
FOR RENEWALS 01LY
- b. DATE AND RESULT OF MOST DATE RSL OURS OPERATED FACILITY RECENT NRC ADMINISTERED DATE REQUALIFICATION EXAMINATION PASS FAIL
- 16. EXFERIENCE DETAIIS
- a. POSITION TITLE FROM TO
- b. FACILITY
- c. DUTIES
- 17. (XHDEBTS (Specify the item number to which you are elaborating. Attach additional sheets as necessary.)
- 18. NRC FORM 396, CERTIFICATION OF MEDICAL EXAMIATIOH BY FACILITY LICESE, IS ATIACHED ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
19a. I certify under penalty of perjury that the information in this document and attachments is true and correct. I further certify that I have -notifie my current 1loer of: (1) all previous employers; (2) an? instance where I have been tested by a Health and Human Services (HES) Certi ie Drug Testing Laboratory or a Licensee's esting facility for alcohol or a controlled substance, and the test results exceeded the cutoff levels established pursuant to 10 CFR Part 26 (3) any instance where I have been arrested for the sale, use or possession of a controlled substance described in i6 CFR Part 26; and (4) any reasons for removal or revocation of unescorted access at a nuclear facility, I also authorize the NRC to submit the results of examin tions to my employers for use in preparing retraining programs, as necessary.
SIGNATURE - APPLICANT DATE CHECK APPLICABLE BOX X
- b. I certi that the above named individual has successfully completed the facility licensees re qirements to be licensed as an eprator/Senior Operator pursuant to Title 10, Code of ederal Regulations, Part 55* and that the individual has a need or an perator/Senior 0 erator license to perform his/her assigned duties and that the facility will be made available for examination.
I also certify under penalty of perjury that the information in this document and attachments is true and correct.
- c. RENEWAL ONLY - I certify that the above named individual meets the aqroved regualification program (with exceptions note i Item 1 ired b section 50.54 (i-l 10 CFR 0. ad thatahp/s a has dischar ed his/her licensed res onsbildite comptently and safely. rue o certify under penalty of perjury the the information ?n Ui documentmand attachments is true and correct..
TRAINING CORDERATOR SEIOR HARAGEET REFEESNTATIV 0N SITE PRINTED OR TYPED NAME PRINTED OR TYPED NAME Robert Clement N
H. E. MORGAN SIGNATURE DATE OZ SIGNATURE NO SIGNATURE REUIRED jDATE FOR NRC USE WAIVER (Check or complete items, as applicable)
MEETS REQUIREMENTS DOES NOT MEET REQUIREMENTS(Explain below)
GRANTED BY DENIED BY EGORY HEADQUARTERS REGION EEADQUARTERS REGION TEN TING ELIGIBILITY MEDICAL SIGNATURE -
REVIEWER DATE OTEER NRC FORM 398 (10-90)-
NC sc r. 356 US. NUCLEAR REGULATCRY CCYM:SSCN Am%: rv Ow
-0 4
CERTIFICATION OF MEDICAL EXAMINATION Ex O
a BY FACILITY LICENSEE N
Rg AND TO THE PAPE.wOW Pa JE-
"-y OFICE OF MaA60EuMET AND BUGET C
NA.*E OF APPLICAT K.WN
-khticG WOOP FACILITY FACILITY DOCKET NUMBER SONGrS kNIT I50o0 A. MEDICAL EXAMINATION CERTIFICATION THIS IS TO CERTIFY ThAT THE ABOVE NAMED APPLICANT FOR AN OPERATOR.'SENIOR OPERATOR LICENSE HAS BEEN EXAMINED BY A PHYSICIAN.
PRINTED NAME 0fophysican)
STATE AND LICENSE NUMBER EXAMINTION TE CECIL ROLBIN M.D.
///IE A
NSEON T
BASED ON THE RESULTS OF THE EXAMINATION. INCLUDING INFORMATION FURNISHED BY THE APPLICANT, THE PHYSICIAN HAS DETEMIN TH APPLICANT'S PHYSICAL CONDITION AND GENERAL HEALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPERATIONAL ERRORS ENDANGERING PUBLIC HEALTH AND SAFETY. I CERTIFY THAT IN REACHING THIS DETERMINATION. THE GUIDANCE CONTAINED IN ANSI/ANS 3.4-1983,OR ANSI/ANS 15.4.1977 IN38)
WAS FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY NRC.
ON THE BASSOF THE RECOMMENDATION OF THE PHYSICIAN. I RECOMMEND THAT THE APPLICANT'S OPERATOR LICENSE BE CONDITIONED AS FO LoLO
- 1. NO RESTRICTIONS
- 2. CORRECTIVE LENSES BE WORN WHEN PERFORMING LICENSED DUTIES
- 3. HEARING AID BE WORN WHEN PERFORMING LICENSED DUTIES
- 4. RESTRICTED LICENSE OR EXCEPTION-Provide details below and sach supporting medical evidence for NRC review.
- 5. RESTRICTION CHANGE FROM PREVIOUS SUBMITTAL-Provide details below and attach supporting medical evidence for NRC review.
PROPOSED WORDING OF RESTRICTION (Block 4 above)
ELATIONSHIP OF RESTRICTION TO DISQUALIFYING CONDITION B1rieflr indicate howrer iction willcorrec the disqualifyingtondition)
REMARKS FOR RESTRICTION CHANGE (Block Saboe)
B. NONMEDICAL CERTIFICATION THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DUTY REOUIREMENTS OF THIS FACILITY FCR LICENSED OPERATORS.
AN FALSE STATEMENT OR OMISSION IN THIS DOCUMENT. INCLUDINE ATTACHMENTS. MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS. I CERTIFY UNDER PENALTY OF PERJURY THAT THE INFOAMATION IN THIS DOCUJMENT AND ATTACHMENTS IS TRUE AND COARECT.
PRINTED NAME AND SIGNATURE (Senior Maapement, Rperetriaon Sitre)
TITLE DATE No Signature Required, Non-Certified H. E. Morgan Application Vice President &. Site Manager.
in accordance with 10 CFR 55.5. Communical ions, this form shall be submitted to the NRC as follows: BY MAIL ADDRESSED TO Regional Adminrirator, Region I Regional Administrator, Region 1R U.S. Nuclear Regulatory Commission U.S. Nuclear Regulatory Commijon RegioNual Admiiaor. RemsionII U.S.
Nuclrar Regulatory Commission 475 Allendale Road
-101
)Aeriena Street. Suite 3100 799 Roosevelt Road King of Prussia, PA 19406 Atlanta, GA 30323 Glee Ellyn. IL 0137 Regional Adminitrator, Region IV Regional Admin;tritor, Region V Direcor. Division of Licensee Pirformance U.S. Nuclear Reulatory Commission U.S. Nuclear Regulatory Commiuon and Quality Evaluation 611 Ryan Plaza Drive. Suite 1000 1450 Maria Lane. Suite 210 RegAonalOpdranortritonsiRegBonnII Arligton. TX 76011 Walnijt C',
CA 94596 U.S. Nuclear Regulatory Cornmmsmion Washingtone C 20555 Pursant o
5PRIVACY ACT STATEMENT Psatto5U.S.C. 552a~a113)1 ena~cted ioa 'a-. by saction 3 of Iris Pri-sicy Act of ROUTINE USES: The inforrmation may be discosed so an apomrcoe Fedeal, State. or su~ply inforenation toshe U.S. Nuclear PegulalorY Commission on NRC Form 36.
and e
t the e the inforCmation indicatmro a voI&Isio or ponenl,oietion of law and in This information is maimained in a tyrantm of records desigrlaterd as NRC.16 and, the cor"a oI'v diieatv
'JdcIprceig nad~in silora~nmyb 5UT.r 01 y..,aI tranifed so an PProprite Fedral. State. and loaal agey to the 210nt relevant enc AUTHORITY: Sections 107 end 61G)l of he Atomic Energy Act of 19!A. as recesRary fAd mn NtC decision about YOU.
amended (42 U.S.C. 2137 end 27011i0).
INDIVID LOTPROIDING NORMA cOleNa Nuy C
onT I
PRINCIPAL PURPOSISI: Infors arn~d on this form it se WHEHE di IDV DICLOF UR SO MAOIDNDAINORMORIONT R
- ANDioj, EoFCTa* ONth whether the ph~ys;Ul cssnd 1ti on a'.d gerca: heairth of the apicant are sucn teatm they vreorreitd. information is not pr*ide*d, owvrthe applrcetior for a *ectl.Iy Operator's will nor it sC e;e oral arron rsnda.Iqr Public healtllend uafety. ThDs informa.
or senior operator'D IDvie'se may be dcnPed.
tion may te wild by ther NRC ngtf so Orrm -v i the i dividual mr~ves the reau~re SYSTEM MANAGER S) AND ADDRESS:
ChefA Opera tor Licensn g
8'arc h. Offce oB r'.ens of 10 CF R SE 0 tak, an e mvw nor Io be s ed n opraol rs Nulee CA 9ar 459or RegulaiSo U.ea N wClear pgu tory Co rymn on. wshrg l DC Co m5m NRC Whigo DC055
NRC FOM 398 (FACSIMrLE)
U.S. NUCLEAR REGULATORY COMISSION APPROVED BY B: NO. 3150-0090 (10-90)
EXPIRES: 1-31-92 t (To be completed by NRC) 10 CFR 55.31 55.35, ESTIMATED BURDEN PER RESPONSE TO COMPLY 55.47, and 5.57 WITH THIS INFORMATION COLLECTION REQUEST: 2.0 ERS.
FORWARD COMENTS REGARDING BURDEN ESTIMATE TO THE INFOR MATION AND RECORDS MANAGEMENT BRANCH FERSCRAL QUALIFICATION STATIMENT - LICENSEE (MNB 7714) U.S.NUCLEAR REGULATORY COM SSION WASHINGTON DC 20555 AND TO THE PAPMWORK REDUCtION PROJECT (3150 0090) OFFICE OF MANAGEMENT AND BUDGET TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED WASHINGTON, DC, 20503
- 1. APPLICANTS FULL NAME (Last, First, Middle) AND ADDRESS A.TYPE OF APPICATION (Check applicable boxes)X HOT COLD (include ZIP Code)
X
- a. NEW
- f. WAIVER REQUESTED
- BARRIE, DOUGLAS CRAIG
- b. RENEWAL 595 Lemonwood Ct.
- c. UPGRADE Oceanside, CA 92054
- d. MULTI-UNIT (AMEND TO INCLUDE ADDITIONAL UNIT)
- a. REPPLICTION3-ELIGIBILITY
- e. RAPPLCATIN MEDICAL 1-FIRST OTE
- 2. CITIZENSHIP
- 3.
BIRTH DATE 2-SECOND Z
X
- a. UNITED STATES MONTE DAY YEAR 3-THIRD U&DAEAS ENA-IY NION SCTIO
- b. OTHER (Specify) 0 7
1 0
5 8
(IF APPL 02 91
- 5. TYPE OF LIMME APPLED FOR
- 6. EV OPS LICENSE(S) HELD a OPERATOR
- c. EXPIRATION DATE
- b. SENIOR OPERATOR MODNT.
DAY YEAR cd.
LIMITED SRM 55U 50 (e.g., Fuel Handler) 7.NAME AND ADDRESS (Include ZIP Code) OF APPLICANT'S EPLOYER
- 10. CURRENT POITION AT FACILITY Sa. PLANTSUPERINTENDENT LJi.
AUXILIARY UNIT OPERATOR/
P. 0. Box 128
- b. ASSISTANT PLANT SUPERINTENDENT INGqU PMENT OPERATOR San Clemente, CA 92674-0128
- c. SHIFT SUPERVISOR (NO ICENSFD OPERATOR)
- d. STAFF ENGINEERr1 OTE (Sefy
- 8. NAME OF APPLICANT'S FACILITY I FACILITY DOCKET NUMBER
- e. SHIFT: TECHNICAL ADVISOR/
E San Onofre Unit 1 I
50-206 SHIFT ENGINEER f.FINSTRUCTOR
- 9. ADDITICEAL FACfJTY DOK= (Multi-unit Licenses)
- g. SENIOR CONTROL ROOM4 OPERATOR h2 T
CONTROL ROI e
OPERATOR 411.
EDMEATIDI STUDY OF YEARS DEGREE To be used for TECHNICAL OF RECEIVED FNMTHIGHEST DEGREE" MYNTHS 7 EIGH~~~~~~~ ~~~~~
~
~
~~
NME IHS ERECDSd OA INA TION UME SECTIONATE X GAUATE ENGINEERING (FIELDS)
(Use Codes) obtained)
TYPE OF TRAINING YS N
GED EQUIVALENCY 0 -NONE Nuclear Power School 6
X NO OHER O1P CERTIFICATE cT 2 -ASSOCIATE Nuclear Prototype Liberal Arts 1
0 3 -BACHELOR.
- b. NUMBER OF PO R-MASTER YEARS OF 5 DOCTORAL COLLEGE 1
- 12. TRAINING (SINCE LAST APPLICATION
- SEEINSTRUCTIONS)
- 13. MaLE E (DO NOT DOUBLE COUNT - SEE INSTRUCTIONS)
- a. ASNTH AND YEAR b NUMBER a.1NNTH ANDYEAR b. NUMBER SWEEKSOFEN S
1-NUCLEAR POWER PLANT FUNDAMENTALS
-ROM
- a. PLANY S E
N N
i A
O B O R/H (Classroom) 1RO 2-PLANT SYSTEMS 2 - EO.
PP LN CASSROOM4 OBSERATION3 EWS/PPNS 9267ER0128Oc._SIFTSUPERVISO 4 - ERS/CRW 3-OPERATING PRACTICE CONTROL ROO OPERATIONS ON SHIFT 5 - OTHER (Specify)
SIMULATOR ITERATIRNG (Includes CasAroom)
STO SIMULATOR NAMES R
OPERATOR Unit 1
-1 SUPERVISOR flhtWIilh~t~i~luflhflh~iflOU~lhIw8 -a PL.ANT STAFF CERTIFIED STARTUP X Y E
A(S) O F NUBER IGEET D
ODESpecify)
NOU. OF REACTIVITY MA YP OY S
Gob s
- f.
E IO R
V GEDEQUIVALENCO AL NUCLEAR (Including Reearch/
PLANT SIMUL.ATOR fhIIIllIIIifilhflIlhIIIwIIwIiIIIf Test Reactor.).
Liea1rt CSEO R OPRAO Nuicear rootpe6)
OTHER (Secify) 16 -
OTHER (Specify)
NRC FORM 398 (10-90)
- 14. FACILITY OPERATOR TRAINING PDGR&AM
- a. GRADUATE OF INPO ACCREDITED OPERATOR
- b. CERTIFIED ON NRC FORM 474 ("SIMULATION TRAINING PROGRAM THAT IS BASED UPON X
YES NO FACILITY CERTIFICATION")
OR NRC APPROVED X
YES A SYSTEMS APPROACH TO TRAINING SIMULATION FACILITY IS USED IN THE
- 15.
FOR RENEWALS ONLY
- b. DATE AND RESULT OF MOST DATE RESULT HOURS OPERATED FACILITY RECENT NRC ADMINISTERED REQUALIFICATION EXAMINATION PASS FAIL 16. EXPERIENCE DETAIIS
- a. POSITION TITLE FROM TO
- b. FACILITY
- c. DUTIES
- 17. COMETS (Specify the item number to which you are elaborating. Attach additional sheets as necessary.)
- 18.
MC FOR4 396, CERTIFICATIC OF MEDICAL EXAMIRATION BY FACILITY LICENSEE, IS ATACHED ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACEMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
19a. I certify under penalty of perjury that the information in this document and attachments is true and correct.
I further certfy hatI hve otifes y crret elorer of: (1 all previous employers; (2) any instance where I have been tested by a Health and Human Services (BS) Certi isd Drug Test ing Lhboratory or a Licen se's testing facilityfrachloa controlled substance, and the test results exceeded the cutoff levels established pursuant to 10 CFR Part 26 (1 n instance where I have been arrested for the sale, use or possession of a controlle substance described in 16 Panyt 26; and (4)uany reasons for removal or revocation of unescortd access at a nuclear facility, I also authorize the NRC to submit the result of examinations to my employers for use in preparing retraining programs, as necessary.
SIGNATURE -
APPLICANT JDATE CHECK APPLICABLE BcM X
- b. I certify that the above named individual has successfully completed the facility licensees -requirements to be licensed a an Operator/Senior Operator pursuant to Title 10, Code of Federal Regulations, Part 55i and that the ind vidual ha aneed or fan Operator/Senior Operator license to perform his/her assigned duties and that the fIliywl be made available for examination.
I also certify under penalty of perjury that the information in this documeint and attachments is true and correct.
- c.
RENEWAL ONLY - I certify that the above named individual meets the a roved re alification program (with exceptions noted in Item 17 as required by section 50.54 i-1 10 CFR 0, and that hhs has discha d his/her licensediresponsibildie mcompetenty adnsafel e alsoccertify under penalty of perjury thaethe information in this document and attachments is true and corect.
TRAING 000DRATOIR SEICR MARAGEMENT REPRESENTATIVE 0N SITE PRINTED OR TYPED NAME Robert Clement P.
E. MORGAN SIGNATURE IDATE SIGNATURE NO SIGNATURE REOUIRED DATE NON-CERTIFIED APPLICATION FR NERC USE WAIVER (Check or complete items, as applicable)
MEETS REQUIREMENTS DOES NOT MEET REQUIREMENTS(Explain below)
CATEGORY GRANTED BY DENIED BY HEADQUARTERS REGION HEADQUARTERS REGION ITTEN TING ELIGIBILITY MEDICAL SIGNATURE -
REVIEWER DATE OTBER NRC FORM 398 (10-90)
CUS. NLE..
F1GULACRY CC,'Yi5S:,
r, :
CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE
!3 7S--!
54 Barrie, Douglas ACILiY F ACILITY DET SER San.Onofre Nuclear Generating'Station, Unit 1 50-206 A. MEDICAL E'AM.INATION CERTIFICATICN 5 -
- S Z7 TF Y 7>AT 7E -.SO\\ E L~E LI ^,:,T F N1:.C-
_C SEAS z
E Xw s y P %
NAM E
'!;j:f S7ATE-AND LICENSE NLI,1-ER EXN A 7 1 Ci D A7 E Michael. Santiago, MD CA G60318 Nov. -25, 1991 EASD ON THE RESULTSOF THE EXAMINATION. INCLUDING INFORVATION FURNISHED BY TNE APPLICANT, T E PHYSIC AN HAS DETERMINEDTHAT APPLICANTS PHYSICAL CONDITION AND GENERAL HEALTH ARE NOT SUCH THAT IT VIGHT CAUSE OPERATIONAL ERRCPS EN ANGERINa PULLIC HEALTH AND SAFETY, I CERTIFY THAT IN REACHING THIS DETERMINATION. THE GUIDANCE CONTAINED IN ANSI/ANS 3.4-153. OR ANSI!ANS 15.4.1S;7 mN i WASI FOLLOWED ANDTHAT DOCUMENTATION IS AVAILABLE FOR REvIEW BY NRC.
ON THE BASIS OF THE RECOMMENDATION CF THE PHYSICIAN. I RECOMMEND THAT THE APPLICANT'S OPERATOR LICENSE BE CONDITIONED AS FOLLOWS:
- 1. NO RESTRICTIONS X 2. CORRECTIVE LENSES BE WORN WHEN PERFORMING LICENSED DUTIES
- 3. HEARING AID BE WORN WHEN PERFORMING LICENSED DUTIES
- 4. RESTRICTED LICENSE OR EXCEFTICN-Pr cviee de 'a;Is below a-4r-jch sup oring medicAt er eters for NRC revew.
- 5. RESTRICTION CHANGE FROM PREVIOUS SUEMITTAL-Pte v,: 'eails beIlow ad Is:h &.-wo:
rIedicaI v;ev:i-t for NRC rvew.
FROPOSED WORDING CF RESTRICTION (4:o)k Ia!- r/
CORRECTIVE LENSES BE WORN WHEN PERFORMING LIC E
S.
RELATIONSHIP OF RESTRICTION TO DISOLALIFYING CONDITION,1riefly irica:s howrcticion wit codrt theconciin REMARKS FOR RESTRICTION CHANGE (Blo:k Sabo-vJ B. NONMEDICAL CERTIFICATION RH!S CERTIFIES THAT THE APPLICANT HAS iEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DUTY REQUIREMENTSOF THIS FACILITY FCR LICENSED OPERATORS.
ANY FAL!E STA7EMEN' OR CVISSION INTNIS 6VENT. NCLUDING ATACm6N-S MAY TU EAuJECT TO CIvIL AND CRIMINAL SANC710it t CERTIFY UNOER FNALTY OF PERJ'.RY I. AT T wE INFCAV47ION IN TwIS DDC~,aENT AND XTVTACN ENT S IS T RUE AND CORRECT.
PRINTED NAME AND SIGNATURE tera4ageen e
on £r)
TITLE DATE No Signature Required, Non-Certified H. E. Morgan Application Vice President & Site Manager In 9C0odance with 10 CFR 55.5. Comrmumria*;s.
this fouri shall be sbni-s o the NRC as follow,: BY MAIL ADDRESSED TO:
- ioad r
r Rer-on I 4I A~nasor*
Rjon II R;or.&1 Mrm aisaio' P.-on III U.S. NuCIdar Ri1uWalory Commiss*ion U.S. NucIar r2witiory Commuion U.S. Nijc1f R#?J!110rV COMia1on 475 Allenede: Rcs
.01 e'arlma Street. Suite 3103 725 ROC14,1It Road Kim; of Prssi.a, PA I9406 Ailari'a* GA 3 3 Glen EIlymIL 60137 Re;goal Al mior, R-on IV S-~o jI Adm~rreior. Regon V D's'vtor. 064;om of License* P'rforrtance
. U.S. Nuclear RoopitIstry Corn,$oQn U.S. oneltat PsoIaiory Corriti~on ltd Owaity EwaI~aion 611 Ryan P!nia Drie, Suite IC0*
145.0 V41 LaOt, STj't 210
.A-n:
OOTlor L
,insihi ArI--non TX 7,11 WaslmjA C'*
CA ;5P6 U.S.U NS Ntar Rrp.paoorry CCmonmoon Wat'ts DC 2A0s3 PRIVACY ACT STA.T EMENT pua",arr 10 5 U.S.C.
' aSi 1)3).frc 4
- e t 'I by secion 3 of the Pi;.c ACT of ROUTINE USES: T1# ;rormr;om rn b d : %d w io am spry i Fo~ei.
S~a,. or 1574 (Pvbtlc Lif 53,57p). 1ho loI:ow;,1 r'.
tn%-'~
- j lurm~shld 10 w.dII ho local "4cy in 11 4 P.,1 the ;mfor,jiicrn itd;,x-a volui;cm or
- sroM.:I v~o tio r 1 -o D y tI r '.aIorfr n 1 0 lI I U
S.
N v c f t P vo ' y C o m r o o r % n N AC F o rm 2 4.
, - ~
t " IM~
0 4 o r m u io ; n Tih.s ;rmlo-.at:on ~ ;I rarr a lir,n 0f '#cre rs ri. rd At I.PC-8 nd.
%No cr.,.ao of &m a.r-artaxi,,
of j~e6caI ino Jh;. Ir orf A~cr6C r-jy Itt Glen. Elyr IL y4 U
N.
R t r C omoFito an ar lyo:Ay a; iny to 0-o *itmj *,l a.C AUTHCRiTY:
Stnc-.&i 107 t i it
- (,) 0l :
Aior mc E nt1y A s L
- Su ta r10- r Y Ann a0 N aC tor U c Byoj.
PrINCPA' PURI YIWHETHER DISCLOSURE IS MANOATCRY CR VOLUNTA / AND EFFECT CN R:INCIFAL PU 3S; EIS): Ir'. r'st:-
- ~e 0 \\s form a
e to remir.e INDIVIDUAL CF.NOT PROVIDING 0FCR.ATiON.
0 i:ic.'
- t -
voi *A.Y. If :r.
l e l u-.11 z,
- r t ;c' e r ;.'>? :c hralhh asd %a'ry. T'.ir.Iot rJ.
or
'o, etrro'a t:.aa rray be eln:.d.
r
'.c 10 Ve by CF.R NRC rail ic ce *&- e f I's i..d, -r..1 1r. ue-SYSTEMI4 VA.N tR:SI AND AD F ES:
of. O;*.*or L**.-*
B-n
. C cl.a
'sr'~a cI 10 CF R Le-c o to rc11 a& o ICcea.
N Fe'.r R.noer P.
.1;rs U.S. Nc'ar P6.8ary Com'r a
'kn... 'cr
. DC Zlt5 FC C
?I 041
RC FORM.398 (FACSIELE)
U.S.
NUCLEAR REGULATORY COMISSION AFFROVED BY OMB: NO.
3150-0090 DATE RECEIVED 10-90)
EXPIRES: 1-31-92 (To be completed by NRC)
.CR755 3155.35, ESTIMATED BURDEN PER RESPONSE.TO COMPLY 5.47, an 5t.WITH THIS INFORMATION COLLECTION REQUEST: 2.0 ERS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE INFOR MAT ION AND RECORDS MANAGEMENT BRANCH PERSONAL QUALIFICATION STATEMENT - LICESEE MNBB 7714 U.S.NUCLEAR REGULATORY COM MISSION WASHINGTON DC 20555 AND TO THE PAPRWORK REDUCtION PROJEfT (3150 00901 OFFICE OF MANAGEMDNT AND BUDGET, TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED WASH NGTON, DO, 20503
- 1. APLICANT'S FULL NAME (Last, First, Middle) AND ADDRESS 4.TYPE OF APPLICATION (Check applicable boxes) X HOT COLD X
- a. NEW
- f. WAIVER REQUESTED (Justi-f on Reverse COTTON, BREWSTER:WILLIAM
- b. RENEWAL WRITTN (Category 41905 Shorewood Court
- c.
UPGRADE Temecula, CA 92390
- d. MULTI-UNIT (AMIND TO 2-OPERATING (Category)
INCLUDE ADDITIONAL UNIT)
- e. REAPPLICATION ELIGIBILITY
-- FRT4-MEDICAL 1-FIRST
- 2. CITIZERSHIP
- 3. BIRTH DATE 2-SECOND 5-OTHER X
- a. UNITED STATES MONTB DAY -
YEAR 3-THIRD
- 5.DNEAENSEDSGENERIC MONE T DA YER
-THRDFUNDAMENTALS EXAM-
~l Y
INATION SECTION
- b. OTHER (Specify) 1 2
1 1
5 0
(IF APPLICABLE) 06 91
- 5.
TYPE OF LICENSE APPLIED FOR
- 6. PREVIOUS LICENSE(S) HELD X
- a. OPERATOR c XIAINDT
- b. OPEROPERATOR
- a. DOCKET NUMBER RO SRO b. LICENSE NUMBER EXPIRATION DE d.FACILITY DOCKET NUMBER b.SNOROEATRMNTH DAY
- dYFAIITAOCERN1E
- c. LIMITED SRO 55-50 (e.g., Fuel Handler) 7.RAME AND ADDRESS (Include ZIP Code) OF APPLICARTS EMPLOYER
- 10.
CURRENT POSITION AT FACILITY South ern California Edison-
- a. PLANT SUPERINTENDENT X. i. AUXILIARY UNIT OPERATOR/
SouternCaliorna EdsonTRAINEE/TURBINE BUILD P. 0. Box 128
- b. ASSISTANT PLANT SUPERINTENDENT ING U PMRNT OPERATOR San Clemente, CA (NO ICENSED OPERATOR) 92674-0128
- c. SHIFT SUPERVISOR
- d. STAFF ENGINEER OHR, Seiy
- 8.
NAME OF APPLICANT'S FACILITY FACILITY DOCKET NUMBER
- e. SHIFT EGNEERL OT (Specify)
San Onofre Unit 1 50-206 SHIFT ENGINEER INSTRUCTOR
- 9. ADDITIONAL FACILITY DOCKETS (Multi-unit Licenses)
- g. SENIOR CONTROL ROOM OPERATOR
- h. CONTROL ROOM OPERATOR
- 11.
EDUCATION HIGH SCHOOL
- c. MAJOR AREA(S)
OF NUMBER HIGHEST DEGREE CODES
- d. VOCATIONAL /
NUMBER CERTIFICATE STUDY OF YEARS DEGREE To be used for, TECHNICAL OF RECEIVED GRADUATE ENGINEERING (FIELDS)
(Use Codes) oGEd)DEGREE TYPE OF TRAINING YES NO X
GED EQUIVALENCY 0-NONE
-1 CERTIFICATE NO OTHER 2
ASSOCIATE Music 2
2 3-BACHELOR
- b. NUMBER OF s
4-MASTER YEARSOF 5 -DOCTORAL COLLEGE.3 General 10
- 12. TRAIING (SINCE LAST APPLICATION - SEE INSTRUCTIONS)
- 13. EERI E (DO NOT DOUBLE COUNT -
SEE INSTRUCTIONS)
- a. HONTH AND YEAR bF NEER a.MONTH AND YEAR b NUMBER FO T O F WEES FRO TO MNTHS 1-NUCLEAR POWER PLANT FUNDAMENTALS FROM TO RAVY (Classroom) 1 -
RO 2-PLANT SYSTEMS 2 - EOOW/PPWO CLASSROOMI OBSERVATION 3 -
/PWS 3-OPERATING PRACTICE 4
ERS/CRH CONTROL ROOM OPERATIONS ON SHIFT 5 -
OTHER (Specify)
SIMULATOR OPERATING (Includes Classroom)
FOSSIL SIMULATOR NAMES 6 -
OPERATOR
- a.
Unit 1
- b.
Y
- SUPERVISOR CERTIFIED STARTUP PXNYEST NO P
PROGRAM COMPLETED 9-OER (Specify)
NO.
OF REACTIVITY MANIPULATIONS PLAT IMLAOR~lliIi~wiillfflt1iII~u(I~fIII~mi~uII~CMRIAL NUCLEAR ( Including Resae arch/
PLANT SIMULATORTest Reactor 10SR IN-REACTOR OPERATOR (Licesd SRO INSTRUCTION 11 - SENIOR OPERATOR (Licensed) 5-EXTRA PERSON ON SHIFT IN CONTROL 12 - SHIFT SUPERVISOR (Licensed)
ROOM.
(13-WEEK MINIMUM)
- a.
IM ONSHFTABOE 0%13 STAFF/SHIFT ENGINEER (Licensed)
(6-WEEK MINIMUM)____
14-AUX./EQUIP. OPER. (Nonlicensed),
QUALIFICATION 15 -PLANT STAFF THER (Specify) 16 11OTHER (Specify)
NRC FORM 398 (10-90)
- 14. FACILITY OPERATOR TRAING PROGRAM
- a. GRADUATE OF INPO ACCREDITED OPERATOR
- b. CERTIFIED ON NRC FORM 474 ("SIMULATION TRAINING PROGRAM TEAT IS BASED UPON X
YES NO FACILITY CERTIFICATION") OR NRC APPROVED X
YES NO A SYSTEMS APPROACH TO TRAINING SIMULATION FACILITY IS USED IN THE OPERATOR TRAINING PROGRAM
- 15. FOR RENEHALS ONLY OURS OPERATED FACILITY
- b. DATE AND RESULT OF MST DATE RESULT OURSOPERTEDFACIITYRECENT NRC ADMINISTERED REQUALIFICATION EXAMINATION PASS FAIL
- 16. EXPERIENC DETAILS
- a. POSITION TITLE FROM TO
- b. FACILITY
- c. DUTIES
- 17. COMMENTS (Specify the item number-to which you are elaborating. Attach additional sheets as necessary.)
- 18. HRC FORM 396, CERTIFICATION OF HEDICAL EXAMIRATION BY FACILITY LICENSEE, IS ATTACEED ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
19a.
I certify under penalty of gerjury that the information in this document.and attachments is true and correct.
I further certify that I have notified my current employer of: (1) all previous employers; (2) any instance where I have been tested by a Health and Human Services (BBS) Certilied Drug Teaing Laboratory or a Licensee's testing facility for alcohol or a controlled substance, and the test results exceeded the cutoff levels established prsuant to 10 CFR Part 26 (3) any instance where I have been arrested for the sale, use or possession of a controlleg substance described in li Part 26 and (4) any reasons for removal or revocation of unescorted access at a nuclear facility, I also authorize the NRC to subit the results of examinations to my employers for use in preparing retraining programs, as necessary.
SIGNATURE - APPLICANT DATE CHE[ APPLICABLE 0C%
X
- b. I certify that the above named individual has successfully completed the facility licensees requirements to be li ensed as an Operator/Senior Oerator pursuant to Title 10, Code of Federal Regulations, Part 55* and that the individual has a need or an Oerator/Senior Operator license to perform his/her assigned duties and that the facility will be made available for examination.
I also certify under penalty of perjury that the information in this document and attachments is true and correct.
- c.
RENEWAL ONLY - I certify that the above named individual meets the a roved requalification program (with exceptions noted in Item 17) as required by section 50.54 (i-1) o 10 CFR 50, and that he/s a has discharged his/her licensed res onsibilities competently and safely. I-also certify under penalty of perjury that the information In this document and attachments is true and correct.
TRAINING CORDIRR SENIOR HARAGEMENT REPRESENTATIVE C SITE PRINTED OR TYPED NAME R
PRINTED OR TYPED NAME Robert Clement H. E. MORGAN SIGNATURE
.DATE SIGNATURE NO SIGNATURE REQUIRED DATE KxSt.47
,.t 3-
~-2
.NON-CERTIFIED APPLICATION FOR NRC USE WAIVER (Check or complete items, as applicable)
MEETS REQUIREMENTS DOES NOT MEET REQUIREMENTS(Explain below)
GRANTED BY DENIED BY TEGORY HEADQUARTERS REGION HEADQUARTERS REGION TEN TING ELIGIBILITY MEDICAL SGNATURE REVIEWER DATE OTHER NRC FORM 398 (10-90)
INRC e 396 US. NUCLEAR REGULATORY COMMISSICN APP'm LY Ova %O x ESTRATO BURDEN PER RESPONSE -0 CowcY w
W S
INRVA"ON COL.C--ON PEQUEST:
'su FORsq CERTIFICATION OF MEDICAL EXAMINATION COMAENTSRE"4040BucENESrMA Er 0
o BY FACILITY LICENSEE Aara sw... i U
AND TO THE PAPERSWO REDUCnew PWECT (3150.:4).
OFFICE OF MANAGEUENT AND BUDGET. vNA evGTON. DC 25C03.
NAME OF APPLICA T FACILITY FACILITY DOCKET NUMBER A. MEDICAL EXAMINATION CERTIFICATION TH;S IS TO CERTIFY THAT THE ABOVE NAMED APPLICANT FOR AN OPERATOR/SENIOR OPERATOR LICENSE HAS BEEN EXAMINED BY A PHYSICIA RI AME ophyvs
)
STATE AND ICENSE EXAMI TION E
BASED ON THE RESULTSOF THE E k NATION. INCLUDING INFORMATION FURNISHED BY THE APPLICANT. THE PHYSICIAN HAS DE RMI THAT THE APPLICANT'S PHYSICAL CONDITION AND GENERAL HEALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPERATIONAL ERRORS ENDANG RING PUBLIC HEALTH AND SAFETY. I CERTIFY THAT IN REACHING THIS DETERMINATION. THE GUIDANCE CONTAINED IN ANSI/ANS 3.4-1983. OR ANSI/ANS 15.4-1977 (N380) WAS FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY NRC.
ON THE B OF THE RECOMMENDATION OF THE PHYSICIAN. I RECOMMEND THAT THE APPLICANT'S OPERATOR LICENSE BE CONDITIONED AS FOLLOW:
-1.
NO RESTRICTIONS
- 2. CORRECTIVE LENSES BE WORN WHEN PERFORMING LICENSED DUTIES
- 3. HEARING AID BE WORN WHEN PERFORMING LICENSED DUTIES
- 4. RESTRICTED LICENSE OR EXCEPTION-Provide del I be and atach supporting medical evidence for NRC review.
- 5. RESTRICTION CHANGE FROM PREVIO SUB ide etails w and attach supporting medical evidence for NRC re tw.
PROPOSED WORDING OF RESTRIC ION IBlo
- 4.
E LATIONSHIP OF RESTRICT ION TO DISOUALI FY ING CONDITION (Briefly indicar how resricrion will correcr the disqualifying condition)
REMARKS FOR RESTRICTION CHANGE (Block Sabove)
B. NONMEDICAL CERTIFICATION THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DUTY REOUIREMENTSOF THIS FACILITY J
F:R LICENSED OPERATORS.
ANY FALSE STATEMENTOR OMISSION INTHIS DOCUMENT. INCLUDING ATTACHMENTS MAY CE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS. I CERTIFY UNDER PENALTY OF PERJUJRY THAT THE INFORMATION IN THIS DOCUMENT AND ATTACHMENTS IS TRUE ANDI CORRECT.
PRINTED NAME AND SIGNATURE (Senior Maraemenr Representatie on Sire]
TITLE DATE No Signature Required, Non-Certified H. E. Morgan Application Vice President & Site Manager In accordance with 10 CFR 55.5, Communications.this form shall be submitted to the NRC as follows: BY MAIL ADDRESSED TO:
Regional Administrator, Region I.
Regional Administrator, Region II Regional Administrator. Region III U.S. Nuclear Regulatory Commission U.S. Nuclear Regulatory Commission U.S. Nuclear Regulatory Commission 475 Allendale Road 101 Uariena Street. Suite 3100 799 Roosevelt Road King of Prussia. PA 19406 Atlanta. GA 30323 Glen Ellyn, IL 60137.
Regional Administrator. Region IV Regional Administrator. Region V Director, Division of-Licensee Performance U.S. Nuclear Regulatory Commission U.S. Nuclear Regulatory Commission and Quality Evaluation
.611 Ryan Plaza Drive, Suite 1000 1450 Maria Lane. Suite 210 Attn: Operator Licensing Branch Arlington. TX 76011 Walnut Creek, CA 94596 U.S. Nuclear Regulatory Commission Washington. DC 20555 PRIVACY ACT STATEMENT Pursuant to 5 U.S.C. 552afe1I3). enacted ;nmo law by section 3 of the Privacy Act of ROUTINE USES: The information may be diaclosed to an aporoD'ia Federal..Siate. or 1974 (Public Law 91579). the following statement rs 'urnished to irdiv duals who local agency in the event the information indicalet a violation or potental violation of l&*
supply information to the U.S. Nuclear Regulatory Commiusion on NRC Form 3H.
and in the even the information indicas a violation or Potental vioation of law and in This information, ia mainained in a system of records designated as NRC-16 and the cowr-e of an adminirtrativ* or judicial proceeding. In dditiyoe.
orcd information ma be dnc'.bee a -S Feoea Refrgr 33978 (A.,5,.X 20.I transferred to an approprie Federal9State. and local agency to the etent relevant and AUTHORITY: Sections 107 and 161(i) of the Atomic Energy Act of 1954, as n~cesry for an NRC decision about you.
amended (42 U.S.C. 2137 and 22011i)).
WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON PRINCIPAL PURPOSEIS): Information anemed on this form is used to determine INDIVIDUAL OF NOT PROVIDING INFORMATION. Daclosue a olvntafY. If the whether the physical conditiorard gene!st Kraith of the aplicant are such tihat they reque-5ted information is not prondod however. the appication for a 'acly Operators will not cause operational errors endangering p.D:it health and safety. This informa.
or senior oprtors license may be dened.
lion may be used by the NRC staff to delermine f the indiedual mers t-e 'equire-SYSTEM MANAGER(S) AND ADDRESS: Chef, Opq )&or B-ancr. Office o rrients 9f 10 CF R 55 to take an ex r.V.ion ot to te issued an operatoras ~casnre.
Nuclear Pscor Regulation U.S. Nuclear disu:ctory Comm aso i
raalrton..SDC aE5o
%RC FORM 396 "1a)
RC FOIH 398 (FACSIMILE)
U.S. NUCLEAR REGULATORY COMMISSION APPFROVE BY OMB: NO. 3150-0090 DATE REEIVED (10-90)
EXPIRES: 1-31-92 (To be completed by NRC) 10 CYR 55 31 55.35, ESTIMATED BURDEN PER RESPONSE TO COMPLY 55.47, and 5t.57 WITH THIS INFORMATION COLLECTION REQUEST: 2.0 ERS.
FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE INFOR MAT ION AND RECORDS MANAGMNT BRANCH PESONAL QUALIFICATION STATEMENT -
LICENSEE MBNAB RECS.
SMCLEAR REGULATORY COM MIS IO WHINGTON DC 20555 AND TO THE PA WDRA REDUCtION PROJEt E3150 0090 OFFIC OF MANAGEMENT AND BUDET, TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED WASHINGTONCEDC, 20503
- 1. APPLICANT'S FULL NAME (Last, First, Middle) AND ADDRESS 4.TYPE OF AFFLICATIQN (Check applicable boxes)COLD (include ZIP Code)
XET I CL X
- a.
NEW
- f. WAIVER REQUESTED FOLTZ, GEORGE ALLEN
- b. RENEWAL WRITTYNnCReess W kItIN(Category) 3545 Paseo De Francisco # 231
- c.
UPGRADE 2-OPERATING (Category)
Oceanside, CA 92056
- d. MULTI-UNIT (AMEND TO INCLUDE ADDITIONAL UNIT)
- e. REAPPLICATION 3-ELIGIBILITY
-FIRST4-MEDICAL 1-FIRST 4
- 2. CITIZENSHIP
- 3. BIRTH DATE 2-SECOND
--- 5-TEER X
- a. UNITED STATES MONTH DAY YEAR 3-THIRD FUNDAMENTALS EF YY
- b. OTHER (Specify) 1 0
1 5
6 4
(IF APPLICABLE) 02 91
- 5. TYPE OF LICESE APPLIED FOR
- 6.
PREVIOUS LICESE(S) HEUD
- X
- a. OPERATOR
- c. EXPIRATION DATE b.SEI OPERA TORa.
DOCKET NUMBER RO SO b. LICENSE NUMBER DAY DE d.FACILITY DOCKET NUMBER
- b. SENIOR OPERATOR MONTH DAY YEAR
- c.
LIMITED SRO 55-50 (e.g., Fuel Handler) 7.HAME AND ADDRESS (Include ZIP Code) OF APPLICANT'S EMPLOYER
- 10. CURRENT POSITIOR AT FACILITY
- a.
PLANT SUPERINTENDENT X i. AUXILIARY UNIT OPERATOR/
Southern California Edison
=
,. TRAINEE/TURBINE BUILD P.' 0. Box 128
- b. ASSISTANT PLANT SUPERINTENDENT INGqU IPMENT OPERATOR San Clement28 CA 92674-0128
- c. SHIFT SUPERVISORSUPERINTENDENTATNRE
- d. STAFF ENGINEER
- 8. NAME OF APPLICANT'S FACILITY FACILITY DOCKET NUMBER
- e. SHIFT TECHNICAL ADVISOR/
E
.. OTHER (Specify)
San Onofre Unit 1 T
50-206 SHIFT ENGINEER
- f.
INSTRUCTOR
- 9. ADDITICAL FACILITY DOCETS (Multi-unit Licenses)
- g. SENIOR CONTROL ROOM OPERATOR
- b. CONTROL ROOM OPERATOR mow
_11.
EDUCATIO IGB SCHOOL
- c. MAJOR AREA(S)
OF NUMBER HIGHEST DEGREE CODES
- d. VOCATIONAL /
NUMBER CERTIFICATE STUDY OF YEARS DEGREE (To be used for TECHNICAL OF RECEIVED HIGHEST DEGREE" TEHICLOF RCEVE X GRADUATE ENGINEERING (FIELDS)
(Use Codes) obtained)
TYPE OF TRAINING NTSYES NO GED EQUIVALENCY 0
NONE Nuclear Power School 6
X NO OTHER 1 -CERTIFICATE NcerPwrSho 2
ASSOCIATE Nuclear Prototype 6
X
_______________ ______3 BACHELOR
- b. NUMBER OF 4 -MASTER YEARS OF 5 -DOCTORAL COLLEGE 0
- 12. TRAINING (SINCE LAST APPLICATION - SEE INSTRUCTIONS)
- 13. EXPEICE (DO NOT DOUBLE COUNT -
SEE INSTRUCTIONS)
- a. MONTS AND YEAR b. NUMBER a.MONTH AND YEAR b. NUMBER FRM TO OFWES NAVY FROM4 TO 1-NUCLEAR POWER PLANT FUNDAMENTALS (Classroom) 1 - RO 2-PLANT SYSTEMS 2 - EOOW/FPWO OBSERVATION 3
EWS/PPWS 3-OPERATING PRACTICE 4 - ERS/CRW CONTROL ROOM OPERATIONS ON SHIFT 5 - OTHER (Specify)
SIMULATOR OPERATING (Includes Classroom)
FOSSIL SIMULATOR NAMES 6 - OPERATOR
- b.
w8 7 -
SUPERVISOR WIIDIUNUIIWI~fII~iEBIIWI!NII8
-PLANT STAFF CERTIFIED STARTUP X YES NO 18 U8 PLATR SAf PROGRAM COMPLETED DUM9
- OTER (Specify)
NO.
OF'REACTIVITY MANIPULATIONS 1110011 PLANTWIIWIIIWISIMULATORIJIIIUIIIWIIICIOMMERIAL NtCX:LM (Including Research/
PLANT SIUI.ATOR IInwIH~ilIlifInIIItI iliimiifi~ilJ w
liffillililliiniTest Reactor) 6:
10- REACTOR OPERATOR (Licensed) 4-SRO INSTRUCTION 11 -
SENIOR OPERATOR (Licensed) 5-EXTRA PERSON ON SHIFT IN CONTROL 12 -
SHIFT SUPERVISOR (Licensed)
ROOMd (13-WEEK MINIMUM)___
TIME ON SHIFT ABOVE 20%
13 -
STAFF/SHIFT ENGINEER (Licensed)
(6-WEEK MINIMUM) 14 - AUX./EQUIP. OPER. (Nonlicensed)
QUALIFICATION 15 -
PLANT STAFF 7-OTHER (Specify) 16 -
OTHER (Specify)
NRC FORM 398 (10-90)
- 14.
FACILITY OPERATOR TRAING POGRAM
- a. GRADUATE OF INPO ACCREDITED OPERATOR
- b. CERTIFIED ON NRC FORM 474 ("SIMULATION TRAINING PROGRAM TEAT IS BASED UPON X
YES NO FACILITY CERTIFICATION" OR NRC APPROVED X
YES NO A SYSTEMS APPROACH TO TRAINING SIMRATIONRACING ISRAMED IN TE OPERATOR TRAINING PROGRAM T
A o
- 15.
FOR REKER.LS (LY b.DATE ANDl RESULT OF MOST REDATT HOURS OPERATED FACILITY
- b. RECENT NRC ADMINISTERED D
RESULT
-REQUALIFICATION EXAMINATION PASS FAIL
- 16.
EXPERIENCE DETAILS
- a. POSITION TITLE PFRM TO
- b. FACILITY
- c. DUTIES
- 17. COMMENTS (Specify the item number to which you are elaborating. Attach additional sheets as necessary.)
- 18. KRC FCQM 396, CERTIFICATION OF MEDICAL EhIRATIC BY FACILITY LICSEE, IS ATIACHED ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
19a. I certify under penalty of perjury that the information in this document and attachments is true and correct.
I further certify that I have notified my current employer of: (1) all previous employers; (2) any instance where I have been tested by a Health and Human Services (HHS) Certified Drug Testin Lboratory or a Licensee's testing facility for alcohol or a controlled substance, and the test results exceede the cutoff levels established pursuant to 10 CFR Part 26 (3)any instance where I have been arrested for the sale, use or possession of a controlled substance described in 16 CR Part 26; and (4) any reasons for removal or revocation of unescorted access at a nuclear facility, I also authorize the NRC to subit the results of examinations to my employers for use in preparing retraining programs, as necessary.
SIGNATURE -
APPLICANT JDATE CEECK APPLICAfBLE BOX X
- b.
I certify that the above named individual has successfully completed the facility licensees requirements to be licensed as an Operator/Senior Operator pursuant to Title 10, Code of-Federal Regulations, Part 55 and that the individual has a need or en Oerator/Senior erator license to perform his/her assigned duties and that the facility will be made available for examination.
I also certify under penalty of perjury that the information in this document and attachments is true and correct.
- c.
RENEWAL ONLY - I certify that the above named individual meets the ap roved regalification proAram (with exceptions noted in Item 17) as required by section 50.54 (i-1) o 10 CFR 50, and that he/she has discharged his/her licensed responsibilities competently and safely.
I so certify wnder penalty of perjury that the information in this document and attachments is true and correct.
TRAINING C0RDIKATOR SERIOR HAAGEMEET RETSESENTATIVE 0N SITE PRINTED OR TYPED NAME PRINTED OR TYPED NAME Robert Clement H. E. M)RGAN SIGNATURE J
DATE SIGNATURE NO SIGNATURE REQUIRED DATE
, 4 3
\\9 NON-CERTIFIED APPLICATION FOR NC USE WAIVER (Check or complete items, as applicable)
MEETS REQUIRDMENTS DOES NOT MEET REQUIRININTS(Explain below)
GRANTED BY DENIED BY CATEGORY HEADQUARTERS REGION HEADQUARTERS REGION ITTEN ERATING IGIBILITY_
MEDICAL SIGNATURE -
REVIEWER DATE OTEER NRC FORM 398 (10-90)
U 0.S.
EGULA7CRY CCYY:!S IC%55 CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE Foltz, George A.
- AZILi~Y SONGS, Unit 1 FACILITY DOCK 50-206 A. MED ICAL EXAMINATION CERTIFICATION.
S. 5 CET:FY T7--O\\ B N P LICA'%T F.RC :
ATOR.5EiO~FRATCR LI ESE E E% V.'AE:
FY.p FSIC:.AN N
. MS-,.
AND LICENSE NLU.'ER ExAv;NATICN DATE V\\ <e - -
\\A o 11-12-91 E-SED ON THE RESULTS CF T-.E EXAMINATIO UDiNG INFORMATION FURN!SHED BY THE APPLICANT, THE PHYSICIAN HAS DETERMINED THAT THE APPLICANTS FnYSICAL =NDITION AND GENERAL HEALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPERATIONAL ERRCPS ENZANGE MiNED kLIHEALTH AND SAF ETYCRTF THTI ECIGTI EEMINATiON.
THE GUIDANCE CONTAINED INANSI/'AN5134-195,RA~/Ncs0P'LCHA FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY NRC..
ON THE BASIS OF THE RECOMMENDATION OF THE PHYSICIAN. I RECOMMEND THAT THE APPLICANT'S OPERATOR LICENSE BE CONDITIONED AS FOLLOWS:
- 1. NO RESTRICTIONS
- 2. COPRECTIVE LENSES BE WORN WHEN PERFORMING LICENSED DUTIES
- 3. HEARING AID BE WORN WHEN PERFORMING LICENSED DUTIES
- 4. RESTRICTED LICENSE OR EXCEFTION-Prcvyde details belcw a-4 rich svpporin; mital ede for NRC review.
- 5. RESTRIC7ION CIANGE FROM PREVIOUS SUEMIT7AL-Prcvde de sits below ard ata: sponir; mediCal rv;den I for NRC rr'ev PROPDSED WORDING OF RESTRICTION (Bicek ( abocr)
Corrective lenses be worn when performing licensed duties.
RELATIONSHIP OF RESTRICTION TO DISOUALIFYING CONDITIONtridl9y ireic:s how trr-lOn wil ic the isquai5fin; condiionj REMARKS FOR RESTRICTION CHANGE (Block 545o.v)
B. NONMEDICAL CERTIFICATION RHIS CERTIFIES TAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DUTY REQUIREMENTSOF TH S FACILITY FR LICENSED OPEFATO.
ANy FAL. E S7.&TEMET OR CuitSiON I TN!S DOCLVENT. INCLUDING A -ACmuN TS.MA~
5E SJECT 70 CIVIL AND CRIMINAL SANCTION I CERTIFY UNZER PENALTY OF PE;.;yv meA1 TWE IN;CPV&70,CN TewjS DOCUMENT AND Afl'AcHI.'NS IS -RUE AND CORRFECT.
PRINTED NAME AND SIGNATURE fSttn ar VM!-
e,*rntn RtprySrnr,j on S;vj TITLE DATE DAT No Signature Required, Non-Certified H. E. Morgan Application Vice President &
Site Manager i acordnce with 10 CFR 55.5.
CommunicJ;ons Ihil form shall beI s-it to the NRCa ~IIlws: BY AIL ADDRESSED TO:
R ao sion N j ar P Irlaor, Rnc on II Pm*-oral Adminimtrajor. Rniort III U.S. Nuclear Pllents ory C ommssion 0
r 51 or,; ~on U.S. Nuclear Re'uliatory Commission K75 Afen ~ Road-.1 *WrrPI S1rat4. Sutt 31D 2??
Ro.eLaeet Road King of Pras:# PA I S0e Atiwa. GAX3Z23 Glen Ellyn, IL 60137 Rros;onal
.rnr.rator V R;dona IV R
.at A1minIrator, RpoD V D rcor.
Dvision of Licenese Perforrrance U.S. Nuclear Pa u"ory Comr-.,:,on U.S. Nc.:rtr Rpgisetory Commiulon ard Ovality Eaitraton A11 Plan P!n, D., S :t 1000 3 14,0 144a Lire. Suite 210 Ann: OP#!aIor L;"nsing B*anch AG%.r n. T X 1 W t C-rdk, CA
- 459 U.S. Nuclear Repilory Comm;as or WabKn.on.
DC 20555 PRIVACY ACT STATEMENT 1
5 U.S.C.
- y. rre a. by o
3 Iof the Pr:.cy Act of ROUTINE USES: TIhe informui;on In4y dibsco d to am scom
- st* Fe.lea S
1 4 ip-bf~c b.- S-1579) '," following r.acar.ant ;%
'urnard hc.~e~ ~ o to~ia ajmnC'y in it e r~n the iMn fjrnIn~t A ie;jr a v0c1nton Or plimr1 vo!1.;of
%.4p'y ;nfrfr?..;on 10 11,t US. Nu',llar Pwaioy C0MnMnu;ono can c NF re ad nt I4e',n i1.4 ;nfon'rSa1;on ;,--er1 I
- CAIr or p0#I& ;~.
of la. a~ r Th's ;Mio,,al:on s1 of 'eods des rgr.ed as '.F.!S and.
he o ur, ofa bam nrsti'or judcaId ock ve d g l a.oi r N Ithsir.f0 rrnst on r U T 7
0 1o f e
A o m cE. ty 4 1 s 1 8 4, '~ I a
r yn 0 t a 'N *, r a*
- F e d e ' I $
- r.e a r~d to :
a a p c y 1 0 AUTHORITY:
1 107? and 1EI-of !i g Aiom<c E~,,
Aci 0f l5S at f.".~ay1 r an NRC di, crr abaoi roni.
C 2 U.SLC. P. 7 aE. If WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT CN P AI C;FAL PURPJ EIeI, Ir.) -aon en* d on ihN term Is u
- cr ;re INDIVIDUAL OF NOT PROvIDING INFCF.MATION.
DuIcls.;*
s cl -a&Iy. If th#
.c as : r oaa r4 aI al~ l~f t.,e ;-:at a'*.-
- its t hey r.'.ad rnr.ation I rhot prow.6*.
- owevr, tt.e
- ,pI
- trier for a 'as.iy
- c ~erarer's Ul 1 cb me tV are: o nzrpe p b I'.raiIth &ad wa'r y. 7P' tricrr*
0F "r;Of o;4*r.or's I.-k s 4r eae:d.
t Ca A ole sAC In Ca ent,-:r.t f t a;vdalrre-u *r.are-SYSTEM MANAGERISI AND ADDEIS: Cn.f O;**sior LOcf-g 8ac'*,
Ottcec ofC.o to n an opeanor I I N.'**a Pow0I RtW!r*;ort U N..?earao Cor'r,.~rt wap.i.ercn DC
,s Na C C 041)
KRC FORM 398 (FACSDMILE)
U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY O: NO. 3150-0090 DATE RECEIVED 10- 9 0)
EXPIRES: 1-31-92 (eted by NRC) 0 CFR 55 31 55.35, ESTIMATED. BURDEN PER RESPONSE TO COMPLY 55.47, and 5.57 WITH THIS INFORMATION COLLECTION REQUEST: 2.0 ERS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE INFOR MAT ION AND RECORDS MANAGEMENT BRANCH PERSONAL QUALIFICATION STATEMENT - LICSEE (NBBA 7714)RU.S.NUCLEAR REGULATORY COM MISSION WAHINGTON DC 20555 AND TO THE PAPRWORK REDUCtION PROJECT (3150 0090I OFFICE OF MANAGEDENT AND BUDGET, TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED WASH NGTON, DC, 20503
- 1. APPLICANTS FULL NAME (Last, First, Middle) AND ADDRES 4.TYPE OF APPLICATION (Check applicable boxes) X HOT COLD (include ZIP Code)
OTL'I1L11L X
- a.
NEW
- f. WAIVER REQUESTED
- FORD, DAVID BRUCE
- b. RENEWAL jRI Non Revers 4270 Casa Buena Way # 161
- c.
UPGRADE Oceanside, CA 92057
- d. MULTI-UNIT (AMEND TO 2-0:ERATING (Category)
INCLUDE ADD TIONAL UNIT) 3-ELIGIBILITY*
- e. REAPPLICATION 1-FIRST.
4-MEDICAL 5-OTHER
- 2. CITIZSHIP
- 3.
BIRTH DATE 2-SECOND MO~
g.DATE PASSED GENERICr X
- a. UNITED STATES NTH DAY YEAR 3-THIRD FUNDAMENTALS EXAM-MI YY 1 0 1 13 6 1 5INATION SECTION
-t
- b. OTHER (Specify) 1 0
1 3
6 5
(IF APPLICABLE) 02 91
- 5.
TYPE OF LICENSE APPLIED FOR
- 6. PREVIOUS LIE (S) HELD X
- a. OPERATOR
- c.
EXPIRATION DATE b.a.
DOCKET NUMBER RO SRO LICENSE NUMBER d.FACILITY DOCKET NUMBER b.~~~ SNO OPRTRkDT DAY YEAR
- c. LIMITED SRO ad55-50 (e.g., Fuel Handler)I I-I L
I
- 7. AME AND ADDRESS (Include ZIP Code) OF APPLICANTS EMPLOYER
- 10. CUMENT POSITION AT FACILITY
- a. PLANT SUPERINTENDENT X i.
AUXILIARY UNIT OPERATOR/
- i Southern California Edison E~ TRAINEE /URE IKE BUILD P 0 Box 128.
- b. ASSISTANT PLANT SUPERINTENDENT ING U PNE OPERATOR Sa lmne A92674-0128 C. SHIFT SUPERVISOR (NO CENSED OPERATOR)
- d.
STAFF ENGINEER
- 8. NAME OF APPLICANTS FACILITY FACILITY DOCKET NUMBER
- e. SHIFT TECHNICAL ADVISOR/
- J.
l, San Onofte Unit 1 50-206 SHIFT ENGINEER
- f.
INSTRUCTOR
- 9. ADDITIONAL FACILITY DOCKETS (Multi-unit Licenses)
- g. SENIOR CONTROL ROOM OPERATOR
- h. CONTROL ROCM OPERATOR
- 11.
EDUCAION IGB SCHOOL
- c. MAJOR AREA(S) OF NUMBER HIGHEST DEGREE CODES
- d.
VOCATIONAL /
NUMBER CERTIFICATE STUDY OF YEARS DEGREE (To be used for TECHNICAL OF RECEIVED GRADUTE ENINEEING (IELDS HIEST DEGREE" 'NH X GRADUATE ENGINEERING (FIELDS)
(Use Codes) obtained)
TYPE OF TRAINING YES NO GED EQUIVALENCY 0
NONE Nucear Power School 6
X NOOHE1 CERTIFICATE NO OTEnE1 2 - ASSOCIATE Nuclear Prototype 6
X Gen Education 1
0 3 -
BACHELOR-
- b. NUMBER OF.
4 - MASTER YEARS OF 15
- DOCTORAL COLLEGE 1
- 12.
TRAINING (SINCE LAST APPLICATION -
SEE INSTRUCTIONS)
- 13.
EXPERIENCE (DO NOT DOUBLE COUNT -
SEE INSTRUCTIONS)
- a. MONTE AND YEAR b. NUMBER a.MNTH AND YEAR b. NUMBER FROM TO OFWES NAVY FROM TO OFMNH 1-NUCLEAR POWER PLANT FUNDAMENTALS TO_____C TO (Classroom) 1 - RO 2-PLANT SYSTEMS 2 - EOOW/PPWO V CLASSROOM1 OBSERVATION 3 - ES/PPWS 3-OPERATING PRACTICE CONTROL ROOM OPERATIONS ON SHIFT 5 - OTHER (Specify)
SIMULATOR OPERATING 1
(Includes Classroom)
FOSSIL SIMULATOR NAMES 6 - OPERATOR
- b.
7 -
SUPERVISOR CERTIFIED STARTUP X YES NO UMR 8 - PLANT STAFF PROGRAM COMPLETED 9 - OTHER (Specify)
NO. OF REACTIVITY MANIPULATIONS PLANT SIULATOR iulIJlll Iii~iinfiln~iiiimillIIIjIllnHUI CMERCIAL NUCLEAR (Including Research!
PLANT SIMULATOR fi n
Test Reactor) 6..........i.nIn 10 -
REACTOR OPERATOR (Licensed) 4-SRO INSTRUCTION 11 - SENIOR OPERATOR (Licensed) 5-ETRA PERSON ON SHIFT IN CONTROL 12 - SHIFT SUPERVISOR (Licensed)
RtI(13-WEEK MINIMUM)
TIM ON SHIFT AOVE 20%
13 - STAFF/SHIFT ENGINEER (Licensed)
(6-WEEK MINIMUM) 14 - AUX./EQUIP.
OPER.
(Nonlicensed)
QUALIFICATION 15 - PLANT STAFF THER (Specify) 16 - OTHER (Specify)
NRC FORM 398 (10-90)
- 14.
FACILITY OPERATOR RAINIG PROGRAM
- a. GRADUATE OF INPO ACCREDITED OPERATOR
- b. CERTIFIED ON NRC FORM 474 ('SIMULATION TANNPRAM TEAT IS BASED PO X
YS NO FACILITY CERTIFICATION") OR NRC APPROVED X
YSN A SYSTEMS APPROACH TO TRAINING SIMULATION FACILITY IS USED IN THE OPERATOR TRAINING PROGRAM
- 15. FR EEWALS OLY
- b. DATE AND RESULT OF MOST DATE RESULT URS OPERATED FACILITY b
NTNR NITRD REQUALIFICATION EXAMINATION PASS I
FAIL
- 16.
EXPERIENCE DETAILS
- a. POSITION TITLE FROM TO
- b. FACILITY
- c. DUTIES
- 17. CHETS (Specify the item number to which you are elaborating. Attach additional sheets as necessary.)
- 18. NRC FEM 396, CERTFICATION OF MDICAL EAMINATION BY FACILITY LICENSEE, IS ATE ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
19a. I certify under penalty of gerjury that the information in this document and attachments is true and correct. I further certify that I have notifie8 my current emplo er of: (1) all previous employers; (2) any instance where I have been tested by a Health and Human Services (HES) Certilie Tet ing Laboratory or a Licensee's testing facility for alcohol or a controlled substance, and the test results exceede the cutoff levels established pursuant to 10 CFR Part 26* (3) any instance where I have been arrested for the sale, use or possession of a controlled substance described in 16 CFR Part 26; and (4) any reasons for removal or revocation of unescorted access at a nuclear facility, I also authorize the NRC to submit the results of examinations to my employers for use in preparing retraining programs, as necessary.
SIGNATURE - APPLICANT h
JDATE U2 CHE AFIICABLE D0M
- b. I certify that the above named individual has successfully completed the facility licensees requirements to be licensed as an. Oerator/Senior Oerator pursuant to Title 10, Code of Federal Regulations, Part 55* and that the individual has a need for an Operator/Senior Oerator license to perform his/her assigned duties and that the facility will be made available for examination.
I so certify under penalty of perjury that the information in this document and attachments is true and correct.
- c.
RENEWAL ONLY - I certify that the above named individual meets the a roved re alification pro ram (with exceptions noted in Item 17) as required by section 50.54 (i-1) oi 10 CFR 50, and that he/sea has discharged his/her licensed responsibilities competently and safely. I also certify under penalty of perjury that the information in this document and attachments is true and correct.
TRAINING COCDINATOR SENIOR HAAGEMENT REPRESENTATIVE 0N SITE PRINTED OR TYPED NAME PRINTED OR TYPED NAME Robert Clement N.
E.
LORGAN SIGNATURE A
DATE SIGNATURE NO SIGNATURE RE UIRED DATE sw2.
2-NON-CERTIFIED APPLICATION FOR NRC USE WAIVER (Check or complete items, as applicable)
MEETS REQUIREMENTS DOES NOT MEET REQUIREMENTS(Explain below)
CATEGORY GRANTED BY DENIED BY HEADQUARTERS REGION HEADQUARTERS REGION ITEN TING ELIGIBILITY MEDICAL SIGNATURE - REVIEWER
.DATE OTHER NRC FORM 398 (10-90)
NRC FCRM 396 U.S. NUCLEAR REGULATORY COMMISSION P
D SY OB:
0NO 3:scree 0 CFR 5523 5525.
ES i.3 u 5
- 7.S
. 55 57 ESThAADT BUCEN ER RESPON4SE
- 0 C
wr 1vS POORMAtON COLLECTION REQUJEST:
!s mm.
FOn ARD CERTIFICATION OF MEDICAL EXAMINATION COMDGERE-WO0GSJOENES'MATTO NEINFORMATON AND RECOO MANAGEMENT BPANCm (MNB8 77,4). US BY FACILITY LICENSEE NL ouet oy oeuAsseON wASmrNoN.oCo05 AND TO THE PAPERORK REDUCTION PRJECT (31 4),
OFFCE OF MAENAOE.MENT AND BUDGET.
WASNGTOeN. DC 2053.
NAME OF APPLICANT FACILITY FACILITY DOCKET NUMBER A. MEDICAL EXAMINATION CERTIFICATION THIS IS TO CERTIFY THAT THE ABOVE NAMED APPLICANT FOR AN OPERATOR/SENIOR OPERATOR LICENSE HAS BEEN EXAMINED BYA PHYSICIAN.
PAIN N A ME tof hysici' STATE AND LICENSE NUMBER EXAMINATION DATE BASED Nov.04, 1991 BASED ON THE RESULTS OF THE EXAMINATI
, INCLUDING INFORMATION FURNISHED BY THE APPLICANT. THE PHYSICIAN HAS DETERMINED THAT THE APPLICANT'S PHYSICAL CONDITION AND AL HEALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPERATIONAL ERRORS ENDANGERING PUBLIC HEALTH AND SAFETY. I CERTIFY THAT IN REACHING THIS DETERMINATION, THE GUIDANCE CONTAINED IN ANSI/ANS 3.4-1983, OR ANSI/ANS 15.4-1977 (N380) WAS FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY NRC.
ON THE BASIS OF THE RECOMMENDATION OF THE PHYSICIAN, I RECOMMEND THAT THE APPLICANT'S OPERATOR LICENSE BE CONDITIONED AS FOLLOWS:
L 1. NO RESTRICTIONS
- 2. CORRECTIVE LENSES BE WORN WHEN PERFORMING LICENSED DUTIES
- 3. HEARING AID BE WORN WHEN PERFORMING LICENSED DUTIES
- 4. RESTRICTED LICENSE OR EXCEPTION-Provide details below and attach supporting medical evidence for NRC review.
- 5. RESTRICTION CHANGE FROM PREVIOUS SUBMITTAL-Provide details below and atadhra rng medical evidence for NRC review.
PROPOSED WORDING OF RESTRICTION (Block 4 above)
RELATIONSHIPOF RESTRICTION TO DISQUALIFYING CONDITION (Briefly indicate howreatriction willconsac the disqualifying condition)
REMARKS FOR RESTRICTION CHANGE (Block Sabovit)
B. NONMEDICAL CERTIFICATION THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DUTY REQUIREMENTS OF THIS FACILITY FOR LICENSED OPERATORS.
LIT ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS. MAY BE SUBJECT TO CIVILAND CRIMINAL SANCTIONS. I CERTIFY UNDER PENALTY OF PERJURY.THA? THE INFORMATION IN THIS DOCUMENT AND ATTACHMENTS IS TRUE AND CORRECT.
PRINTED NAME AND SIGNATURE Seniror Manapement RepresentraHe onSire)
TITLE DATE No Signature Required, Non-Certified H. E. Morgan Application Vice President &.Site Manager in accordance with 10 CFR 55.5, Communications, this form shall be submitted to the NRC as follows: BY MAIL ADDRESSED TO:
Regional Administrator, Region I Regional Administrator. Region II Regional Administrator. Region III U.S. Nuclear Regulatory Commission U.S. Nuclear Regultory Commiuon U.S. Nuclear Regulatory Commission 475 Allendale Road 101 Mariena Sireet. Suite 3100 799 Roosevelt Road King of Prussia. PA 19406 Atlanta. GA 30323 Glen Ellyn, IL 60137 Regional Administrator. Region IV Regional Administrator, Region V Director, Division of Ucensee Performance U.S. Nuclear Regulatory Commission U.S. Nuclear Regulatory Comminion and Quality Evaluation 611 Ryan Plaza Drive. Suite 1000 1450 Maria Lane. Suite 210 Ann: Operator Licensing Branch Arlington, TX 76011 Walnut Creek. CA 94596 U.S. Nuclear Regulatory Commision Washing on. DC 20555 PRIVACY ACT STATEMENT Pursuant to 5 U.S.C. 552a(e)(3). enacted imo low by section 3 of the Privacy Act of ROUTINE USES: The Information may be disclosed to an appropriate Federal, State, or 1974 (Public Law 93579). the following riatement is 'umished to individuals who local agency in the event the information indicates a violation of potential violation of Ia.
supply information to the U.S. Nuclear Regulatory Commission on NRC Form 396.
and in the event the information indicates a violation or Potential violation of law and in This information is maintained in a system of records designated as NRC-16 and. the cours of ar administrative or judicial proceeding. In addition, this information may be dvscribe at SS Fed*.&* Registr 33978 lAgiist 20. 1990).
transferrd to an appropriate Federal, State, and local agency to the extent relevant rro AUTHORITY: Sections 107 and 161(i) of the Atomic Energy Act of 1954. as neasary for an NRC decision about you.
amended (42 U.S.C. 2137 and 2201 i).
1WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON PRINCIPAL PURPOSE(S): Information emered on this form is used to determine INDIVIDUAL OF NOT PROVIDING INFORMATION. Disclosure is voluntary. if the whether the physical condition and general health of the applicant ere such that they requested information is not provided, however, the applicetion for a facility opetors will not cause operational errors eneangering public health and afery. This inforrma' or senior operator' license may be denied.
ton may be used by the NRC rtaff to determine if the individil mevtts the require' SYSTEM MANAGER(S) AND ADDRESS:
)-,
Ope or Licening Biarch. Offce o1 S ments of 10 CF R 55 to taker an esami'tion or to be issued an opretorR's license.
Nuclear SEaSctor Regulation, U.S. Nuclear.
egulatore Comaision. Washington. DC 20S5o reesar FOor an6 NR;dciio.aouyu
NRC FIRM 398 (FACSIMILE)
U.S.
NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0090 DATE RECEIVED
~10-90)
EXPIRES: 1-31-92 0 CFR 55 31 55.35, ESTIMATED BURDEN PER RESPONSE TO COMPLY (To be completed by NRC) 5.47, and 5t.57 WITH THIS INFORMATION COLLECTION REQUEST: 2.0 ERS.
FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE INFOR MAT ION AND RECORDS MANAGEMENT BRANCH PERSORAL QUALIFICATIOR STATEMENT -
LICENSEE
.B B 7714)U.S.NUCLEAR REGULATORY CDM SSION WEBINGTON DC 20555 AND TO THE PAPtRWORK REDUCtION PROJECT 3150 0090) OFFICE OF MANAGRCNT AND BUDGET, TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED WASHNGTON, DC 20503
- 1. APPLICANTS FULL RAME (Last, First, Middle) AND ADDRESS 4.TYPE OF APPLICATION (Check applicable boxes) X HOT COLD (include ZIP Code)
X
- a. NEW
- f. WAIVER REQUESTED GUERRERO, AUGUST CERISTOPHER CABRERA
- b. RENEWAL WRtTTNonCaeeo
.39555 Silverberry Ct.
- c. UPGRADE Murrieta, CA 92562
- d. MULTI-UNIT (AMND TO 2-OPERATING (Category)
INCLUDE ADDITIONAL UNIT) 3-ELIGIBILITY
- e. REAPPLICATION X
- a.
UNITED STATE 1-FIRST ER(pcf
- 2. CITIZEMMEP
- 3. BIRTH DATE 2-SECOND X gDATE PASSED GENERIC X
- a.
UNITED STATES MONTE DAY YEAR 3-THIRD FUNDA ENTALS b.OTER(Specify)
INTONSCTO 1
0 2
IF APPLICABLE) 0 2 7
91
- 5. TYPE OF LID APPLTO F
- 6. PR2POES LI(Ct(S) HEL X
- a. OPERATOR C. EXPIRATION DATE b.SNO PRTRa.
DOCKET NUMBER RO SRO b. LICENSE NUMBER, DAYCIT YEARTNUBE kVNT d.ACIITY5OCKTTNMBE c.TLIMITED SRO 55-I50 (e.g., Fuel Handler) 7NAME ANDADDRES (Include ZIP Code) OF APPLICANT'S EPLOYER
- 10. CU(ENT POSITION AT FACILITY
- a. PLANT SUPERINTENDENT Ei.
AUXILIARY UNIT OPERATOR SouternCalforna Eiso
-L TRAINEE/TURBINE BUILD P. 0. Box 128
- b. ASSISTANT PLANT SUPERINTENDENT ING qU I
NT OPERATOR San Clemente, CA (NOMONTE DAYEREAR 92674-0128
- c. SHIFT SUPERVISOR
(
ENSED OPERATOR)
- d. STAFF ENGINEER
- 8.
RAM OF APPICANT'S FACILITY FACI50T20DOCKET NUMBER
- e. SHIFT TECHNICAL ADVISOR/
J. OTHER (Specify)
San Onofre Unit 1 I
50-206 SHIFT ENGINEER
- f.
INSTRUCTOR
- 9. ADDITIONAL FACILITY DOCKETS (Multi-unit Licenses)
- g. SENIOR CONTROL ROOM OPERATOR
- b. CONTROL ROOM-OPERATOR
.11. EDUCATION IGE SCHOOL
- c. MAJOR AREA(S) OF NUMBER HIGHEST DEGREE CODES
- d. VOCATIONAL /
NUMBER CERTIFICATE STUDY OF YEARS DEGREE To be used for TECHNICAL OF RECEIVED X
GRADUATE ENGINEERING (FIELDS)
(Use Codes) obtained)
TYPE OF TRAINING YES NO GED EQUIVALENCY 0
NONE Nuclear Power School 6
X 1-CERTIFICATE b.NO OTHER 2
ASSOCIATE Prototype 6
X
- b. NUMBER OF 3 -BACHELOR
-4 4MASTER YEARS OF 5 -DOCTORAL COLLEGE 0
- 12.
TRAINING (SINCE LAST APPLICATION - SEE INSTRUCTIONS)
- 13. EXPERIENCE (DO NOT DOUBLE COUNT - SEE INSTRUCTIONS)
- a. MONTH AND YEAR bF WEMBER a.MONTH AND YEAR b NUMBER FO T O FWEEIC Ot' MONTHS 1-NUCLEAR POWER PLANT FUNDAMENTALS FROM TO REVY (Classroom) 1 - RO 2-PLANT SYSTEMS 2 - EOW/PPW0 CLASSROOM OBSERVATION 3 -
EWS/PPWS 3-0PERATING PRACTICE 4 -
ERS/CRW CONTROL ROOM OPERATIONS ON SHIFT 5 - OTHER (Specify)
SIMULATOR OPERATING (Includes Classroom)
FOSSIL SIMULATOR NAMES 6 - OPERATOR
- a. Unit 1
.Uifimwilnjrh~m~lhm~lsj~fhII~nIIIII~~lI 7 - UPERVISOR
- b.
CERTIFIED STARTUP XO YES NO PROGRAM COMPLETED S
O
- OTER(secfy NO.
OF REACTIVITY MANIPULATIONS 1....
III PLANT S
O11111111111 CCI44411114 NULA (Including41444 HI SIMLATR I!
9111111111111Test Reactor 5
10 -
REACTOR OPERATOR (Licensed) 4-SRO INSTRUCTION 11 -
SENIOR OPERATOR (Licensed) 5-EXTRA PERSON ON SHIFT IN CONTROL Rt (13-WEEK MINIMUM~.)12-SITSPR SO(Lcne)____
.TIME ON SHIFT ABOVE 20111ll 13 - STAFF/SHIFT ENGINEER (Licensed)
(6-WEEK MINIMUM) 14 - AUX./EQUIP. OPER. (Nonlicensed)
QUALIFICATION 15 -
PL.ANT STAFF f
lER (Specify) 16 - OTli (Specify)
NRC FORM 3.98 (10-90)
- 14.
FACILITY OPERATOR TRAINING PROGRAM
- a. GRADUATE OF INPO ACCREDITED OPERATOR
- b. CERTIFIED ON NRC FORM 474 ("SIMULATION TRAINING PRORAM THAT IS BASED UPON X
YES NO FACILITY CERTIFICATION") OR NRC APPROVED X
YES NO A SYSTEMS APPROACH TO TRAINING TION FACILITY ISU SED IN THE OPERATOR TRAINING PROGRAM
- 15. FOR RENEWALS ONLY b.DATE AND RESULT OF MOST REDATE BOURS OPERATED FACILITY RECENT NRC ADMINISTERED DRUL REQUALIFICATION EXAMINATION PASS FIL
- 16. EXPERIENCE DETAILS
- a. POSITION TITLE FROM TO
- b. FACILITY
- c. DUTIES
- 17.
CHENTS (Specify the item number to which you are elaborating. Attach additional sheets as necessary.)
- 18.
HRC FQBM 396, CERTIFICATION OF MEDICAL EAMINATION BY FACILITY LICENSEE, IS ATTACHED ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
19a. I certify under penalty of perjury that the information in this document and attachments is true and correct.
I further certify that I have no ifie my current employer of: (1) all previous employers; (2) any instance where I have been tested by a Health and Human Services (HES) Certilied Drug Testing~ Lkboratory or a Licensee's testing facility for alcohol or a controlled substance, and the test results exceded the cutoff levels established pursuant to 10 CFR Part 26 (3) any instance where I have been arrested for the sale, use or possession of a controlle8 substance described in 1 CRPart 26; and (4) any reasons for removal or revocation of unescorted access at a nuclear facility, I also authorize the NRC to submit the results.of exam hations to my emplyyers for use in preparing retraining programs, as necessary.
SIGNATURE - APPLICANT fDATE CE= APPLICABLE BO X
- b. I certify that the above named individual has successfully completed the facility licensees requirements to be licensed as an Operator/Senior Operator pursuant to Title 10, Code of Federal Regulations, Part 55i and that the individual has a need or an Operator/ Senior Op erator license to perform his/her assigned duties and that the facility will be made availble for examination.
I also certify under penalty of perjury that the information in this document and attachments is true and correct.
- c. RENEWAL ONLY - I certify that the above named individual meets the ap roved re alification program (with exceptions noted in Item 17) as required by section 50.54 (i-1 o
10 CFR 0, and that he/s a has discharged his/her licensed responsibilities competently and safely. I also certify under penalty of perjury that the information in this document and attachments is true and correct.
PRINTEDORCTYPEINRSENIIR HAAGEMENT REPRESENTATIVE 0M SITE PRINTED OR TYPED NAME PRINTED OR TYPED NAME Robert Clement H. E. MORGAN SIGNATURE (D
r DATE SIGNATURE NO SIGNATURE R UEUIRED DATE
~-~'~V
[79Z.NON-CERTIFIED APLICATION FOR RC USE WAIVER (Check or complete items, as applicable)
MEETS REQUIREMENTS DOES NOT MEET REQUIREMNTS(Explain below)
GRANTED BY DENIED.BY CATEGORY HEADQUARTERS REGION HEADQUARTERS REGION ITTEN TING LIGIBILITY MEDICAL SIGNATURE - REVIEWER DATE OTHER NRC FORM 398 (10-90)
NRC -:.,*
."6 U.,
R REGULATORY COYYISSIC Appq.%r nr
-11 Zc It cE E
CERTIFICATION OF MEDICAL EXAMINATION AND IC,,S-%:GN N'
tn
$8 "di BY FACILITY LICENSEE NEA:
A -
eN
\\..'E CF PL.N Guerrero., August C.
ACILITY FACILITY DOCKET NUMBER San Onofre Nuclear Generating Station, Unit 1 50-206 A. MEDICAL EXAMINATION CERTIFICATION
V.NE B" A pSCy
- RINTED tiA.*E !ofphystJn)
STA7E AND LICENSE NUMBER EXAM:NATICN DATE Steven Rosen, MD CA G24823 11/19/91 BASED ON THE RESULTSOF THE EXAMINATION. INCLUDING INFORMATION FURNISHED BY THE APPLICANT, THE PHYSICIAN HAS DETERMINED THAT THE APPLICANT'S PHYSICAL CONDITION AND GENERAL HEALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPERATIONAL ERRORS ENDANGERING PUBLIC HEALTH AND SAFETY, I CERTIFY THAT IN REACHING THIS DETERMINATION. THE GUIDANCE CONTAINED IN ANSI/ANS 3.4-19S3, OR ANSI/ANS 5.s-1977 (N380) WAS FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY NRC.
ON THE BASIS OF THE RECOMMENDATION OF THE PHYSICIAN. I RECOMMEND THAT THE APPLICANT'S OPERATOR LICENSE BE CONDITIONED AS FOLLOWS:
XX
- 1. NO RESTRICTIONS
- 2. CORRECTIVE LENSES BE WORN WHEN PERFORMING LICENSED DUTIES
- 3. HEARING AID BE WORN WHEN PERFORMING LICENSED DUTIES
- 4. RESTRICTED LICENSE OR EXCEPTION-Provide details below and
- ach supporting medical evidence for NRC review.
S. RESTRICTION CHANGE FROM PREVIOUS SUBMITTAL-Prov-de details below and attach upporting cal evidence for NRC review" PROPOSED WORDING OF RESTRICTION (Block 4 sbove; RELATIONSHIP OF RESTRICTION TO DISQUALIFYING CONDITION (Briefly irdicxbar how ricilon willwrma the disqifying cltondfiionj REMARKS FOR RESTRICTION CHANGE IBlock SAbSovi)
B. NONMEDICAL CERTIFICATION THIS CERTIFIES THAT THE APPLICANT HASBSEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DUTY REQUIREMENTSOF THIS FACILITY FOR LICENSED OPERATORS.
ANY FALSE STATEMENT OR OMIsSION IN'TMIS DOCUMENT. INCLUDING ATTACrMENTS.MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONL I CERTIFY UNDER PENALTY OF PERJURY THT TWE INFCrMATION IN TwIS DOCUMENT AND ATTACNMENTS IS TRUE AND CORRECT.
PRINTED NAME AND SIGNATURE tSi,;or Maapemem Aeprsnri. on SireJ TITLE DATE No Signature Required, Non-Certified Vice President & Site Manager H. E. Morgan Application In accordance with 10CFR 55.5. Comrnmunications. this formshall be subminedto the NRC&a follows: BY MAIL ADDRESSED TO:
Regional Acmininsrator. Region I Regional Adrninistrator. Region II Rn;ornal Administraor. Region III U.S. Nuclear Regulatory Commission U.S. Nuclear Repulaory Commisnion U.S. Nuclear Reg.latory Comminsion 475 Allendale Road 101 Varie'na Street. Suite 3100 79 Rocuelt Road King of Pruiea. PA 19406 AtlanTs. GA 30323 Glen Ellyn, IL 60137.
Reg;onal Adminisraior. Region IV Regona Admnistrator, Replon V D;rector. Division of Licenrn Performance U.S. Nuclear Rewp.ulatory Commission U.S. Nucltar Regulatory Commisnion and Quality Evaluation 611 Ryan P:ara Drive. Suite 1COO 1450.&a4 Lane, Suite 210 Ann: 0peator Licening B'anch Arliragion.TX 76011 Wainjt Crk. CA 94596 U.S. Nuclear Reqirrory Comminion Washing on. DC 20555 PRIVACY ACT STATEMENT Pursuant to 5 U.S C. 5528le113). enasied mo !a. by see on 3 of the Pria.cy Act of ROUTINE USES: The informir;on may be diaclowd to am appropsriae Fe.looraI Stare. o 1974 (Public L* 93579). the folilowng ratement s burnished to it.d vals who local agency in the ieret the inforrraticor ndican a violation or ptren;I violation of ia i uDply ;nforf.,tI;on to the U.S. Nuclear Pagulaiory Commiuion on NPC Form 36. and in the erstn the infornation indicr.at a violation or poiential viotation of Ia and ir This informalon ; ma;rnramed in a syr ern of rfcords desigr.ed as P.RFCr and.
the coursa of br edrrnistratie or judicial pwocveding. In donion. thi infoimation ray be CmC't.e 8I15 SC.
Anil~ 3 97 IA.p I 55.
trirasfened to arn ficroprie Feali Strte. anld local agenrcy to the eatent relevant anc AUTHORITY: Setcions 107 and 161(i) of the Atomic Erer;y Act of 1954. as rrucenary for an NRCdec;&ion about you.
amereed (42 U.S.C.2137 and 2201(,)l.
WH9THER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT CN PRINCIPAL PURPOSE(SI: Infoimtilon eirrn*rd on this form is used to rmermine INDIVIDUAL OF NOT PROVIDING INFORMATION. Duclosure & -oltunay. If the
-brhtiber the physoaul cndition and gqneal eabbh of the aDDicant se sc01 t 1.at they
'trmred information is not prov6d.
Ioweve,. the applicro.on for a feclity oreator's w;I not caute osibetrc0aI errors tnds'er;n; p.;l;C htabl:
and Lafry. Thirform.
O benhor ostores licernai ray We darted.
Ion rebe ICd by tea NRC raf to deerr.mr-e dfthe rdiv.duac f
t
'irr re SYSTEM MANAGERISi AND ADDRESS:
C>:of. O.a'ator Lcans.rg 8vrch. Offi c' minis of 10 CFR A65 to take an eaarm r.a;n or 10 4 inupd en o;-ersior' I care.
Nuclear Ractor R*9..tiion. U.
Nucleat Poigiu'aory Co-jrmas;on.Wba.hgen. DC 205
-. A C u~
f 041)
NEC FOM 398 (FACSIMILE)
U.S.
NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0090 DATE (10-90)
RCIE
~10-0EXDPIRES:
1-31-92 (To be completed by NRC)
CFR 55 31 55.35, ESTIMATED BURDEN PER RESPONSE TO COMPLY 55.47, and 5.57 WITH THIS INFORMATION COLLECTION REQUEST: 2.0 HRS
.FORWARD COMM ENT S REGARDING BURDEN ESTIMATE TO THE INFOR MATION AND RECORDS MANAGEMENT BRANCH PERSORAL QUALIFICATION STATEMENT -
LICENSEE (tBB 7714),U.S.NUCLEAR REGULATORY COM ISS ION W HIGTON DC 20555 AND TO THE PAPtA:RO REDUCtION PROJEfT (3150 0090) OFFICE OF MANAGEMENT AND BUDGET, TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED GTONDC, 20503
- 1. APPLICANTS FULL NAME (Last, First, Middle) AND ADDRESS 4TYP OF APPLICATIO (Check applicable WIT TBISs INOMAINLOLETO (include ZIP Code)
XEaRDING fR WAIVER REQUESTED HOWARD,M ROBERT PTNELL
- b. RENEWAL ORDS MANAEMENeTr 341-M N. Melrose Dr.
- c.
UPGRADE Vista, CA 92083 T
N O
-OPEATING (Category) 0090)MOFFIE-OFNMANAGMENTOADB E
INCLUDE ADDITIONAL UNIT)
- e. REAPPLICATION 3kLb LITC 1-FIRST
.4-EDICAL
- 2. CITIse P
- 3.
BIRTH DATE 2-SECOND X S.ATE PASSED GENERIC Vi. a CNTDSATE 92083
- d. MUT-UI AMNT
-0PRTN (Ctoy X.
NTE TAES~NT AY YEAR 3-THIRD FUNDAMENTALS EXAM-Ft mm YY INCL ADDy TNINATIO SECTION b.OTE((Specify) 1 0
1 1
6 2
IF APNPLICABLE) 02 91
- 5. TYPE OF LICENSE APPLIED FOR
- 6. PREVIOUS LICERSE(S) HELD X
- a. OPERATOR c XIAINDT ba.SENR OPERATOR
- b. SENIOR OPRAORMOTE DA YA
- c. LIMITED SRO 55-50 (e.g., Fuel Handler) 7.RAME AND ADDRES (Include ZIP Code) OF APPLICANT'S EMPLOYER
- 10. COEENT POSITION AT FACILITY Southern California Edison
- a. PLANT SUPERINTENDENT L1
- i. AUXILIARY UNIT OPERATOR/
Soutern alifrni Edion IX I TRAINEE/TURBINE BUILD P. 0. Box 128
- b. ASSISTANT PLANT SUPERINTENDENT ING U
T OPERATOR 92674-0128
- c. SHIFT SUPERVISOR (N
ENSED OPERATOR)
- d. STAFF ENGINEER
- 8.
RAME OF APPLICANT'S FACILITY FACILITY DOCKET NUMBER
. SHIFT EGN L ADVISOR/
J.
OTHER (Specify)
San Onofre Unit, 1 50-206 SHIFT ENGINEE
- f.
INSTRUCTOR
- 9. ADDITIONAL FACILITY DOCKETS.(Multi-unit Licenses)
- g. SENIOR CONTROL ROOM OPERATOR
- h. CONTROL ROOM OPERATOR
- 11. EDUCATI0N IGB SCHOOL
- c.
MAJOR AREA(S) OF NUMBER HIGHEST DEGREE CODES od.
VOCATIONAL /
NUMBER CERTIFICATE STUDY OF YEARS DEGREE To be used for TECHNICAL OF RECEIE GRADUATE ENGINEERING (FIELDS)
(Use Codes) obtained)
TYPE OF TRAINING ONTHSY YES NO GED EQUIVALENCY Chemical 2
0 0 - NONE Nuclear Power School 6
X N
1 CERTIFICATE NO OTHER 2
ASSOCIATE Nuclear Prototype 6
X
_______7__
3-BACHELOR
- b.
NUMBRiOF 4-MASTER YEARSOF 5 -DOCTORAL COLLEGE '2LE
- 12. TRAINING (SINCE LAST APPLICATION - SEE INSTRUCTIONS)
- 13. EXPERIECE (DO NOT DOUBLE COUNT - SEE INSTRUCTIONS)
- a. MONTS AND YEAR b NUMBER a.MONTH AND YEAR b.
NUMBER 1-NUCLEAR POWER PLANT FUNDAMENTALS FRO TO NAVY FROM TO OF MONTHS (Classroom) 1 -
RO 2-PLANT SYSTEMS-2 -
EOOW/PPwO CLASSROOM.
3 -
EWS/PPWS OBSERVATION 4-ES/PPW 3-OPERATING PRACTICE 4 - ERS/CRW CONTROL ROOM OPERATIONS ON SHIFT 5 - OTHER (Specify)
SIMULATOR OPERATING (Includes Classroom)
FOSSIL SIMULATOR NAMES 6-OPERATOR
- a. Unit' 1iafiilfU11 11iiffi
- b.
M b= ftfluiinhIIIIw 7I -II S~nI~nIUPERVISOR CERTIFIED STARTUP 1XI YE NO8-PLNSTF PROGRAM COMPLETED 9 - OT (Specify)
NO.
OF REACTIVITY MANIPULATIONS PLANTlllllUl~lllliill COMMERCIAL. NUCL.EAR (Including Research!
PLANT SIMULATOR Test Reactor) 5 0
1-REACTOR OPERATOR (Licensed) 4-SRO INSTRUCTION 11 - SENIOR OPERATOR (Licensed) 5-EXTRA PERSON ON SHIFT IN CONTROL SHIFT SUPERVISOR (Licensed)
Rnom (13-WEEK MINIMUM)
TIME~ ON SHIFT ABOVE 20% OE 13 - STAFF/SHIFT ENGINEER (Licensed)
(6-WEEK MINIMUM) 14 - AUX/EQUIP. OPER. (Nonlicensed)
QUALIFICATION 15 - PLANT STAFF 16 -
OTHER (Specify)
NRC FORM 398 (10-90)
- 14. FACILITY OPERATOR RAINIG PROGRM.
- a.
GRADUATE OF INPO ACCREDITED OPERATOR 1
- b. CERTIFIED ON NRC FORM 474 ("SIMULATION TRAINING PROGRAM 'HAT IS BASED UPON X
YES NO FACILITY CERTIFICATION") OR NRC APPROVED X
YES NO A SYSTEMS APPROACH TO TRAINING SIMULATION FACILITY IS USED IN THE OPERATOR TRAINING PROGRAM
- 15.
FOR RENERALS ONLY
- b. DATE AND RESULT OF MOST DATE RESULT OURS OPERATED FACILITY RECENT NRC ADMINISTERED REQUALIFICATION KKAMINATION PASS FAIL E
.16.
EXPERIENCE DETAILS
- a. POSITION TITLE FROM TO
- b. FACILITY
- c.
DUTIES
- 17. COHMENTS (Specify the item number to which you are elaborating. Attach additional sheets as necessary.)
- 18. NRC FORM 396, CERTIFICATION OF MEDICAL EKEMIRATIOB BY FACILITY LICSEE, IS ATIACHE ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT.TO CIVIL AND CRIMINAL SANCTIONS.
19a..I certify under penalty of erjury that the information in this document and attachments is true and correct. I further certifr tat I have notifieg my current emjl.oer of: (1) all previous employers; (2) any instance where I have been tested by a Aealth and Human Services (HES) Certi ise Drug Teatint Laboratory or a Licensee'a testing facility for alcohol or a controlled substance, and the test results exceeded the cutoff levels established prsunt to 10 CFR Part 26-3 any instance where I have been arrested for the sale, use or possession of a controlle usubstance described in lF Part 26; and (4) any reasons for removal or revocation of unescorted access at a nuclear facility, I also authorize the NRC to submit th resut of examinat ons to my employers foruse in preparing retraining programs, as necessary.
SIGNATURE -
APPLICANT DATE CEC APPLICABLE BOX X
- b. I certify that the above named individual has successfully completed the facility licensees requirements to be licensed as an Operator/Senior Operator pursuant to Title 10, Code of Federal Regulations, Part 55' andqthat the individual has S
ed r an erator/Senior O erator license to perform his/her assigned duties and thane fac iity will be made avai tal or examination.
I also certify under penalty of perjury that the information in this document and attacmets is true and correct.
c..RENEWAL ONLY.- I certify that the above named individual meets the ap roved regalification program (with exceptions noted in Item 17 as required by section 50.54 1i-1 10 CFR 50, and that he/a e has dischar d his/her licensed responsibilities competently and safely ru alsoccertify under penalty of per ury the the information In this document and attachments istu and correct.
TRAINIG COORDINATOR SI R HARAGEMT REERESEATIVE C SITE PRINTED OR TYPED NAME PRINTED OR TYPED NAME Robert Clement P
H. E. MORGAN SIGNATURE J
1 L
i DATE SIGNATURE NO SIGNATURE REQUIRED DATE YC~
ev
.NON-CERTIFIED AFPLICATION FOR NRC USE WAIVER (Check or complete items, as applicable)
MEETS REQUIREMENTS DOES NOT MEET REQUIREMENTS(Explain below)
CATEGORY GRANTED BY DENIED BY HEADQUARTERS REGION HEADQUARTERS REGION TEN TING ELIGIBILITY MEDICAL SIGNATURE -
REVIEWER DATE OTHER NRC FORM 398 (10-90)
US. N..:IZ
. F. ft ULA CRY C C YSSIC %
CERTIFICATION OF MEDICAL EXM'INATIONS BY FACILITY LICENSEE Howard, Robert
- 'LZ L 17 Y FACILTY DOCKET NUSER San Onofre Nuclear Generating Station, Unit 1 6
A. MEDICAL E)CAMIN'ATION CERTIFICATION 5~ 5 T0:EPT:FY -AT T-
.\\'-'
FLI:ANT FO AN CRERTOR.NI,R
- PEATCR UCIE SE S E~
'x*~v: :y s.vq IED)
STATE AND LICENSE NUMiER Ex y;NATIC DATE Michael Santiago, MD CA G60318 Nov. 12, 1991 BASED ON THE RESULTS CF THE EXAMINATION. INCLUDING INFOFMATION FURN:HED BY THE APPLICANT, THE PHYSICIAN 'AS DETEMiONED THAT THE APPLICANT'S PHYSICAL CONDITION AND GENERAL HEALTH ARE NOT S'UCH THAT IT V.IGHT CAUSE OPERATIONAL ERRORS ENDANOE2iNG PUBLIC HEALTH AND SAFETYI CERTIFY THAT IN REACHING THIS DETERYMINATION.THE GUIDANCE CONTAINED IN ANSI/ANS 2.4-1;3 OR ANSIANS S.41577 (N35f WAS FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW sY NRC.
TH S'SCF THE RECOMMENDATION OF THE PHYSICIAN.
I RECOMMEND THAT THE APPLICANT'S OPERATOR LICENSE 5E CONDITIONED AS
- 1. NO RESTRICTIONS
- 2. CORRECTIVE LENSES BE WORN WHEN PERFORMING LICENSED DUTIES
- 3. HEARING AID SE WORN WHEN PERFORMING LICENSED DUTIES
- 4. RESTRICTED LICENSE OR EXCETION-Prcvet details below &-4 r*ach supporling medical eviders for NRC review.
- 5. RESTRICT ION CANCE FROM PREVIOUS SUEi7TTAL-P t
j1 &
rnim.ia for NdC rr,;du PRCPOSED WORDING OFRESTRICTION (i;xk 4 obc RELATIONSHIP OF RESTRICTION TO DISOLALIFYING CONDITION tit i
h aw recrkwion will wrrt the dia;oli.'ir con'li;onj REMARKS FOR RESTRICTION CHANGE (Block 5aboa ]
S. NONhEDICAL CERTIFICATION HIS CERTIFIES 0HAT THE APPLICANT HAS EEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DUTY REOUIREWENTS OF THIS ILI FCR LICENSED OPERATORS.
ACT ANY' FALI STATEvEST OR OWISSION INTHIS DOCUMENT iNCLUDING AT.AC.*ENTS mAYbE S:eJSCTTOCIVIL AND CRIMINAL SANC701.
I CERTIFY UNIR FENALTV OF STr E 1NFCPVXLT1-N Iw TIIS DOCUMENT AND Ai7ACHM.N.S HiS TRuE AND CORRECT.
PRINTED NAME AND SIGNATURE (Senior,Ma/jnent ;epers's0u ni.9 TITLE DATE No Signature Required, Non-Certified H. E. Morgan Application Vice President & Site Manager In secordance wies t0 CF R S5.5. Communication, this form &hall be sub-J::4 t the NRC &%
follow:
BY MAILADDRESSED TO:
R -;or.af A nIrator ii, eonI Reioal An Itrao.
Rn.on II A
- r.
- III U.S. Nuclear Reputatory Cornmisson U.S. Nuclear AaluAtiory CommInion
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(4*~ I2 U.SC. ;I'7 s-4~1.I WHETHER DISCLOSUrE IS M-ANDAICRY OR VOLUN'TAr.Y AND EFFECT ON FRI-CIPALPUFCE): Irfo,-,I;on ave on INs form s utpda i cro'rn;r INDIVIDUAL OF NOT PROVIDING
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a ACT STATME
NRC FORM 398 (FACSIMLE)
U.S..NUCLEAR REGULATORY COMMISSION APRTED BY OMB: NO. 3150-0090 DATE REIVED (10-90)
EXPIRES: 1-31-92 (To be completed by NRC) 10 CTR 55.31 55.35, ESTIMATED BURDEN PER RESPONSE TO COMPLY 55.47, and 53.57 WITH THIS INFORMATION.COLLECTION REQUEST: 2.0 HRS. FORWARD COtMENTS REGARDING BURDEN ESTIMATE TO THE INFOR MATION AND RECORDS MANAGEMENT BRANCH PERSONAL QUALIFICATION STATEMENT - LICENSEE (MBB 7714) U.S.NUCLEAR REGULATORY COM MISSION WASHINGTON DC 20555 AND TO TEE PAPtRWORK REDUCtION PROJECT (3150 0090) OFFICE OF MANAGEMENT AND BUET, TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED WASHINGTON, DC, 20503
- 1. APPLICANT'S FULL NAME (Last, First, Middle) AND ADDRES 4.TYPE OF APPLICAI (Check applicableHOT COL (include ZIP Code) 70 X
- a. NEW
- f. WAIVER REQUESTED
- HUFFMAN, GARY BERNARD JR.
- b. RENAL i
Regre 8222 Teresa Dr.
- c. UPGRADE San Diego, CA 92126
- d. MULTI-UNIT (AMEND TO INCLUDE ADD ITIONAL UNIT) e.REAPLICTIO 3-ELIGIBILITY REAPPLICATCON 1-FIRST 4-EIA
- 2. CITIESHIP
- 3. BIRTH DAE
-SECOND
- a. UITE STTESX
- 8. DATE PASSED GENERIC X
- a. UNITED STATES MONTH DAY YEAR 3-THIRD FUNDAMENTALS EXAM-r*M YY I
~
~INATION SECTION
-r b.. OTHER (Specify) 0 6
1 7
6 3
(IF APPLICABLE) 02 91
- 5. TYPE OF LICENSE APPLIED R
- 6. PREVIUS LI (S)
HELD X
- a. OPERATOR
- c. EXPIRATION DATE
- a.
DOCKET NUMBER.
RO SRO b. LICENSE NUMBER d.FACILITY DOCKET NUMBER
- b. SENIOR OPERATOR MNTH DAY YEAR
- c. LIMITED SRO 55-50
- (e.g.,
Fuel Handler) 7.NAME AND ADDR.
(Include ZIP Code) OF APPLICANTOS A
TPLOYER 1o.
cRRecT POSITIcN A FAcI
- a. PLANT SUPERINTENDENT
- i. AUXILIARY UNIT OPERATOR/
-Southern California Edison TRAINEE TURBINE BUILD P.' 0. Box 128
- b. ASSISTANT PLANT SUPERINTENDENT ING ERATOR San Clemente, CA NLI MNTO 92674-0128
- c. S SUPERVISOR (NO CENSED OPERATOR)
- d. STAFF ENGINEER DDITIONALpUNI
- 8. NAME OF APPLICANT'S FACILITY FACILITY DOCKET NUMBER
- e. SHIFT TECHNICAL ADVISOR/
San Onofre Unit 1 50-206 SHIFT ENGINEER S f.
INSTRUCTOR
- 9. ADDITIOPAL FACILITY DOCKET (Multi-unit Licenses)
- g. SENIOR CONTROL ROOM4 OPERATOR
- 2.
CONTROL RO OPERATOR
-6.PEVIOUSLICESE(11.
E)UCATIEL GB SCHOOL
- c. MAJOR AREA(S)
OF NUMBER HIGHEST DEGREE CODES
- d. VOCATIONAL /NUMBER CERTIFICATE STUDY OF YEARS DEGREE To be used for TECHNICAL OF RECEIVED GAA2G0PGHIGHEST DEONTSoY X GRDUAE EGINERIG (IELS)
UseCodes) obtained)
TYPE OF TRAINN.
.YS N
GED EQUIVALENCY Mechanical Eng 2
0 0 -NONE Nuclear Power School 6
X D1 IACERTIFICATEL O : ASSOCIATE Nuclear Prototype 7________
3
-BACHELOR
- b. NUMBER OF 4 -
MASTER YEARS OF 5 -
DOCTORAL-Y COLLEGE 2
- 12. TRAING (SINCE LAST APPLICATION
-SEE INSTRUCTIONS)
- 13. EXPERNE (DO NOT DOUBLE COUNT -SEE INSTRUCTIONS)
- a.
UNTM AND YEAR b. NUMBERB.
ANY b
NUMBER OF WEEKS YEA NBE 1-NUCLEAR POWER PLANT FUNDAMENTALS
- i. AUXILIT O P ATO
- (Classroom) 1 - RD 2-PLANT SYSTbS 2 -
EOOW/PSWO CLASSROOM OBSERATION3
- EWS/PPWS OSRaInlmne CA_(NO_
ENSDOERAOR 4 -
ESFS/CRW 3-OPERATING PRACTICE CONTROL ROOM OPERATIONS ON SHIFT 5 -
OTHER (Specify)
F.IMINSRUTO SIMULAb.R CONTRM 6OOPERATOR a.11.
EDUC 105 UPERVISOR PROGRAM COMLETED NO OTHERlHNlhffIll~ilIilh~IfIii~lI~nI (Specify)___________________
NO. OF REACTIVITY MANIPULATIONSD se d for (IncludingOFese X
PGADUTE ENIMUEER (FED)(sCoe)ObM dERCAL TYPEEA OFcudn RaINNG MOTShES N
PLANTEE.2SIMALOCIRT Test Reactor) 12 10 -
REACTOR OPERATOR (Licensed)
- 12.
INSTRUCTION L
11 - SENIOR OPERATOR (Licensed)
S-EXRLPERSON ON SHIFT IN CONTROL 12 - SHIFT SUPERVISOR (Licensed) 4 SR IRSCR ROOM (13-WEEK MINIMUM)
IONRSMA VE S
- 13.
.STAFF/SHIFT ENGINEER (Licensed)
(6-WEEK MINIMUM) 14 - AUX/EQUIP..OPER.
(Nonlicensed)
UAL FICATION D Y15 PLANT STAFF.
-OTHER (Specify) 16 -
OTHER (Specify)
NRC FORM 398 (10-90)
- 14. FACILITY OPERATOR TRAINING PROGRAH
- a. GRADUATE OF INPO ACCREDITED OPERATOR
- b. CERTIFIED ON NRC FORM 474 ("SIMULATION TRAINING PROGRAM THAT IS BASED UPON X
YES NO FACILITY CERTIFICATION" OR NRC APPROVED X
YES No A SYSTEMS APPROACH TO TRAINING SIMULATION FACILITY IS SED IN THE OPERATOR TRAINING PROGRAM
- 15. F(E REEWALS OLY I b. DATE AND RESULT OF MOST DATE RESULT HOURS OPERATED FACILITY RECENT NRC ADMINISTERED REQUALIFICATION EXAMINATION I
PASS FAIL
- 16. EXPERIENCE DETAILS
- a.
POSITION TITLE FROM TO
- b. FACILITY
- c. DUTIES
- 17. COMMENTS (Specify the item number to which you are elaborating. Attach additional sheets as necessary.)
- 18. NRC FORM 396, CERIIFICATION OF MEDICAL EKANIRATION BY FACILITY LICENSEE, IS ATTACHED ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
19a. I certify under penalty of perjury that the information in this document and attachments is true and correct.
I further certify that I have notified my current employer of: (1) all previous employers; (2) any instance where I have been tested by aibealth and Human Services (HBS) Certified Drug Testing Laboratory or a Licensee's esting facility for alcohol or a controlled substance, and the test results exceeded the cutoff levels established prsuant to 10 CFR Part 26* 3 any instance where I have been arrested for.the sale, use or possessionof a controlled substance described in 16 m Part 26; and (4) any reasons for removal or revocation of unescorted access at a nuclear facility, I also authorize the NRC to submit the results of examinations to my em oyprs for use ip preparing retraining programs, as necessary.
SIGNATURE -
APPLICANT
/.DATE CEC APPLICABLE BttK X
- b. Icertifthatsthe above named indivdual has successfully completed the facility licensees requirements to be licensed as an Operator/Senior Operator pursuant to Title 10, Code of Federal Regulations, Part 55* and that the individual has a need or an Oerator/Senior Oerator license to perform his/her assigned duties and that the facility will be made available for examination.
I also certify under penalty of perjury that the information in this document and attachments is true and correct.
- c. RENEWAL ONLY - I certify that the above named individual meets the ap roved re alification program (with exceptions noted in Item 17) as required by section 50.54 (i-1 o 10 CFR 50, and that hpae has discharged his/her licensed responsibilities competently and safely. I also certify under penalty of perjury that the information in this document and attachments is true and correct.
TERAINING 00RDINAITOR SENIOR MANAGEMENT REPRESENTATIVE 0E SITE PRINTED OR TYPED NAME PRINTED OR TYPED NAME Robert Clement PEH.
E. MORGAN SIGNATURE C1 JDATE SIGNATURE NO SIGNATURE RE UIRED DAT vL 2
NON-CERTIFIED PLICATION E
FOR NRC USE WAIVER (Check or complete items, as applicable)
MEETS REQUIREMENTS DOES NOT MEET REQUIREMENTS(Explain below)
GRANTED BY DENIED BY CATEGORY HEADQUARTERS REGION HEADQUARTERS REGION TTEN ERATING ELIGIBILITY MEDICAL SIGNATURE -
REVIEWER DATE OTHER NRC FORM 398 (10-90)
CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE Huffman, Gary FILtY jFACILITY OCKET NLA' ER San Onofre Nuclear Generating Station, Unit 1 50-206 A. MEDICAL EYA,.Y.INIATIONCER TIFICATIN 7 S S 4'T CE:E E.C.'.E
'IATFR;ZSr~~
- ~
~r~
IN ED 1I. f: :-1 5
E A%: ICENSE NvEER EAN IC T AE S. Rosen, MD CA G24823 Nov. 26, 1991 EASED ON THE RESULTS CF THE EXAMINATION. INCLUDiNG INFCAY.ATION FURNSHED BY THE APPLICANT, THE PHYSIC: AN HAS E
. MIN T
TH AFPLICANT' PHYSICAL CON:ITISN AND G.ENERAL HEALTH ARE NOT SUJCH THAT IT MIGHT CAUSE OPERATIONAL ERRc.S ENDANERING PUBLIC HEAL TH AND SAFETY, I CERT:FY THAT IN REACHING THIS DETERMINATION. THE GUIDANCE CONTAINED INANSIUANS 3.4-1553.OR AN51ANS 1!.4.197 IKI WAS FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY NRC.
ON THE EASISOF THE RECCMMENDATION OF THE PHYSICIAN. I RECDMMEND THAT THE APPLiCANTS OPERATOR LICENSE BE CONDITIONED AS FOLLiS
- 1. NO RESTRICTIONS
- 2. CORRECTIVE LENSES BE WORN WHEN PERFORMING LICENSED DUTIES 3.. HEARING AID EE WORN WHEN PERFORMING LICENSED DUTIES
- 4. RESTRICTED LICENSE OR EXCEFTION-PrCvide delaii briew a,- rucJh sui ppr;ig r
i vie for NRC review.
S. RESTRICTION CiANGE FROM PREVIOUS SUBMITTAL-Prever deaiIs brecw ad a
-r r-j ev for NRCry PROPOSED WOROING OF RESTRICTION (Elxk ebc.1)
RELATIONSHIP OF RESTRICTION TO DISOUALIFYING CONDITION (Srittly irdice: how re ic-lon wi/corrct at diI 4; co ilon)
REMARKS FOR RESTRICTION CHANGE (13=k 5abo.i)
B. NONMEDICAL CERTIFICATION THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DUTY REQUIREMENTS OF THIS FACILITY FCR. LICENSED OPERATORS T FTHSFCLT Nf FAL!E S1ATCmST OR CmISSrON INT HI DOCUMENT, ItCLUDNG ATACrwEN1S MAY BE S%.LI.ECT TO CIVIL AND CRIMINALSANCTIOI.
ICERTIFY UNtRFENALTY PEPivrY.THAT T-E INP.WA~TICN IN T.WI DrCLwmic AND *77ACHWETiS ISAE AND ORAECT.
O PRINTED NAME AND SIGNATURE Senior M.nt Reprssie on rr TITLEE No Signature Required, Non-Certified H. E. Morgan Application Vice President & Site Manager In cordance wi.h Io CFR MS. Commnm;c:i;ons, this form &hall be sab-.i.Ie the NRC a folliws: BY MAILADESSED TO:
Regiost Acmirstr.astar.
Roo I
- Regioal AAmnc;rrrutorn Ii III U.S. N.ciar Re.oy Commission U.S. Nuctar RepjIbory Commuio US. Nuci ReniIllory Cornrlson 475 Alierate Rad 101 Varrma Srrest. Suiie 31W 7?9 Rocs9),fi F King of Prussla, PA I51 Atia Ia. GA XCJ;3 Glatti.IL 60137 Rei;omal Ad kminmaor R.gIon IV Fi Armn;nrar Rep;on V D;,oor.
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DC 6CS^1 PRIVACY ACT STArEnENT wtalIcr 5 U.SC. EE1AWe131.
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NRC FCBH 398 (FACSIMILE)
U.S. NUCLEAR REGULATORY CCMMISSION APPROVED BY OMB: NO. 3150-0090 DTR IVE (10-90)
EXPIRES:
1-31-92 CFR 55.31 55.35, ESTIMATED BURDEN PER RESPONSE TO COMPLY 55.47, and 5.57 WITH THIS INFORMATION COLLECTION REQUEST: 2.0 ERS. FORWARD COMMENTS RE ING BURDEN ESTIMATE TO TEE INFOR PERSNAL UALFICAION TAMNT -LIMATION AND RECORDS MANAGEMENT BRANCH PERSOAL QALFICAIO STATET.- LICEE (MNBB 7714) U.S.NUCLEAR REGULATORY COM MISSION WASBINGTON DC 20555 AND TO THE PAPtRWORK REDUCtION FROJEfT (3150 0090) OFFICE OF MANAGEDENT AND BUDGET, TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED WASHINGTON, DC, 20503
- 1. APPLICANTiS FULL NAME (Last, First, Middle) AND ADDRESS 4.TYPE OF APPLICATION (Check applicable boxes)COLD (include ZIP Code)X O
I1CL X
- a. NEWL
- f. WAIVER REQUESTED
- JOHNSON, MICHAEL ALVAB
- b. RENEWALIT onCRees 727 Calle Camisa
- c.
UPGRADE San Clemente, CA 92672
- d. MULTI-UNIT AMEND TO 2-OPERATING (Category)
INCLUDE ADDITIONAL UNIT) 3-ELIGIBILITY
- e. REAPPLICATION
--- RT4-MEDICAL 1-FIRST-
- 2. CITIZENSHIP
- 3. BIRTH DATE 2-SECOND 5-OTHER X
UNIED SATESX g.DATE PASSED GENERIC X
- a. UNITED STATES MONTS DAY YEAR 3-THIRD FUNDAMENTAS E
EXM-MM YY jINATIONSETO
- b. OTHER (Specify) 1 0
2 8
5 8
(
NLICABLE) 02 91
- 5. TYPE OF LICENSE APPLIED FOR
- 6.
PREVIOUS LICENSE(S) BELD
- a. OPERATOR
- c. ECPIRATION DATE SENIOR OPERATOR
- b.
ENOR PEATOMONTH IDAY YEAR
- c. LIMITED SRO 55-.
50 (e.g.,
Fuel Handler) 7.RAME AND ADDRESS (Include ZIP Code) OF APPLICANTS EMPDLOYER
- 10. CURRENT POSITION AT FACILITY Southern California Edison
- a. PLANT SUPERINTENDENT X i. AUXILIARY UNIT OPERATOR/
Sout.hern Clifoni Edison TRAINEE/TURBINE BUILD SPan 0Bomnt2e
- b. ASSISTANT PLANT SUPERINTENDENT ING EU PMENT OPERATOR 92674-0128.
- c. SHIFT SUPERVISOR (N
CENSED OPERATOR)
- d. STAFF ENGINEER
- 8. NAME OF APPLICANT'S FACILIY FACILITY DOCKET NUMBER
- e. SHIFT TECHNICAL ADVISOR/
. OTHER (Specify)
San Onofre Unit 1 50-206 SHIFT ENGINEER
- f.
INSTRUCTOR
- 9.
ADDITIONAL FACILITY DOCKETS (Multi-unit Licenses)
S. SENIOR CONTROL ROOM OPERATOR
- h. CONTROL ROom OPERATOR
- 11.
EDUCATION IGB SCHOOL.
- c. MAJOR AREA(S)
OF NUMBER HIGHEST DEGREE CODES
- d. VOCATIONAL /
NUMBER CERTIFICATE STUDY OF YE ARS.
DEGREE To be usead for TECHNICAL OF RECEIVED GRAUAE NG~IN (I~)
HIGHEST DEGREE" MNH GRADUATE ENGINEERING (FIELDS)
(Use Codes) o btained)
TYPE OF TRAINING NTES GED EQUIVALENCY 0
NEIFICATE Nuclear Power School 6
X NO OTHER 2
ASSOCIATE Nuclear Prototype 6
X General 2
0 3-BACHELORX
- b. NUMBER OF 4-MASTER YEARSOF 5 -DOCTORAL COLLEGE 2
- 12. TRAINING (SINCE LAST APPLICATION -
SEE INSTRUCTIONS)
- 13.
EnTECE (DO NOT DOUBLE COUNT -
SEE INSTRUCTIONS)
- a. MONTH AND YEAR b. NUMBER a.MONTH AND YEAR b. NUMBER OF WEEKS O
NH FROM5 TO NAVY FOFt TOTH 1-NUCLEAR POWER PLANT FUNDAMENTALS FROM TO (Classroom) 1 -
RO 2-PLANT SYSTEMS 2 -
EOOH/PPW CLASSROOM2 OO/5W OBSERVATION 3.- EWS/PPWS 4 - ERSC.
3-OPERATING PRACTICE 4
_-_ERS/CRW CONTROL ROOM OPERATIONS ON SHIFT 5 - OTHER (Specify)
SIMULATOR OPERAIING (Includes Class oom)
FOSSIL SIMUATOR NAMES 6 - OPERATOR b.RW 8
mHliauilnlli 7 - SUPERVISOR.
CERTIFIED STARTUP X YES NO 8
a MMUM Mumummy 8 - PLANT STAFF PROGRAM COMPLETED 11 9 - OTHER (Specify)
NO.
OF REACTIVITY MANIPULATIONS f1(
n PLANT SIMULATOR II i
mmM UMEm COMMERCIAL NUCLEAR (Including Research/
PLANTaSItULATOR a
Test Reactor) 7==
10 - REACTOR OPERATOR (Licensed) 4-SRO INSTRUCTION 11 -
SENIOR OPERATOR (Licensed) 5-EXTRA PERSON ON SHIFT IN CONTROL 12 -
SHIFT SUPERVISOR (Licensed)
ROOM~ (13-WEEK MINIMUM)
TIME ON SHIFT ABOVE 20 13 -
STAFF/SIFT ENGINEER (Licensed)
(6-WEEK MINIMUM) 14 -
AUX./EQUIP. OPER. (Nonlicensed)
UALIFICATION 15 -
PLANT STAFF TR (Specify) 1
- OTHER (Specify)
NRC FORM 398 (10-90)
- 14. FACILITY OPERATOR TRAINING PROGRAM
- a. GRADUATE OF INPO ACCREDITED OPERATOR
- b. CERTIFIED ON NRC FORM 474 ("SIMULATION TRAINING PROGRAM THAT IS BASED UPON X
YES NO FACILITY CERTIFICATION") OR NRC APPROVED X
YES NO A SYSTEMS APPROACH TO TRAINING SIMULATION FACILITY IS USED IN TEE OPERATOR TRAINING PROGRAM
- 15. FOR EEKALS OLY
- b.
DATE AND RESULT OF MDST DATE RESULT HOURS PERATED FACILITY RECENT NRC ADMINISTERED.
REQUALIFICATION EXAMINATION PASS FAIL
- 16. EXPERIENCE DETAILS
- a. PC'.!ON TITLE FROM TO
- b. FACILITY
- c.
DUTIES
- 17. CUMENTS (Specify the item number to which you are elaborating. Attach additional sheets as necessary.)
- 18. HRC FORM 396, CERTIFICATION OF MEDICAL EAMINATION BY FACILITY LICSEE, IS ATTACHED ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
19a. I certify under penalty of gerjury that the information in this document and attachments is truo and correct.
I further ceartify that I have notified my current emloyer of: (1) all previous employers; (2) any instance where I have been tested P
by a Health and Human Services (HHS) Certi ied Drug Teat in Loratory or a Licensee's testing facility for alcohol or a controlled substance, and the test results exceeded the cutoff levels established pursatt 0CR at6
)n instance where I have been arrested for the sale, use or possession of a controlle ubstance described in 16 Pat 26 and (4) any reasons for removal or revocation of unescorted access at a nuclear facility, I also authorize the NRC to subit the results of examinations tormy employers for use in preparing retraining programs, as necessary.
SIGNATURE -
APPLICANT DATE CEECK APP.ICABLE BDK
- b. I certify that the abo named individual has successfully completed the facility licensees requirements to be licensed as3 andOperator/Senior Operator pursuant to Title 10, Code of Federal Regulations, Part 55-and that the individual has a nedTra Operator/.Senior Operator license to perform his/her assigned duties and that the facility will be made avail1able for examination.
I also certify under penalty of perjury that the information in this document and attachments is true and correct.
- c. RENEWAL ONLY - I certify that the above named individual meets the a roved re ali fication pro ram (with exceptions noted i; Item 17) as required by section 50.54 i-OR 10 CFR 50, and that he/age has discharged his/her licensed respons bilities competently and safely.ruI as certify under penalty of perjury that the information in this document and attachments is true and correct.
TRAINIG C DIKA
~SENIOR MANAGEENT REPRESENTATIVE 05 SITE PRINTED OR TYPED NAME PRINTED OR TYPED NAME Robert Clement P.
E. MRGAN SIGNATURE D(
DATE SIGNATURE NO SIGNATURE REU D
DATE
~
I SZi NON-CERTIFIED APLICATION F(
NBCUSE WAIVER (Check or complete items, as applicable)
MEETS REQUIREMENTS DOES NOT MEET REQUIREMENTS(Explain below)
CATEGORY GRANTED BY DENIED BY HEADQUARTERS REGION HEADQUARTERS REGION TTEN TING ELIGIBILITY MEDICAL SIGNATURE -
REVIEWER DATE OTHER NRC FORM 398 (10-90)
CUS S.'t.'.iR PEULATCRY OCZY:SS;C'C F
-B 1w CERTIFICATION OF MEDICAL EX MINATION
-NJ S
BY FACILITY LICENSEE X 2=4.
~~ZE
' ~ &.: LZE?.
-ks- -57c"i X
Johnson, Michael A.
tC ILI7Y FAC Lr ITV YOCKET NU BER San Onofre-Nuclear Generating Station, Unit 1
.50-206 A. MEDICAL EXAMINATION CERTIFICATION ED NA?.' isu es:.-1 STATE AND LICENSE NUtEER E
/:'ATICN ATE Steven Rosen, MD CA G24823 Nov. 18, 1991 BASED ON THE RESULTS OF THE EXAVINATION. INCLUDING INFCRY'.ATION FURNISHED BY THE APPLICANT, THE PHYSIC!AN HAS DET E
'D THAT THE APPLICANT S PHYSICAL CONDITICN AND GENERAL HEALTH ARE NOT SUCH THAT IT VIGHT CAUSE OPERATIONAL ERRCPRS ENDANiz ;-
BLIC HELTH AND SAFETY. I CERTIFY THAT IN REACHING THIS DETERMINATION. THE GUIDANCE CONTAINED IN ANsiANS14-1953.0R ANStA
. 5 SLIC HI AS FOLLOWED AND THAT DOCUVENTATION IS AVAILABLE FOR REVIEW BY NRC.
417 (8350 AS ON THE BASIS OF THE RECOMMENDATION OF THE PHYSICIAN. I RECOMMEND THAT THE APPLICANT S OPERATOR LICENSE EE CONDIT IONED AS FOLLOWSi:
- 1. NO RESTRICTIONS
- 2. CORRECTIVE LENSESEE WORN WHEN PERFORMING LICENSED DUTIES
- 3. HEARING AID SE WORN WHEN PERFORMING LICENSED DUTIES
- 4. R.ESTRICTED LICENSE OR EXCEFTICN-Prevde details below a'- rach sUPortin; me-i~j evidenot for NRC review.
- 5. RESTAICTION CWANCE FROM PREVIOIS SUEMITTAL-Prevt details btlow and sac :Poor%; rrt-eical ryeet for NRC TROPOSED WORDING OF RESTRICTION tx:k 4 aJ.o.)
RELATIONSHIP OF RESTRICTION TO DISOLALIFYING CONDITION iSodln icj:e how toi will earrct the dis;alif' in; conhonI REMARKS FOR RESTRICT ION CHANGE (Btock 5a+/-!ovJ S. NONMEDICAL CERTIFICATION THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS AND FITNES FOR DUTY REQUIREMENTSOF THIS FACILITY FCR LICENSED OPERATOR.
ESFRDT EURMNSO HSFCLT AN FALSE STATEuET OR C8. SS1 ION THIS D.ENT.
INCLUDING AT-, AC~mEN7 S. mAY11 S.E LECrT 7O CIVIL AND CRIMINAL SANCIONS.I CERTIFY VKNER PENALY OF PEP1vR-.&7 -T E I xCr..w,-IDN IN TWI DOCUMENT AND ATTACMfiS 1STRUE AND CORRECT.
PRINTED NAME AND SIGNATURE (Senior arnnm RepresentsThe on Sral TITLE CATE No Signature Required, Non-Certified H. E. Morgan Application Vice President & Site Manager In acc-rdance wth 10 CF R 55.5,Commwn c;ions, this form $hall be submiied to the NRC as foll~w: BY MAIL ADDRESSED TO:
R.ora hSF2.IRo.I.
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1a6a, GA Su33 S 7?2 Roo.eet RoIL Ailwa GA 0323Glen Eltyn, IL 601--7 Re ot.a At n.p ator, Reg; IV oral Mmi;nrator. Re;ort V D'avc.or. Division of L:*sre Performance 611. P e.rtPa.Jicry Cer*.r,of U.S. N~e tar R a9g latory Cormm kjaon and Quality E.tLstion 611 Parr P's:a Dr;-e Suitt 1 :03 14a0 W.rLa La.#, Su te 210 A-Il: 00 a-or Le-s; so ch ArI, TX 7v,1 W Cinet C'm, CA
- dSpa U.S. Nuisear Resolcory Cr-*n s or Wash;,
en.DC 20CSS PRIVACY ACT STATEMENT 1 10 S U.S.C.
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KRC FORM 398 (FACSEILE)
U.S. NUCLEAR REGULATORY COMMISSION APlOVED BY OMB: NO. 3150-0090 DA RECEIVED (10-90)
EXPIRES: 1-31-92 (To be completed by NRC) 10 CFR 55 31 55.35, ESTIMATED BURDEN PER RESPONSE TO COMPLY 55.47, and 5.57 WITH THIS INFORMATION COLLECTION REQUEST: 2.0 ERS.
FORWARD COtMENTS REGARDING BURDEN ESTIMATE TO THE INFOR MAT ION AND RECORDS MANAGEI-NT BRANCH PERSORAL QUALIFICATION STATEMENT -
LICENSE g MMBNADRCRS NG LBRC0 PERSCAL ~ALIFCAII STAI~T -LI~SE
(?B 7714) U.S. NUCLEAR REGULATORY CO4 ISSION WA5BINGTON DC 20555 AND TO THE PAPtRWORK REDUCtION PROJECT 3150 0090) OFFICE OF MANAGMENT AND BUET, TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED WASHINGTON, DC, 20503 NEN A
B E
- 1. APPLICANT'S FULL NAME (Last, First, Middle) AND ADDRESS 4.TYPE OF APPLICATION (Check applicable boxes)
OT COLD (include ZIP Code)
X
- a.
- NEW,
- f. WAIVER REQUESTED JOHNSTON, MICHAEL ARTHUR
- b. RENEWAL 29711 Saint Andrews Court
- c.
UPGRADE 2-OPERATING (Category)
Murrieta, CA 92563
- d. MULTI-UNIT (AMEND TO INCLUDE ADDITIONAL UNIT) 3-ELIGIBILITY
- e. REAPPLICATION 1-FIRST 4~IA
- 2. CITIZESHIP
- 3. BIH DATE 2-SECOND 5-OTHE X g.DATE PASSED GENERIC X
- a. UNITED STATES MONTE DAY YEAR 3-THIRD FUNDAMENTALS EXAM-M Y
INATION SECTION
- b. OTBE Seiy
- b. OTR (Specify)
- 2.
1 1
2 5
5 (IF APPLICABLE) 02
.91
- 5. TYPE OF LICENS APPLIED FOR
- 6. PREVIOS LICESE(S) HELD
-DT X
a.XOP.RNTORfc.WAIVERATIQNEDATE ba.
DOCKET NUMBER RO SRO b. LICENSE NUMBE d.FACILITY DOCKET NUMBER
- b. SENIOR OPERATOR MONTc DAY
- c. LIMITED SRO 55-M5D (e.g., Fuel Handler) 7.RAME AND ADDRESS (Include ZIP Code) OF APPLICANT'S D(PLO YER l0. Cam=N POITION AT FAILITY
- a. PLANT SUPERINTENDENT T
- i. AUXILIARY UNIT OPERATOR/
TRAINEETURBINE BUILD P. 0. Box 128
- b. ASSISTANT PLANT SUPERINTENDENT
-INGEU PMNT OPERATOR San.
REAPPLICATION Sa lmne A92674-10128
- c. SHIFT SUPERVISOR (NO CENSED OPERATOR) 3._BIRTHDAE 2-d.
STAFF ENGINEER 8.~~~~~~~I APLIABE 02 91c AILT AIIY OKTNM E OF LIC S ALI ER
- e. SHIFT TECHNICAL ADVISOR/
OTHER (Specify)
San Onofre Unit 1 50-206
.SHIFT ENGINEER X a.OPERATORc.EXIRAEf.
INSTRUCTOR
- 9. ADDITIOAL FACILITY DO aD E
(Multi-unit Licenses)
- g. SENIORCONTROL RO DAY OPERATOR
- h. CONTROL ROOM OPERATOR c.LIMITEDSRO-5EDUATI 7 GA SCHOOL
- c. MAJOR AREA(S) OF NUMBER HIGHEST DEGREE CODES
- d. VOCATION NUMBER CERTIFICATE STUDY OF YEARS DEGREE fodisonr ICAL.
F RECEIVED HIGHEST DEGREE' MONTHS X GRADUATE ENGINEERING (FIELDS)
_Use Codes) obtained)
TYPE OF TRAINING
.YES NO GED EQUIVALENCY 0B0
-xNONE1 1 -nCERTIFICATE NO OTE 2
-ASSOCIATE Nuclear Prototype 6
X General 1
0 3 -BACHELOR
- b. NUMBERPOF S4 MASTER YEARS OF 5
DOCTORAL COLLEGE 1
i
-i
- 12. TRAINII9 (SINCE LAST APPLICATION -
SEE INSTRUCTIONS)
- 13.
O)(DO NOT DOUBLE COUNT SEE INSTRUCTIONS)
- a. A PNT AND YEAR. NUMBER a.ONTH AND YEAR b. NUMBER FO TO OF WEEKS NAYOF MNTHS S1-NUCLEAR POWER PLANT FUNDAMENTALS 2FR-To (Classroom) 1___
1-RO
- 2-PLANT SYSTEM 2 -
EOOW/PPWO CLASSROOM4 OBSERVATION
.3-ESP~J 3-OPERATING PRACTICE
- ERS/CRU CONTROL Rb OPERATIONS ON SHIFT 5 - OTR (Specify)
SIMUXATOR OPERATINGIE Electrical tr (Includes Classroom)
FOSI SIMULATOR.NAS 6 -
OPERATOR NO OTHE~~~~~eneral 1
1 2-BSH OE ulerPrtoye
- b. U i OF S
SUPERVISOR CEAREGEF8
- PA T STAFF CERTIFIED STARTUP X YES1 No PROGRAM CMOTLETED A
YEA OTO MO (Specify)
NOFOF REACTIVITY MANIPULATIONS LAN P R
A NALNEAR (Including Re eaFrch/
-CPLANT IMTEM Test Reactor) 10 - REACTOR OPERATOR (Licensed) 4-SRO INSTRUCTION 11 - SENIOR OPERATOR (Licensed) 5-EXTRA PERSON ON SHIFT IN CONTROL 12 -
SHIFT SUPERVISOR (Licensed)
ROOM4 (13-WEEK MINIMUM)_________
- a. TIME ON SHIFT ABOVE 20%POE 13 - STAFF/SHIFT ENGINEER (Licensed)
(6-WEEK MINIMUM) 14 - AUX/EQUIP. OPER. (Nonlicensed)
UL ATION 15 -
PLANT STAFF n
cify) 16 - OT (Specify)
NRC FORM 398 (10-90)
- 14. FACILITY OPERATOR TRAINING PROGRAM
- a. GRADUATE OF INPO ACCREDITED OPERATOR
- b. CERTIFIED ON NRC FORM 474 ("SIMULATION TRAINING PROGRAM THAT IS BASED UPON X
YES NO, FACILITY CERTIFICATION") OR NRC APPROVED X
YES NO A SYSTES APPROACH TO TRAINING.
SIMULATION FACILITY IS USED IN THE OPERATOR TRAINING PROGRAM
- 15. FOR RENEALS CHLY
- b.
DATE AND RESULT OF MOST DATE RESULT HOURS OPERATED FACILITY RECENT NRC ADMINISTERED REQUALIFICATION EXAMINATION PASS FAIL
- 16.
EKFERIENCE DETAIIS
- a. POSITION TITLE FROM TO
- b. FACILITY
- c. DUTIES
- 17. COMIENTS (Specify the item number to which you are elaborating. Attach additional sheets as necessary.)
- 18. NEC FCRM 396, CERTIFICATION OF MEDICAL EKAMINATION BY FACILITY LICENSEE, IS ArTACHED ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
19a. I certify under penalt of erjury that the information in this document and attachments is true and correct.
I further certi that I hsve ie (curent emloyer of: (1) all previous employers; (2) an instance where I have been tested by a Wealth and Hmn Sries RS Cr ied Drua Tes ng Lhoratory or a Licensee's teating facility for alcohol or a controlled substance, and the test results exceede the cu off levels established pursuant to 10 CFR Part 26 3
instance where I have been arredted for the sale, usC or possession of a controlle substance described in 16 rt 26; and (4) any reasons for removal or revocation of unescorted access at a nuclear facility, I also authorize the NRC to subait the results of examinations to my employers Ar uo in preparing retraining programs,. as necessary.
SIGNATURE - APPLICANT JDATE CEC APPLICABLE BO0 X
- b.
I certify that the above named individual has successfully completed the facility licensees requirements to be licensed as an Operator/Senior Operator pursuant to Title 10, Code of Federal Regulations, Part 55i and hat the individual has a need or an Operator/enior Oerator license to perform his/her assigned duties and that the facility will be made able for examination.
I also certify under penalty of perjury that the information in this document and attachments is true and correct.
- c. RENEWAL ONLY - I certify that the above named individual meets the apiroved re alification program (with exceptions noted in Item 17 as required b section 50.54 (i-1 o 10 CFR 0, and that b e has discharaedhis/er liee r
bilities compeently d
also certify under penalty of perjury the the information in this document and attachments is true and correct.
TRAINING COORDINATR SENICR MANAGEMENT REPRESENTATIVE 0N SITE PRINTED OR TYPED NAME PRINTED OR TYPED-NAME Robert Clement P.
E. MORGAN SIGNATURE DATE SIGNATURE NO SIGNATURE REUIRED DATE LU z-NON-CERTIFIED APLICATION DT FCR NC USE WAIVER (Check or complete items, as applicable)
MEETS REQUIREMENTS DOES NOT MEET REQUIREMENTS(Erplain below)
CAEOYGRANTED BY DENIED BY CATEGORY HEADQUARTERS REGION HEADQUARTERS REGION ITTEN TING IGIBILITY MEDICAL SIGNATURE - REVIEWER DATE OTHER NRC FORM 398 (10-90)
NPC Form 396 U.S. NUCLEAR REGULATORY COMMISSION TD V OMB:
N3 3!X-=4
- 191)
ESPIRES: 75.4 0 C -5 3. 5 57 5 :7, 5 3E1.IAATE5 O57W N PER RESPONSE 10 Courty w.4 Tws INORMATON CO..ECTION REOEST:
ki
. FO AqD CERTIFICATION OF MEDICAL EXAMINATION COMMENTSEGAFONGBURDENESTRAETCTEINFORMAION BY FACILITY LICENSEE N
nTO N C AND TO rHE PAPERN0KREOUCioN PROJECT (3150=4),
OFFICE OF MANAGEJENT AND BUDGET, WSGTON. DC 205w.
NAME OF APPLICANT M~ichael Arthur John-,fan FACILITY FACILITY DOCKET NUMBER SONGS UNIT 1 50-206 A. MEDICAL EXAMINATION CERTIFICATION THIS IS TO CERTIFY THAT THE ABOVE NAMED APPLICANT FOR AN OPERATOR/SENIOR OPERATOR LICENSE HAS BEEN EXAMINED BY A PHYSICIAN.
PRINTED NAME (olphysician)
STATE AND LICENSE NUMBER EXAMINATION DATE Steven Rosen, M.D.
Calif. G24823 10-29-91 BASED ON THE RESULTS OF THE EXAMINATION. INCLUDING INFORMATION FURNISHED BY THE APPLICANT, THE PHYSICIAN HAS DETERMINED THAT THE APPLICANT'S PHYSICAL CONDITION AND GENERAL HEALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPERATIONAL ERRORS ENDANGERING PUBLIC HEALTH AND SAFETY. I CERTIFY THAT IN REACHING THIS DETERMINATION, THE GUIDANCE CONTAINED IN ANSI/ANS 3.4-1983. OR ANSI/ANS 15.4-1977 (N380) WAS FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY NRC.
ON THE BASIS OF THE RECOMMENDATION OF THE PHYSICIAN. I RECOMMEND THAT THE APPLICANT'S OPERATOR LICENSE BE CONDITIONED AS FOLLOWS:
- 1. NO RESTRICTIONS
- 2. CORRECTIVE LENSES BE WORN WHEN PERFORMING LICENSED DUTIES
- 3. HEARING AID BE WORN WHEN PERFORMING LICENSED DUTIES
- 4. RESTRICTED LICENSE OR EXCEPTION-Provide details below and attach supporting medical evidence for NRC review.
- 5. RESTRICTION CHANGE FROM PREVIOUS SUBMITTAL-Provide details below and attach supporting medical.evidence for NRC review.
PROPOSED WORDING OF RESTRICTION (Block 4 above)
EL.ATIONSHIP OF RESTRICTION TO DISQUALIFYING CONDITION 8/riefly indicate how rerctioI will corac the disqualifying condition)
REMARKS FOR RESTRICTION CHANGE (Block Sabove)
S. NONMEDICAL CERTIFICATION THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DUTY REQUIREMENTS OF.THIS FACILITY FOR LICENSED OPERATORS.
ANY FALSE STATEMENT OR OM SSION INTHIS DOCUMENT. INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS. I CERTIFY UNDER PENALTY OF P ERJURY.THAT THE INFORMATION IN THI1S DOCUMENT AND ATTACHMENTS IS TRUE AND CORRECT.
PRINTED NAME AND SIGNATURE (Senior Management Repr riveon Sire; TITLE DATE No Signature Required, Non-Certified Application Vice President &. Site Manager H. E. Morgan In accordance with 10 CFR 55.5. Communications, this form shall be submitted to the NRC as follows: BY MAIL ADDRESSED TO:
Regional Administrator. Region I Regional Administrator. Region II RegionalAdministralor. Region IIl U.S. Nuclear Regulatory Commission U.S. Nuclear Regulatory Commission U.S. Nuclear Regulatory Commission 475 Allendale Road 101 )arierta Street. Suite 3100 799 Roosevelt Road King of Prussia, PA 19406 Atlanta, GA 30323 Glen Ellyn, IL 60137 Regional Administrator, Region IV Regional Administrator, Region V Direor. Division of Ucensee Performance U.S. Nuclear Regulatory Commission U.S. Nuclear Regulatory Commission and Quality Evaluation 611 Ryan Plaza Drive, Suite 1000 1450 Maria Lane. Suite 210 Ann: Operator Licensing Branch Arlington. TX 76011 Walnt Creek,, CA 94596 U.S. Nuclear Regulatory Commission Washington, DC 20555 PRIVACY ACT STATEMENT Pursuant to 5 U.S.C. 552s013), enacted into law. by section 3 of the Privacy Act of ROUTINE USES: The information may be disclosad to an a ppropriat Federal Stae. o 1974 (Public Law 93.579), the following r~smrrt it 'nithed to individuals who local aedy in the event the information indicates a violation or potential violation of law supply information to the U.S. Nuclear R9g4.a5ory Commission on NRC Form 36.
and in the avant the information indicates a violation or potental violation olaw and in This rmatio is maintained in a system of records designated as NRC16 and.
the cour-e of an administrative or judicial proceeding. In addition, this information may be
$e1cvibvO ar 55 Fooral Regirer 33978 IAugur 20, ra90.
trnfered to an appropriate Federal. State. and local agency to the extent relevant &no AUTHORITY: Sections 107 and 161i) of the Atomic Energy Act of 1954. as nocessary for an NRCdecision about you.
amended (42 U.S.C. 2137 and 2201(i)).
WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON PRINCIPAL PURPOSE(S): Information errered on this form is used to determine INDIVIDUAL OF NOT PROVIDING INFORMATION. Diclosure s volunary. if the whether the physical condition and general heaih of the applicant are such that they recusited information is not provded. however the application for a Iaciboy operators will not cause operational errors endangering public health and safety. This informa.
or enororator's licen may be denied.
tion may be used by the NRC ratf to etermine if the indivdual meris the e*uire-SYSTEM MANAGER(S) AND ADDRESS: Ch'vi Ope,)or Lcansxg Branch. Otice of rnerts of 10 CFR 55 to take an examritiorr or to re snue-d an operator's lInse t Nuclear Peactor anulsation U.S. Nuclear Raouaiogr Conmison, Washrorn.
DC 2ay5b NcC FORMe o
n4N)
RC FORM 398 (FACSIMILE)
U.S. NUCLEAR REGULATORY CCMIlSSION APPROVED BY CHB: NO. 3150-0090 (0-90)
EXPIRES: 1-31-92 0 CFR 55 31 55.35, ESTIMATED BURDEN PER RESPONSE TO COMPLY (To be completed by NRC) 55.47, and 5.57 WITH THIS INFORMATION COLLECTION RE T: 2.0 ERS.
FORWARD COMENTS RE ARDING BURDEN ESTIMATE TO THE INFOR PERSONAL QUALIFICAIC STAET - LICENSEE MATION AND RECORDS MANAGEMNT BRANCH FEL-RAL UALIICAIO11 STAEMET - ICEREE(MNBB 7714 U.S.NUCLEAR REGULATORY COM ISSION W AINGTON DC 20555 AND TO THE PAP WORK REDUCtION PROJECT (3150 0 OFFICE OF MANAGEDENT AND BUDGET, TO REAIN VALID, THIS FORM MUST NOT BE ALTERED WANHINGTON, DC, 20503
- 1. APPLICANT'S FULL.AME (Last, First, Middle) AND ADDRESS 4.TYPE OF APPLICATION (Check applicable boes) X HOTCOLD (include ZIP Code)_I qO D L
a.NWf.
WAIVER REQUESTED
- JOZWIAK, CHET WAYNE
- b. RE R
634 Quail Dr.
- c. UPGRADE Lake Elsinore, CA 92530
- d. MULTI-UNIT AtEND TO INCLUDE ADDITIONAL UNIT)
- 2. REAPPLICATION X1-FITSTA4-MEDICAL
- b.
OTEER(Specify
- 2. CITIZESHIP
- 3. BIRTH DAE 2-SECOND 5
.DATE.PASSED GENERIC X
- a. UNITED STATES tENTH DAY YEAR 3-THIRD FUNDAMENTALS 1*1 YY
- b. OTER (peciy) 4INATION SECTIONM 01 O 0 7
6 (IF APPLICAB 02 91
- 5.
TYPE OF LICEnS APPLIED FOR
- 6. PREVIOUS LICENSE(S) BEI.D.
X aOPERATOR
- c. EXPIRATION DATE b.SEIO PEATRa.
DOCKET NUMBER RD SRO b. LICENSE NUMBER DAY d.FACILITY DOCKET NUMBER
- d.
STINUNI NPRTRDA O
2Y PRAIGACteoR C.LIMITED SRO 55-J -7 I
1 1 50-:
(e.g.,
Fuel Handler) 7.1111 AND ADRES (Include ZIP Code) OF AFPI.CANT'S EMPLOYER 10.. CURRENT POSITION AT FACILITY N
UERAUXILIARY UNIT OPATOR Southern California Edison A
PITNLJ INEETURBINE BILD P. 0. Box 128
- b. ASSISTANT PLANT SUPERINTENDENT INGqU PMNT OPERATOR San Clemnente, CA 927-18c HF UEVSR(NONLCENSED OPERATOR) 92674-028
- c.
HIFT-SUDIVISO
- d. STAFF.ENGINEER 2-SECOND
.Y OTHER (Specify) e.X SHIFT TECHNICAL ADVISORG San Onofre Unit 1 50-206 SHIFT ENGINEER INATININSTRUCTOR
- 9. ADDITIOAL FACILITY DZT (Multi-unit Licenses) gs.
SENIOR CONTROL ROO OPERATOR
- h. CONTROL RO OPERATORE R c.LIMITEDS511.
EDA IGE SCHOOL
- c. MAJOR AREA(S) OF NUMBER
- HIGHEST, DEGREE CODES
- d. VOCATIONAL INUMBER CERTIFICATE STUDY OF YEARS DEGREE To be used for, TECHNICAL OF RECEIVED (eINERNg.,ES FuelES Dandler) 50-H -ESF 7.GRADUATE ES.(
I NG IELD)
(Use Codes) obtained)10.
PE OF CTIINT No GED EQUIVALENCY 0 -NONE Nuclear Power School 6
X NO O
TlBHER8A 1
.CERTIFICATE P
92674H0122 ASSOCIATE Nuclear Prototype (
3 BACHELOR
- b.
NUMBEROF S
T T-MASTER YEARS OF 5-DOCTORAL COLLEGE 0
R 12 TRAINI G (SINCE LAST APPLICATION (SEEINSTRUCTIONS)
- 13. aE RIE (DO NOT DOUBLE COUNT SEE INSTRUCTIONS YES
_NO
- a. MONTH AND YEAR b NUMBER a.MONTH AND YEAR b. NUMBER Of WEEKS OF MONTHS FROMI TO NAVYFRN T
1-NUCLEAR POER PLANT FUNDAMENTALS -V_
FROM TO O
ON (Classroom) 1 -
RO 2-PLANT SYSTEMS 2 - EOOW/PPWO CLASSROOM2 O0/PW 3 -
EWS/PPWS OBSERVATION 4 - ERS/CEW 3-OPERATING PRACTICE CONTROL ROOM OPERATIONS ON SHIFT 5 - OTHER (Specify)
SIMULATOR OPERATING (Includes Classroom)
FOSSIL SIMULATOR NAMES 6 -OPERATOR a.,Unit 1 liffilliillilf ill ilm UPERVISOR
- b.
CERTIFIED STARTUP X YES I NO PROGRAM COMPLETED m
9 - OTHER (Specify)
NO.
OF REACTIVITY MANIPULATIONS 11 ilfl 11111!
1 [IIIill~ ~*
IAL NUCLEAR (Including Research/
PLANT SIMULATOR 4
Test Reactor) 10 1 t 101 REACTOR OPERATOR (icesd 4-SRO INSTRUCTION 11 --
SENIOR OPERATOR (Licensed) 5-EXTRA PERSON ON SHIFT IN CONTROL 12 - SHIFT SUPERVISOR ROOM4 (13-WEEK MINIMUM)
(Licensed)________
- a.
I~ONSHFT BOE 0Z13
- STAFF/SHIFT ENGINEER (Licensed)
(6-WEEK MINIMUM)
!II ilin14-AUX./EQUIP. OPER.(Nonlicensed)
EQUALIFICATION 15 - PLANT STAFF 1: Ir-OTER (Specify) 16 - OTHER (Specify)
NRC FORM 398 (10-90)
- 14.
FACILITY OPERATOR TRAINING PROGRAM
- a. GRADUATE OF INPO ACCREDITED OPERATOR
- b. CERTIFIED ON NRC FORM 474 ("SIMULATION TRAINING PROGRAM THAT IS BASED UPON X
YES NO FACILITY CERTIFICATION" OR NRC APPROVED X
YES NO A SYSTEMS APPROACH TO TRAINING SIMULATION FACILITY IS ED IN THE OPERATOR TRAINING PROGRAM
- 15.
FOR RERALS ONLY
- b.
DATE AND RESULT OF MOEST DATE RESULT' OURS OPERATED FACILITY RECENT NRC ADMINISTERED REQUALIFICATION EXAMINATION PASS FAIL
- 16. EXPERIENCE DETAILS
- a. POSITION TITLE FROM TO
- b. FACILITY
- c. DUTIES
- 17. COENTS (Specify the item number to which you are elaborating. Attach additional sheets as necessary.)
- 18. RRC FORM 396, CERTIFICATION OF MEDICAL EKhMINATION BY FACILITY LICENSEE, IS ATTACEED ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
19a. I certify under penalty of perjury that the information in this document and attachments is true and correct. I further certify that I have notifie8 my current employer of: (1) all previous employers; (2) any instance where I have been tested by aealth and Human Services (HES) Certiiead Drug Teatin Laboratory or a Licensee's testing facility for alcohol or a controlled substance, and the test results exceeded the cutoff levels established pursuant to 10 CFR Part 26
- 3) any instance where I have been arrested for the sale, use or possession of a controlled substance described in 16 CR Part 26; and (4) any reasons for removal or revocation of unescorted access at a nuclear facility, I also authorize the NRC to submit the results of examinations,to my employers for use in preparing retraining programs, as necessary.
SIGNATURE -
APPLICANT (4FL DATE
/1 CHECK APPLICABLE BOK X
- b. I certify that the above named individual has successfully completed the facility licensees requirements to be licensed as an erator/Senior Operator pursuant to Title 10, Code of Federal Regulations, Part 55* and that the individual has a need or an Operator/Senior Operator license to perform his/her assigned duties and that the facility will be made available for examination.
I also certify under penalty of perjury that the information in this document and attachments is true and correct.
- c. RENEWAL ONLY -'I certify that the above named individual meets the ap roved realification program (with exceptions noted in Item 17) as required by section 50.54 (i-1 oZ 10 CFR 50, and that hp/ae has discharged his/her licensed res onsibilities competently and safely.
Ia so certify under penalty of perjury the the information In this document and attachments is true and correct.
TRAINING 000RDEIATOR SEIOR MAAGMNT REPRESENTAIVE ON SITE PRINTED OR TYPED NAME PRINTED OR TYPED NAME Robert Clement H. E. MORGAN SIGNATURE O LL L
DATE r
SIGNATURE NO SIGNATUREDRE UIREDTIN JDATE GO~~j LI CCy V -(?.
NON-CERTIFIED APPLICATION F
KRC USE WAIVER (Check or complete items, as applicable) lEETS REQUIRMENTS DOES NOT MEET REQUIREMENTS(Explain below)
GRANTED BY DENIED BY CATEGORY HEADQUARTERS REGION HEADQUARTERS REGION TEN TING LIGIBILITY MEDICAL SIGNATURE REVIEWER DATE OTHER NRC FORM 398 (10-90)
- PC S 6
- S:E GUL AORY CZYySSIC%
CERTIFICATION OF MEDICAL EX M INATION BY FACILITY LICENSEE
- San Onofre Nuclear Generating Station, Unit 1 50--206 A. MEDICAL EYAMINATION CERTIFICATI C 5 S
-:F Y\\
. - A r
T C R L i 7 -E -= 0 o
%C
- STAE AND LICENSE N'BER Ex AT ICN DATE Q, e CI In CLC-C O V j
Nov. 05, 1991 ASED ON TSE Rst S OF TE ExAV NAn N.L tNG INFOFMATION FURNISHED BY THE AFPLICANT. TE PHYSICIAN HAS DET EM.%O THA TTE 4PPLicaS PiYs;cAL CONDIION-4 AND GENRAL H
LTH ARE NOT SUCH THAT IT MIGHT CAUSE OFERATICNAL ERRORS ENDANGERING PUSLIC HEALTH AND SAFETY, I CERTIFY THAT IN REACHING THIS DETERMINATION.THE GUIDANCE CONTAINED INANSIANSA.14-13,CR ANSI,'ANS15.4-1977 iNID) WAS FOLLOWED ANDTHAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY NRC.
ON THE BASISOF THE RECOMMENDATION CF THE PHYSICIAN, I RECOMMEND THAT THE APPLICANT'SOPERATOR LICENSE BE CONDITIONED AS FOLLOYWS:
- 1.
NO RESTRICTIONS
- 2. CORRECTIVE LENSES SE WORN WHEN PERFORMING LICENSED DUTIES
- 3. HEARING AID SE WORN WHEN PERFORMING LICENSED DUTIES
- 4.
RESTRICTED LICENSE OR EXCEPTIN-P:vde details below are ch s
- nring r-dicI evidenos for NRCreview.
- 5. RESTRICTicN CRjANGE FRCMe PREVIOUS SUIIAL-Pee:Is b
_wa a:
p~rti-; reicl ev a for NRC rivie.
POSED WORDING OF RESTRICTION (Sixk isk.5)v]
RELATIONSHIP OF RESTRICTION TO DISOLALIFYING CONDITION(Sriefly uirdleshow ri-on wilcorret t di l
REMARKS FOR RESTRICT ION CHANGE (Block 5ao)
B. NONMEDICAL CERTIFICATION THIS CERTIFIES TAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DUTY REOUIREMENTS OF THIS FACILITY FCR LICENSED OPERATORS.
ANY FAL!E STATEMENT OE OviCSiOU IN TWS OCLvNT INCLUING ATACENTS MAY sE S.ECT TO CIVIL AND CAIMIN&L S4NC IOkL I CERTIFY UN EA PENALTY OF PEJt;Ry T H1AT _ HE IUTFY.ATICN IN THIS D061 'tNT AND ATTACNM. ENT S IS TMUE AND COARECT.
FRINTED NAME AND SIGNATURE ISen;or MA!er.-vent Represernwrtijo
)
TITLE DATE No Signature Required, Non-Certified H. E. Morgan Application Vice President
& Site Manager In accoreance with 10 CFR M5S. Commuc.Aea:ions, this form shall be submined the NRC s follo.-: BY MAIL ADDRESSED TO:
Rteg.Ror.al Adminimar.tor. Rmreoon I
II p..1;raf RoPe..on it U.S. NuclNear Reglatory Comm;u;on U.S. Nuorar Ry.i!slory CoComimiio 47S5 Airendsie Reid 101 Vrfrr.1 Stnert.
Suite 3100 7?
Rozu-th Road King of Pruss:a, PA 19406 Atlanta. GA X323 Gian Ellyn. IL 60137 RcG;oxal Admnim.mator.
Rno IV A m;hinrslor* Reqom V D'vmor D;,;%
of L;c#mts Pirformarce U.S. NuCItar R6 tiJuory Commision U.S. N ir Roog.,Ialory Co.;on sr4 Ovaaiiy Eaaiaon 611 Plan P!aa Ore,. Sr.h 1000 1450 LA.. Suite O 210
.Ann:
Owsloc S BnrJ%
ArltN.ttU. TX 76S11 Nuclar Ce.
oA Co mno U.S. Nclear Re.p.ilat ory Cor-missjon Wa;nz.
DC 2CES5 PRIVACY ACT STEAlnL&
E1NT p.'.Ant 10 U.S.C.
tBa ce-3 ; r.o 'a-ty icton 3 of llt Pi..cy Aci It ROUTINE USES: Th
- . nfor~rr.;o my t-o d~d~
to am appmpe'ais rv,.
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(Y ACETHER DISCLOSSE RE IS TANEAICRY R VOLUTAY AD EFFECT TRI:;PAL Pons0 1
Iu!oy Com m
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INDIVIDuAL OF NOT PAO'o lDidG. a VATION o ;I g at v c:'
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- d. at C '$ a th e-c d ofC i yr-s;on a r o
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!desti 1,
a s c AUTHCITY:
S. tr
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trardnc toanh
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SYSTEM
.ANAGERIS)
AND ADDFE:S: Cm:1.
O;-talor L*:*..*g B*a*cn, Ost..
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U.& Nuce'ar Fe..alaey ce'* as A...
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NRC FORM 398 (FACSMILE)
U.S. NUCLEAR REGULATORY COMMISSION AFFRVE BY O:
NO. 3150-0090 0)R5 15.5 EXPIRES: 1-31-92 (To be completed by NRC) 0CFR 553 5.5, ESTIMATED BURDEN PER RESPONSE TO COMPLY 55.47, WITH THIS INFORMATION COLLECTION REQUEST: 2.0 ERS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE INFOR ERmSOAL QALIFICATION STATEMENT -
IDE E
MATINBAND RECORDS MANAGEMENT BRANCH FP2SEAL~IALFICII~STAI~EN I~SE (NESB 7714U US NUCLEAR REGULATORY COM ISSION W
INTON DC 20555 AND TO THE PAPtRWORK REDUCtION PROJECT (3150 0090) OFICE OFMANAGEENT ANDBUDGET TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED WAS0NGONCEDOF MONAGEMENT AND BD2GET, 1 APLICANTiS FULL RAME (Last, First, Middle) AND ADDRESS 4.TYPE OF APPLICATION (Check applicable boxes) X HOT COLD (include ZIP Code)
LX
- a. NEW WAIVER REQUESTED MCGAULEY, MICHAEL GERALD b.stf RNALRI NonCReeify
- b. RENEWAL WRT Ctgr 3545 Paseo De Francisco # 231
- c.
UPGRADE Oceanside, CA 92056
- d. MULTI-UNIT (AMEND TO 2-OPERATING (Category)
INCLUDE ADDITIONAL UNIT) 3-ELIGIBILITY
- e. REAPPLICATION 4-MEDICAL 1-FIRST
- 2. CITIZENSHIP
- 3. BIRTH DATE 2-SECOND T
- a. UNITED STATES HONTH DAY YEAR 3-THIRD X g.DATE PASSED GENERIC INATION SCTION M
y
- l.
OTHER (Specify) 0 9
1 7
6 2
(IF APPLICABLE) 02 91
- 5.
TYPE OF LICENSE APPLIED FOR
- 6. PREVIOUS LICERSE(S) HEED X
- a. OPERATOR
- c. EXPIRATION DATE b.OEOROPERATOR
- a.
DOCKET NUMBER RO SRO b. LICENSE NUMBER O
DA d.FACILITY DOCKET NUMBER b.SNOROEATRMNTH DAY I.AILT AOKE UME
- c. LIMITED SRO 55-0 (e.g., Fuel Handler) 50 7.NAME AND ADDRES (Include ZIP Code) OF APPLICANT'S EMPLOYER
- 10. CURRENT POSITION AT FACILITY Southern California Edison
- a.
PLANT SUPERINTENDENT X i. AUXILIARY UNIT OPERATOR/
P. 0. Box 128 L_
TRAINEE TURBINE BUILD SanClement28 CA
- b. ASSISTANT PLANT SUPERINTENDENT IN E U MNT OPERATOR 92674-0128
- c. SHIFT SUPERVISOR (NO CENSED OPERATOR)
- d. STAFF ENGINEER
- 8. NAME OF APPLICANT'S FACILITY FACILITY DOCKET NUMBER
- e. SHIT ECNAL ADVISOR/ [
OTHER (Specify)
San Onofre Unit 1 50-206 SHIFT ENGINEER f.
INSTRUCTOR
- 9. ADDITIONAL FACILITY DOCKETS (Multi-unit Licenses)
- g. SENIOR CONTROL ROOM OPERATOR
- b. CONTROL ROOM OPERATOR
- 11.
EDUCATION IGE SCHOOL
- c. MAJOR AREA(S) OF NUMBER HIGHEST DEGREE CODES
- d. VOCATIONAL /
NUMBER CERTIFICATE STUDY.
OF YEARS DEGREE 1,HIGHe used for
.TECHNICAL OF ER RECEIVED IGETDEGREE" X GRADUATE ENGINEERING (FIELDS)
(Use Codes) obtained)
TYPE OF TRAINING MONTHS TYPE OFTRAININ YES NO GED EQUIVALENCY Computer 2
2 0
NONE Nuclear Power School 6
X NO OTHER1-CERTIFICATE N
F G
r 2 -
ASSOCIATE Nuclear Prototype 6
X b.NMRO Gene ral 10 3-BACHELOR b.NER OF-4 MASTER COLLEGE
.3J
_5 DCOA
- 12.
RAINING (SINCE LAST APPLICATION - SEE INSTRUCTIONS)
- 13. EERIENCE (DO NOT DOUBLE COUNT - SEE INSTRUCTIONS)
- a. MDNTH AND YEAR b. NUMBER a.M4NTH AND YEAR b NUMBER OF WEEKS a.OToADYA b
NMBE FROM TO OFWES NAVY FROM TO MNH 1-NUCLEAR POWER PLANT FUNDAMENTALS FROMTO_
RV__FRO TO MONTES (Classroom) 1 -
RO 2-PLANT SYSTEMS 2 -
EOOW/PPWO CLASSROOM OBSERVATION 3 -
EWS/PPWS 3-OPERATING PRACTICE 4
ERS/CRW CONTROL ROOM OPERATIONS ON SHIFT 5 - OTHER (Specify)
SIMULATOR OPERATING (Includes Classroom)
FOSSIL SIMULATOR NAMES Immfi MINH 6_-_OPERATOR a.I Uni 1ili A
Mimliflffll i~
m munm
- b.
11 1
W 7 - SUPERVISOR CERTIFID STARTUP X E N101WBM 815MI 8 - PLANT STAFF PROGRAM COMPLETED HWI N l
I I
9illlliiij OTHER (Specify)
NO. OF REACTIVITY MANI PUL.ATIONS If MlilIII~fIIII~IIiIII~IillJII 11nh1111111ji PLANT IMULAOR I
OMMERIAL NUCLEAR (Including tR;eerch/
PLAiNTtimlamIlMmmLAmmmmmRmnTest Reactor) 6 I III~~~lillilililfililiffi fillulilifilffilillilutiilTllllilRelllil 6
10 -
REACTOR OPERATOR (Licensed) 4-SRO INSTRUCTION 11 -
SENIOR OPERATOR (Licensed) 5-EXTRA PERSON ON SHIFT IN CONTROL 12 - SHIFT SUPERVISOR (Licensed)
ROt (13-WEEK MINIMUM)
TIME ON SHIFT ABOVE 20% PER----
13 -
STAFF/SHIFT ENGINEER (Licensed)
(6-WEK AMINIMUM) 14 - AUX./EQUIP. OPER. (Nonlicensed)
QT15-PLANT STAFF THER (Specify) 16-OTHER (Specify)
NRC FORM 398 (10-90)
- 14.
FACILITY OPERATO TRAINING PROGRAM
- a. GRADUATE OF INPO ACCREDITED OPERATOR
- b. CERTIFIED ON NRC FORM 474 ("SIMULATION TRAINING PRORAM THAT IS BASED UPON X
YES NO FACILITY CERTIFICATION" OR NRC APPROVED X
YES NO A SYSTEMS APPRCACH TO TRAINING SIMULATION FACILITY IS SED IN TEE OPERATOR TRAINING PROGRAM
- 15.
FOR RENEWALS ONLY
- b. DATE AND RESULT OF MDST DATE RESULT HOURS OPERATED FACILITY RECENT NRC ADMINISTERED REQUALIFICATION EXAMINATION PASS FAIL
- 16. EXPERIENCE DETAILS
- a. POSITION TITLE FROM TO
- b. FACILITY
- c. DUTIES
- 17. CCHIENTS (Specify the item number to which you are elaborating. Attach additional sheets as necessary.)
- 18.
NRC FOBM 396, CERTIFICATION OF MEDICAL EKAMINAION BY FACILITY LICERSEE, IS ATTAC ANY FALSE STATEMENT OR CHISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
19a. I certify under penalty of perjury that the information in this document and attachments is true and correct.
I further certify that I have no ifie mycurrent employer of: (1) all previous employers; (2) any instance where I have been tested by a Health-and Human Services (EBS) Certilied Drug Testing Laboratory or a Licensee's t esting facility foralcohol or a controlled substance, and the'test results exceeded the cutoff levels establishedegursuant to 10 CFR Part 26 3
n instance where I have been arrested for the sale, use or possession of a controlle substance described in l C
Pt 26; d (4) y reasons for removal or revocation.of unescorted access at a nuclear facility, I also authorize the NRC to submit the result of examinations to my employers for use in preparing retraining programs, as necessary.
SIGNATURE - APPLICANT DATE CEC APPLICABLE BOX X
- b.
I cert y that the above named individual hat successfully completed the facility licensees requirements to be licensed as an Oprator/Senior Operator pursuant to Title 10, Code of Federal Regulations, Part 55-and that the individual has a ned or an Operator/ Senior Operator license to perform his/her assigned duties and that the facility will be made availal for examination.
I also certify under penalty of perjury that the information in this document and attacmets is true and correct.
- c. RENEWAL ONLY -
I certify that the above named individual me the ap roved r alification pro with exceptions noted inj Item 17) as required by section 50.54 1i-1) o. 10 CFRT5, and that he/sehsdcardhi/r
- foPt(
P.
.0:,2 db de1 a
iate a
o n
a a
dshe d cepis/her licensed res nt ibilitis e
ently and safely I also certify under penalty of perjury tha the infrmaioninthi doumnt adattachments is true and correct.
TRAINING COODINATOR SENIOR MANAGEMENT REFRESENTATIVE 01 SITE PRINTED OR TYPED NAME PRINTED OR TYPED NAME Robert Clement H. E. MORGAN SIGNATURE (DATE SIGNATURE NO SIGNATURE R TEUIRED DATE SIjj
~
- i j
NON-CERTIFIED APLICATION FO NRC USE WAIVER (Check or complete items, as applicable)
MEETS REQUIREMENTS DOES NOT MEET REQUIREMENTS(Explain below)
GRANTED BY DENIED BY CATEGORY HEADQUARTERS REGION HEADQUARTERS REGION TTEN TING ELIGIBILITY MEDICAL SIGNATURE REVIEWER DATE OTHER NRC FORM 398 (10-90)
- C
- US L.:.REOULATCRY CO.'Y!SiC%
El :-B
>soW CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSE E 4U -'
X7-..
- Mc Gauley, Michael FACILTY DOCKET N'UWBER
- San Onofre Nuclear Generating Station, Unit 1 50-206 A. MEDICAL EXAMINATION CERTIFICATION 7*
- S7- :7:~ 7-4
-E
-'-\\
E A AL.
- = 4-ERA~."E EREIRCEA
~ ~~::
y Z SRINTED AVE ft'fs*s:.s 1 ST TE AND LICENSE NU.EER ExAMNATION DATE Steven Rosen, MD CA G24823 ENov.
18, 1991 EASED ON THE RESULTSOF THE EXAMINATION. INCLUDING INFORMATION FURN:SHED BY THE APPLICANT, THE PHYSICIAN HAS DETERMIN THAT THE APPLICANTS PHYSICAL CONDITION AND GENERAL HEALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPERATIONAL ERRCRS EN3ANGERING PUDLTHEA H AND SAFETY, I CERTIFY THAT IN REACHING THIS DETERMINATION.THE GUIDANCECONTAINED IN ANSIANS M.,153 OR ANSI!ANS 15.4.1577 LIC HEALH FOLWE-.DTAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY NRC.
S1-417 (N350) WAS ON THE BASIS OF THE RECOMMENDATION OF THE PHYSICIAN. I RECOMMEND THAT THE APPLICANT'S OPERATOR LICENSE BE CONDITIONED AS FOLLCWS:
-. NO RESTRICTIONS
- 2. CORRECTIVE LENSES BE WORN WHfEN PERFORMING LICENSED DUTIES
- 3. HEARING AID SE WORN WHEN PERFORMING LICENSED DUTIES
- 4.
RESTRICTED LICENSE OR EXCEPTION-Provies de &;Is below a-4 rch supporin i
eiden for NRC revie.
- 5. RESTRICTION CH1 ANGE FROM PREVIOUS SUEMITTAL-Progto deCa:Is below a&rd,111:" &
-Pl vdeea for NRC ICY PROPOSED WORDING CF RESTRICTION ISloxk 4 dbvte RELATIONSHIP OF RESTRICTION TO DISOLALIFYING CONDIT ION (Sriefly irest;:*
how REMARKS FOR RESTRICTION CHANGE (Slock 5a+/-lom)
-. NONMEDICAL CERTIFICATION 5TCFSF STHAT THEAPPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DUTY REQUIREMENTS OF THIS FACILITY FCR LICENSED OPERA-FORS.
LNt' FALE STA Ems% CMISSiN N THIS D0CUWENT* INCLUDING A77AC.t41ENS NAY SE S.JIECT TO CIVIL AND CRIMIN&L SANCTIONS. I CERTIFY UNZER PENALTY OF THA T1 CnMTIG I THS DCUMNT NDATTACHm.EN-,S S TRUE AND CORRECT.LSCTO IETIYUDRENL P
PRINTED NAME AND SIGNATURE eiM n
i on TITLE DATE No Signature Required, Non-Certified H. E. Morgan Application Vice President & Site Manager Sit accordance wi3 10 CFR 55.5. Commnictions, this formt shallbe submined to the NRC 4 foll~ws: BY MAIL ADDRESSED TO:
U ieioNral Acm Ahr aior, ReIin I
Regiona r
a e
U Nwclaar Corrmiion U.S. N:!ear Re.Iatory Comminion U.S. Nuclea R iory CommiOn
£75AI~r~a 1 Ra ~101 Var~rma Slteet Suitt 3100 7?9 Rtoci*,,Ii Roa~d King of Prussa. PA 1I406 Atlan'a. GA S323 Glen Elyn, IL 3037 Res;orII Am n nator. Region IV
'o-jt M
?minrtrator, Regon V D;'evtor. D of LCamtet Performance U.S. Nucker P#pj'stoy Coratedsion U.S. Nudetar RequaoyC m iir
$ £11 Pyain Paz Dri. e Suie 1C0 145.0 W.4a Lar., 5.1i: 210 A-%?: O..#IO(
Lcgair~g B'anL%
A T 1WAIM6 C-CA 64598 U.S. Nuclear ePatiory Commissbon Dim
- o.
D C.inofLcese 5romac FRIVACY ACT ST ATE M E NT v 10 5 U.S.C. 5aI,
) 11 r
ao ty ac';on 3 of the Pr...y Ac t of ROUTINE USES: Te-a infrtr-on r#Y t4 d:dod 0d am aKr-
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- 1. NI oIIo.; N r.a:arveri is I o
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- dcres
, ;olsnion or ms r I lotaion f 'aw luDOY a o forr,.,.t 10 1 re r.
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and n
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s fir sn NRC e:Co samAt you.
PRINCIPAL P-.PCSs)
WHETHER DISCLOSURE IS wANCAiCRi CR VOLUNTARY AND EFFECT GN FatherI CP Z5r SI.s*eo*.e o n er re ont hi fOrm
% wit-c t Cr m;re INDIVIDUAL OF 'SOT P O'V'IDING I.FC;..DATION.
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NRC FRM 398 (FACSIMILE)
U.S. NUCLEAR REGULATORY COMMISSION APFROVED BY OMB: NO. 3150-0090 ilo-90)
~ ~~EXPIRES:
1-31-92 DT EEVI 00CFR 55 31 55.35, ESTIMATED BURDEN PER RESPONSE TO COMPLY (To be completed by NRC) 55.47, amd 5.57 WITH THIS INFORMATION COLLECTION REQUEST: 2.0 ERS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE INFOR MAT ION AND RECORDS MA14AGEMENT BRANCH PERSONAL QUALIFICATION STATEMENT - LICENSEE (NBB 74
.S.NC LEARREGULATRYC0M MSS ION W BINGTON DC 20555 AND TO
.TE.PAPtRWORK REDUCIl0N PROJEfT (3150 TO U4IN ALD,0090 OFFICE OF MANAGEMENT AND BTSGE, TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED WASH INGTON, DC, 20503
- 1. APPLICANTS FULL NAME (Last, First, (include ZIP Code)
A(
X a NE
- f. WAIVER REQUESTED
- POORE, MARK ANDERSON
- b. R 2926B Camino Capistrano
- c. UPGRADE San2-OPERATING (Category) a e
Ad.
MULTI-IT AMEND TO INCLUDE ADDITIONAL UNIT)
-LGBIT M dde) AD ADRESe.
REAPPLICATION (-lGbILITY 1-FIRST 4-DICAL
- 2. CITIZSHIP
- 3.
BIRTH DATE 2-SECOND 5-OTHER X a. UNITED STTS~ET A
ER3HX
&.DATE PASSED GENERIC STTSMONTH DAY I
UEA 3-TBIRD
.ANEMSDGNRI
-7l Y FUNDAMENTALS EA-
!2I Y
INATION SECTION Tf 0_8.1 2,1 9 1 5 8
(IF APPLICALE) :
02 91
- 5. TYPE OF LICENSE APPLIED FOR
- 6. PREVIOUS LICENSE(S) HELD X
- a. OPERATOR aDOKTNME c., EXPIRATION DATE b.a.
DOCKET NUMBER RO SRO b. LICENSE NUMBER d.FACILITY DOCKET NUMBER
- b.
ENOROPRAORMONTH:
DAY
- YEAR,
- c.
LIMITED SRO 55-50 (e.g., Fuel Handler)
-7.RAME AND ADDRESS (Include ZIP Code) OF APPLICANT'S EMPLOYER
- 10. CORENT POSITION AT FACILITY Southern California Edison
- a. PLANT SUPERINTENDENT X i. AUXILIARY UNIT OPERATOR/
P.O.
Box 128
- b. ASSISTANT PLANT SUPERINTENDENT TRIG/NEE URBTNE BRATD San Clemente, CA (NONLIC EN OPERATOR 92674-0128
- c. SHIFT SUPERVISOR (NORICENSED OPERATOR)
- d. STAFF ENGINEER
- 8.
hAME OF APPLICANT'S FACILITY FACILITY DOCKET dR
. STFF EGHNEERL ADVISOR/
ENG E
OTHER (Specify)
San Onofre Unit 1 I
50-206 SHIFT ENGINEER
- f.
INSTRUCTOR
- 9. ADDITIONAL FACILITY DOCKETS (Multi-unit Licenses)
- g. SENIOR CONTROL ROOM OPERATOR
- h. CONTROL ROOM OPERATOR
- 11.
EDUCTION GH SCHOOL
- c. MAJOR AREA(S)
OF NUMBE S
IGHEE DEGREE CODES
- d. VOCATIONAL /
NUMBER CERRECE STUDY OFYEARS DEGREE
~To be used for NEUMBER OF CEIIVAE GRADUATE ENGINEERING (FIELDS)
(Use Codes) obtained)
TYPE OF TRAINING MONTHS YES NO GED EQUIVALENCY 0
NONE Nuclear Power School 6
X NOOHR1-CERTIFICATE-NO FF OTER 2
ASSOCIATE Nuclear Prototype 6
X Mathematics 2
1 0
3 -BACHELOR-
- b. NUMBER OF 4-MSE YEARS OF 5-DOCTRA-COLLEGE 2
5 DOCTORAL
- 12.
TRAINING (SINCE LAST APPLICATION -
SEE INSTRUCTIONS)
- 13. EXPERIENCE (DO NOT DOUBLE COUNT -
SEE INSTRUCTIONS)
- a. MONT AND YEAR b UMBER a.DONTH AND YEAR b NUMBER 1-NUCLEAR POWER PLANT FUNDAMENTALS FROM TO NAVYFRO TO MONTHS (Classroom) 1 -
RO 2-PLANT SYSTEMS 2 -
EW/PPWO CLASSROOM 2
OBSERVATION 3
EWS/PPWS 3-OPERATING PRACTICE 4 - ERS/CRW CONTROL ROOM OPERATIONS ON SHIFT 5 -
OTHER (Specify)
SIMULATOR OPERATING (Includes Classroom)
FOSSIL 1r SIMULATOR NAMES FOSSIL-OERTO.
R.Unt1NAE Wfll (Milifilimall inaun 6 -
OPERATOR flilfmfiffhllUN IUH!PRH M"~rIfflfumm unny
- b.
Ulll111111011MMillaimilulmiufin 10Mi 7 -
SUPERVISOR CERTIFIED STARTUP N
nllhiIlllU IUalan ilanuaMlifil 8 -
PLANT STAFF PROGRAM COMPLETED ifitl ilafnnnnna CERTIFIEDiSTART E
m 9 - OTHER (Specify)
NO. OF REACTIVITY MANIPULATIONS W lmiMI~munmaminallmanLmR rniiu~C(IwInuRLIAu.
NUCLEAR (IncLluding arch/
PLANT SIMULATOR fwwIwiummIIurnIJwf1InlTetRator) rh ill~iilM1M~lilhnEMMM~iU~ilIM!!Test Reactr 9
d II!InillIhffin na~nn tiuIfn I~nn 9
10 -
REACTOR OPERATOR (Licensed) 4-SRO INSTRUCTION R I11
- SENIOR OPERATOR (Licensed) 5-EXTRA PERSON ON SHIFT IN CONTROL 12 - SHIFT SUPERVISOR (Licensed)
ROOM!
(13-WEEK MINIMUM)
- a. TIME ON SHIFT ABOVE 20% POWER
-13 STAFF/SHIFT ENGINEER (Licensed)
(6-WEEK MINIMUM) 14 -
AUX./EQUIP. OPER. (Nonlicensed)
QU5ALIFICATION 15 - PLANT STAFF THER (Specify) 16 - OTHER (Specify)
NRC FORM 398 (10-90)
- 14. FACILITY OPERAT TRAING PROGRAM
- a. GRADUATE OF INPO ACCREDITED OPERATOR
- b. CERTIFIED ON NRC FORM 474 (SIMULATION TRAINING PROGRAM THAT IS BASED UPON X
YES NO FACILITY CERTIFICATION")OR NRC APPROVED X
YES A SYSTEMS APPROACB TO TRAINING SIMULATION FACILITY IS USED IN THE OPERATOR TRAININGPROGRAM
- 15.
FOR REEALS ON.Y
- b. DATE AND RESULT OF MOST DATE RESULT HOURS OPERATED FACILITY RECENT NRC ADMINISTERED REQUALIFICATION EXAMINATION I j
j j
I
- 16.
EEPERIENC DETAILS
- a. POSITION TITLE FRCM TO
- b. FACILITY
- c. DUTIES
- 17. COMTS (Specify the item number to which you are elaborating. Attach additional sheets as necessary.)
- 18.
KRC FOM 396, CERTIFICATION OF MEDICAL EMINATION BY FACILITY LIESEE, IS ATTACHED ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
19a. I certify under penalty of perjury that the information in this document and attachments is true and correct.
I further certif that I have noifie my currn employer of: (1) all previous employers; (2) any instance where I have been tested by a ealth and Human Services (HES)ertilied Drug Teatint Laboratory or icensee's beating facility for alcohol or a controlled substance, and the test results exceeded the cutoff levels established ursuant to 10 CFR Part 26(3an instance where I-have been arrested for the sale, us or possession of a controll Rsubstance described in 16 Ck PR art 26; and (4) any reasons for removal or revocation of umescorted access at a nuclear facility, I also authorize the NRC to submit the result of examinatignjsto my employe rs._foruse in preparing retraining programs, as necessary.
SIGNATURE - APPLICANT JDATES..
'2 C
APPLICABLE BCE X
- b. I certify that the above named individual has successfully completed the facility licensees requirements to be licensed as anOPeratorSenior Operator pursuant to Title 10, Code of Federal Regulations, Part 55 and that the individual has a need tor an Operator/ senior Operator license to perform his/her assigned duties and that the facility will be made available for examination.
I al so certify under penalty of perjury that the information in this document and attachments is true and correct.
- c. RENEWAL ONLY -I certify that the above named individual meets the ap roved requalification pro ram (with exceptions noteinIe17 as required by section 50.54 (i-1 )o 10 CFR 50, and that he/sh as dischare hi/e Ii cnsed responsibilities competently and safely. I also certify under penalty of perury tat the information nthis document and attachments is true and correct.
TEAINING CXKEDIXATOR SEICR K&AEM REPRSTAIVE ON SITE PRNE RTYE AE Robert Cle cent PRINTED OR TYPED NAME H
.MRA SIGNATURE
(
I
,v DATE SIGNATURE NO SIGNATURE REOU TDATE 34 Q ']&NON-CERTIFIED APPLICATION FO NBC USE WAIVER (Check or complete items, as applicable)
MEETS REQUIREMENTS DOES NOT MEET REQUIREMENTS(Explain below)
GRANTED BY DENIED BY
- CATEGORY HEADQUARTERS REGION HEADQUARTERS REGION TTEN TING LIGIBILITY MEDICAL SIGNATURE -
REVIEWER DATE OTER NRC FORM 398 (10-90)
.,~l
-i WIRSt iv Wt CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSE E0..s Poore, Mark
't ILI-Y FACILITY DOCKET NUN'SER San Onofre Nuclear Generating Station, Unit 1 50-206 A. MEDICAL EYAMINATION CERTIF ICAT O.N 7-AT7E.O\\EN
LIT rZ A%
PAT C;.5ENI C-EA7CR LI~EWAS SEE A'L rB Sc P o R IA N E ::
7S E AND LICENSE NULEER EXAM(NATICN DATE C. Rolbin, MD.
CA A019523 NA O2,A9E Nov.. 21, 1991 BASED ON THE SULTS CF THE EXAMINATION. INCLUDING INFC;..A7bON FURNISHED BY THE APPLICANT THE PHYSIC!AN SOET miN-D THAT THE APPLICNT'S PHYSICAL CONDITION AND GENERAL HEALTH ARE AT SUCH THAT IT MIGHT CAUSE OPERATIONAL ERCP ENANGERIN D PUBLIC HEALTH AND SAFETY. I CERTIFY THAT IN REACHING THIS DETERMINATION. THE GUIDANCE CONTAINED IN ANSIANS 3.4-1 OR ANS umANG.1 LIC EALTH FOLLOWED AND THAT DOCUIAENTATION IS AVAILABLE FOR REVIEW BY NRC, IANS15.4.iS77 (N350) WAS ON T.
10SIS OF THE RECOMMENDATION OF THE PHYSICIAN. I RECOMMEND THAT THE APPLICANT'S OPERATOR LICENSE BE CONDITIONED AS FOL)
V;S:
/ 1. NO RESTRICTIONS
- 2. CORRECTIVE LENSES BE WORN WHEN PERFORMING LICENSED DUTIES
- 3. HEARING AID BE WORN WHEN PERFORMING LICENSED DUTIES
- 4. RESTRICTED LICENSE OR EXCEFTICN-Prov;e erails belowe.-Id rauch sumorn I evidenms NRCIeview.
- 5.
R.STRICTIN ChANGE ROM PREVIOUS SUBVIT7AL-Pr,. -
Is below je a::h s: oy I r*ical e for NRC rei;.
FROPOSED WORDING OF RESTRICTION tSI*Xk 4abckT RELATIONSHIP OF RESTRICTION TO DISOLALIFYING.CONDITION, $ritfly irtc'kj:showreZrcion hilloetc thedialfyin condhionJ REMARKS FOR RESTRICTION CHANGE (Black S 5he ]
- 8. NONMEDICAL CERTIFICATION THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS AND FITNES FOR DUTY REOUIREMENTSOF THIS FACILITY FOR LICENSED OPERATORS.
ANY FALSE S7so...
CA Ow.&issION INTHIS D IJET,~
INCLUDING AT-rACHENTS MA' BE S U D LIECT TO CIVIL AND CRIMIN. SA CION.L I CERTIFY UNDER FENALTY OF I'E;J.R
'HAI7,1E INC lIC IN TH~IS DDCV$AEINT AND &-1,ACx.#ETS ISTRUE AND COARECT.
FRINTED NA E AND SIGNATURE i
Reer var* coi S.Vir TITLE DATE No Signature Required, Non-CertifiedD H. E. Morgan Application Vice President & Site Manager In accrdance wit 10 CFR '5.5 Commun jcaons, this form
.Ill be sbmi:ed to the NRC as fcllows: BY MAIL ADDRESED TO:
Ra-~or~al Iennr~a~ Rej~or 11I~iiito.Rqo I
UU.S. NC so0 r R:wIslory Commuiork U.S. Ntlsar R sIaiory Comnriss r 4'J A fl.i h PAt Roo d 101 Varr7.
S'.i,,i, S.JiI 31D3 7?
Ftcw',It Road Ki~g of Pressia. PA. 190Atrlan-a. GA 30323 G:t Eeye, IL 60137 Uc~o.S Nuclearr Re.teo, r on R-c Adrinurnrtor, Rgor%
V Dc.or D;iv;I;n of Lcentre Ptrlerrmnce U.S. Nu:Itst PzatDi~e.urY CmihoO U.S. N,.!tir RPsJiiory Commiuon and Qlity Evaluation 611 P.-n PX:1 Ol. SIf 1061 145-0 Va'4 LAr.*, Svite 210 A
vrt: O rator L B, nch A,
Ton.
X 6: 11 Wa,Ihn Ci. CA $4596 U S. Nxelar, Repi!slory CommiIsork aIe'ron.DC 20555 FRIVACY ACT STATEMENT Pw~a o c U.S.C.
55,,13 n10! Ia..
y %#c-,;o 3 of the Fr.c AcT of ROUTINE USES: The ;nforr.,1bcr '1.aY L4e d~o~
1 an aj m~tas1 I'vi~vol State. o, 6B4I.b~
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t, 9 C' eal the mvrsal of &~,mn rtai or in Ade~ oin.
Ii irnforrraon may lite r33,1 A
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gybru a4 s to an aproopte F aoda. Sre, arid loeti As* c-y to the teient ets tar c AUTHORITY: S.ctcre~ lC7 ard 161('1 '1 Il.
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FPRINCIPAL PURFCSEIS):
sIF-le rr%,,,d rCi11to d.fm 1~.1 or'n INDIVIDUAL OF NOT PROVIDIliG NF4CRMAT IOI. D
- ta.. ol,,wvey. if 1dr
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NRC FORM 398 (FACSIMILE)
U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0090 DATE REEIVED 110-90)
EXPIRES: 1-31-92 (To be completed by NRC) 10 CFR 55 31 55.35,.
ESTIMATED BURDEN PER RESPONSE TO COMPLY 55.47, and 5.57 WITH THIS INFORMATION COLLECTION REQUEST: 2.0 ERS.
FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE INFOR MATION AND RECORDS MANAGEMENT BRANCH PERSONAL QUALIFICATION STATEMENT - LICENSEE (MNBB 7714 U.S. NUCLEAR REGULATORY COM MISSION W BINGTON DC 20555 AND TO THE PAPRWORK REDUCtION PROJECT (3150 OFFICE OF MANAGEDENT AND BE
- IET, TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED WASHI NGTON, DC, 20503
- 1. APPLICANT'S FULL NAME (Last, First, Middle) AND ADDRESS 4.TYPE OF APPLICATION (Check applicable b eYX HOT F COLD (include ZIP Code)
X
- a. NEW f.WAIVER REQUESTED SCANLON, PATRICK LOUIS EDWARD R
949 Penguin Circle
- c. UPGRADE Vista, CA 92083
- d. MULTI-UNIT (AMEND TO 2-OPERATING (Category)
INCLUDE ADDITIONAL UNIT)
- a. REAPPLICATION3-LGBIT 1-FIRST 4-MEDICAL
- 2. CITIZENSEIP
- 3. BIRTH DATE 2-SECOND X
- a. UNITED STATES MONTH DAY YEAR3-THIRD DATE PASSED GENERIC
- b. OTHER (Specify) 1 2
0 9
6 2AT IN SEC IO
- 5. TYPE OF LIOSE APPLAL T
F(R
- 6. PREVIabS LIbxSE(S) HELD
- a. OPERA OR
- c. EXPIRATIO DATE
- a. DOCKET NUMBER RD SRO b. LICENSE NUMBER d.FACILITY DOCKET NUMBER
- b. SENIOR OPERATOR MONTc DAY YEAR C. LIMITED SRO 55-(-
(a (e.g., Fuel Handler) 7.HAM AND ADDRESS (Include ZIP Code) OF APPLICAT'S EMPOYER
- 10.
CURRENT POSITION AT FACILITY
- a. PLANT SUPERINTENDENT
)
- i. AUXILIARY UNIT OPERATOR Southern California-Edison RAL TTRAINEEINE BUILD P. 0. Box 128
- b. ASSISTANT PLANT SUPERINTENDENT ING URNB PEAO San Clemente, CA 5
N-0TL ENR OPERATOR 92674-0128
- c. SHIFT SUPERVISOR P
EN ER 3-d.
STAFF ENGINEER INNf.
INSTRUCTOR
- 9. ADDITIONAL FACILITY DOCKETS (Multi-unit Licenses) 8.SENIOR CONTROL ROOMI OPERATOR
- 5.
TYPE OF LICENSE APPLIED FTRN6.
CONTROL ROOM OPERATOR GX SCHOOL
- c. MAJOR AREA(S) OF NUMBER HIGHEST DEGREE CODES
- d. VOCATIONAL /
NUMBER CERTIFICATE STUDY OF YEARS DEGREE Td be us ed for TECHNICAL OF RECEIVED
'HtIGHESTDEGREE"
-N1-S 7.GRADUATE ENGINEERING (FIELDS)
(Use Codes) Rb10.nCOETYPE OF TRAINING YES NO GED EQUIVALENCY Mechanical 2
0 0 -
NONE NNT
- i. AUXl U
O aNOTHER CAEb.TASSISANP TENDucle T
Powe G
EU PR NOOHR2
-ASSOCIATE Nuclear Prototype 6
X
________________3 BACHELOR
- b. NUMBER OF S
- MASTER YEARS OF 5 -
DOCTORAL COLLEGE 2
1
- 12. TRAINING (SINCE LAST APPLICATION_
SEE INSTRUCTIONS)
- 13. EXEIENCE (DO NOT DOUBLE COUNT SEE INSTRUCTIONS)
- a. A NTH AND YEAR b NUMBER a..ONTH AND YEAR b NUMBER Of WEEKS Of' MONTHS b.O CONRO ROOM OPERATOR 1-NUCLEAR POWER PLANT FUNDAENTALS F
(Classroom) 1 RD 2-PLANT SYSTEMSO2 FRM O
0/ONE CLASSROOM 2
EOOW/PFWO OBSERVATION 3 - EWS/PFWS 4 - E.S/CRW 3-OPERATING PRACTICE 4
__ERS/CRH CONTROL ROOM OPERATIONS ON SHIFT 5 - OTHER (Specify)
SIMULATOR OPERATING (Includes Classroom)
FOSSIL SIMULATOR NAMES 6 - OPERATOR
- a. Unit 1 -lgIjffllfflH~h~I~g~l;~~j~
b.II tllina l hIha llm lIl l u111 lii J 7 -
SUPERVISOR CERTIFIED STARTUP X YES NO M
8 -
PLANT STAFF PROGRAM COMPLETED 11 A 9 - OTHER (Specify)
NO.
OF REACTIVITY MANIPULATIONS infliflim iLANTSIMULATOR lliNllm inumMUMINIfflIIng COMMERCIAL NUCLEAR (Including Research/
PI ltANT SIMULATOR mt mTest Reactor) 5m-10 - REACTOR OPERATOR (Licensed)
- 4-SRO INSTRUCTION 11 - SENIOR OPERATOR (Licensed) 5-EXTRA PERSON ON SHIFT IN CONTROL 12 - SHIFT SUPERVISOR (Licensed)
- ROOM (13-WEEK MINIMUM)
TIM ON SHIFT ABOVE 201 13 - STAFF/SHIFT ENGINEER (Licensed)
(6-WEEK MINIMUM) 14 -
AUX./EQUIP.
OPER.
(Nonlicensed)
UALIFICATION_
15 -
PLANT STAFF THER (Specify) 16 -
OTHER (Specify)
NRC FORM 398 (10-90)
- 14. FACILITY OPERATOR TRAINIG PROGRAM
- a. GRADUATE OF INPO ACCREDITED OPERATOR
- b. CERTIFIED ON NRC FORM 474 ("SIMULATION TRAINING PROGRAM THAT IS BASED UPON X
YES NO FACILITY CERTIFICATION")OR NRC APPROVED X
YES NO A SYSTEMS APPROACH TO TRAINING SIMULATION FACILITY IS USED IN TEE OPERATOR TRAINING PROGRAM
- 15. FOR RENEWALS ONLY
- b. DATE AND RESULT OF MOST DATE RESULT OURS OPERATED FACILITY RECENT NRC ADMINISTERED REQUALIFICATION EEAMINATION
.PASS FAIL
- 16. EUPERIENE DETAILS
- a. POSITION TITLE FROM TO
- b. FACILITY
- c. DUTIES
- 17. COMMENTS (Specify the item number to which you are elaborating. Attach additional sheets as necessary.)
- 18. NRC FORM 396, CERTIFICATION OF MEDICAL EXAMIRATICN BY FACILITY LICENSEE, IS ATIACHED ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
19a. I certify under penalty of gerjury that the information in this document and attachments is true and correct. I further cer ify that I have notifie my current employer of: (1) all previous employers; (2) any instance where I have been tested by a Health and Human Services (HES) Certilied Drug Testing Laboratory or a Licensee's testing facility for alcohol or a controlled substance, and the test results exceedea the cutoff levels established usuant to 10 CFR Part 26 (3) any instance where I have been arrested for the sale, use or possession of a controlled substance described in 16 CFR Part 26; and (4) any reasons for removal or revocation of unescorted access at a nuclear facility, I also authorize the NRC to submit the results of examinatiors to my employers for use in preparing retraining programs, as necessary.
SIGNATURE - APPLICANT s
/DATE CEC AFFLICABLE BOK
/
X
- b. I certify that the above named individual has successfully completed the facility licensees requirements to be licensed as an Operator/Senior Oerator pursuant to Title 10, Code of Federal Regulations, Part 55 and that the individual has a need or an Operator/Senior O-erator license to perform his/her assigned duties and that the facility will be made available for examination.
I a so certify under penalty of perjury that the information in this document and attachments is true and correct.
- c. RENEWAL ONLY - I certify that the above named individual meets the ap roved requalification pro ram (with exceptions noted in Item 17) as required by section 50.54 (i-1o 10 CFR 50, and that he/se has dischar ed his/her licensed responsibilities competently and safely. I also certify under penalty of perjury thae the information a this document and attachments is true and correct.
IRTAIING 000RDINATOR SENIOR MARAGEMENT REPR TATIVE 0 SITE PRINTED OR TYPED NAME PRINTED OR TYPED NAME Robert Clement H. E. MORGAN SIGNATURE 7
)'
DATE SIGNATURE NO SIGNATURE REQUIRED JDATE U k4 Ja'~~
i -i NON-CERTIFIED APPLICATION FOR NRC USE WAIVER (Check or complete items, as applicable)
MEETS REQUIREMENTS DOES NOT MEET REQUIREMENTS(Explain below)
GRANTED BY DENIED BY CATEGORY EADQUARTERS REGION HEADQUARTERS REGION TEN TING ELIGIBILITY MEDICAL SIGNATURE -
REVIEWER DATE OTER.
NRC FORM 398 (10-90)
\\C 6
.U S. '
.EG RECULAICRY CCY.Y.!S S iCr.
r >e L-s CERTIFICATION OF MEDICAL EXAMINATION
-.4 BY FACILITY LICENSEE
... 4ZA.
Scanlon, Patrick
_-AZL17Y F ACIL ITY DC T NU1 ER San Onofre Nuclear Generating Station, Unit 1 50-206 A. MEDICAL E XMiNAT ION CERTI FICATICN ei' M.D.
s alif.
A L195-23 Nov.13,1991 SoOED BY THE APPLICANTs TIs PcFYSCTAN AS EXA ND T.HAT TIUE APPLICANTS PHYSICAL CNZITION AND GENERAL HEALTH ARE NOT SUCH THAT IT MIGHT CAUSE OFERATIONAL E RFCS DN ING E TL T
L AND SAF ETYI CERTIFY THAT IN REACHING THIS DETERMINATION. THE GUIDANCE CONTAINED IN ANSI/ANS 2.4-153 CR ANSI ANS L5.41L7 ICN15 WAS FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY NRC,.
ON THE BIS OF THE AECOMMENDATION OF THE PHYSICIAN. I RECOMMEND THAT THE APPLICANTS OPERATOR LICENSE SE CONDITONED AS FOLLCYPS
. NO RESTRICTIONS
- 2. CORRECTIVE LENSES E WORN WHEN PERFORMING LICENSED DUTIES
- 3. HEARING AID BE WORN WHEN PERFORMING LICENSED DUTIES
- 4. RESTRICTED LICENSE OR EXCEFTICN-Provide deIls beow
-4 r ch sup-n m c
e NRCrevew.
- 5. AEST RICTION C FAGB ROM PREVIOUS SUEMIT'AL-Pre:
de:sit s blow ar4 I ch svp: :: rig rinjt e
frNCr PROPOSED WORDING CF RESTRICTION (6Ixk 4 shcov; Corrective lenses be worn when performing licensed duties.
RELATIONSHIP OF RESTRICTION TO DISOUALIFYING CONDITION '5r;dur irr":8 hown wilorrect the dis1uaify; conditon)
REMARKS FOR RESTRICTION CHANGE Block Sabsoe)
B. NONMEDICAL CERTIFICATION THIS CERTIFIESSTATTHE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DUTY REQUIFEMENTS OF THIS FACILITY FOCR LICENSED OPERATORS.
SFA L!E S TEMET OF CMvISIoN IN THIS DOCUMENT, INCLUDING AT7ACkWENTS, MAY SI E rVESCT TO CIVIL AND CRIMINL SANMONa4 I CE.RTIFY UNZEA PINA L
PERy -. HAT wE I" 4TIOW IN T "IS DOCUMENT A ND ATTACHMEn5 S S Tut AND CORRECT.
PRINTED NAME AND SIGNATURE [Senior Anmem Reper ri onS-r TITLE No Signature Required, Non-Certified H. E. Mor: an Application Vice President & Site Manager In ac rc'aCt witht 10 CFR 55.5. Commu;ou sn, Ihil forn $hall be subri:,: 10 the NRC as 1olko : BY MAIL ADDRESED TO:
Rna-lr,
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- Rt,;orxaI A vairS1Ir RP;on I1 FR,-;ar~aI A4~~r.F Rq~en III U.S.
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475 Allendale P~ad
- 1.
101 S/a r rTi. Suit 31D3
.. P els.rI Rjoa Con hs K~ng of Prussa* PA 1S s Ailan*s. GA X323
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U.S.
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1450 Mlarl L=4 a 0us W10e.
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F 11 DSLSEISANARYGvoUT 11-1FEC.G
NRC FORM 398 (FACSMILE)
U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY Cff: NO. 3150-0090 DATE R (10- 9 0 )
EXPIRES: 1-31-92 10 CFR 55.31 55.35, ESTIMATED BURDEN PER RESPONSE TO ToMPd N
55.47, and 5.57 WITH THIS INFCRYATION COLLECTION REQUEST: 2.0 ERS.
FORWARD COMMNTS.
REGARDING BURDEN ESTIMATE TO THE INFOR MATION An RECORDS MANAGMNT BRANCH PERSONAL QUALIFICATION STATEMENT - LICENSEE.
(1B 7714) U.S.NUCLEAR REGULATORY COM MISSION WASHINGTON DC 20555 AND TO THE PAPtR'ORX REDUCtION PROJEdT (3150 0090)N OFFICE OF MANAGMNT AND BUDGET, TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED WASHIGTON, DC, 20503
- 1. APPLICANT S FULL NAME (Last, First, Middle) AND ADDRESS 4.TYPE OF APPLICATION (Check applicable (include ZIP Code)
X
-a. NEW L
- f. WAIVER REQUESTED
- SCHOTT, STEVEN JEROME
- b. RENEWAL W
(Cer 1006 Shorecrest Rd.
- c. UPGRADE Carlsbad, CA 92009
- d.
TI-IT 2-PETN
(
o INCLUDE ADDITIONAL UNIT)
- e. REAPPLICATION3-IGILT 1-FIRST4-MEDICAL
- 2. CITIzESHIP
- 3. BIR DAE.
2-SECOND
- a. UNITED STATES MONTH DAY YEAR 3-THIRD FNDAETASE GENRI 6
~INATION SECTION
- b. OTHER (Specify) 0 5
3 0
6 3
(IF APPLI 02 91
- 5. TYPE OF LICENSE APPLIED FOR
- 6.
PREVIOUS LICENSE(S) HEL X
- a. OPERATOR c EXPIRATION DATE
LICENSE NUMBER d.FACILITY DOCKET NUMBER
- b. SENIOR OPERATOR MONTHT DAY YEAR
- c.
LIMITED SRO 55 APPOVE BY 0MI: NO.
310009 (e.g., Fuel Handler) 7.NA%% AND ADDEST (Include ZIP Code) OF APPLICANT'S ITPLOYER
- 10. CURRENT POSITION AT FACILITY
- a.
PLANT SUPERINTENDENT XIi. AUXILIARY UNIT OPERATOR Southern-RCalifornia Edison TTRAINETURBINE BUILD P. 0. Box 128
- b. ASSISTANTPLANT SUPERINTENDENT INGREEU N
ENT OPERATOR Sn Clemente, CA U
S R RCENSED OPERATOR)
THd. STAFFEGORK ENGINER lN O
T 1
NAME OF APPLICA S FACI FACILITY DOCKET NUMBER
- e. SHIFT TECHNICAL ADVISOR/
B T
WASSINGTRTOND,200 San Onofre Unit 1 50-206 SHIFT ENGINEER
- 9. ADDITIONAL FACILITY DOTS (Multi-unit Licenses)
- g. SENIOR CONTROL ROOM OPERATOR
- h. CONTROL R--- OPERATOR e.REAPP-11.
EDUCAIO IGH SCHOOL
- c. MAJOR AREA(S)
OF NUMBER HIGHEST DEGREE CODES
- d. VOCATIONAL /NUMBER CERTIFICATE STUDY OF YEARS DEGREE MTo be used for TECHNICAL OF RECEIVED HIGHEST DEGREE" X GRADUATE ENGINEERING (FIELDS)
(Use Codes) obtained)
TYPE OF TRAINING YES NO GED EQUIVALENCY 0
NONE 1
A BCERTIFICATELE) 0 NO OTHIER 2 -ASSOCIATE Nuclear Prototype6 X
BACHELOR L
E
- b. NUMBER OF 4
EMASTER YEARS OF 5 -DOCTORAL COLLEGE 0
1
- 12. TRAINING (SINCE LAST APPLICATION-SEE INSTRUCTIONS)
- 13. EERIENCE (DO NOT DOUBLE COUNT-SEE INSTRUCTIONS)
- a. MONTH AND YEAR b NUMBER N.MONTH AND YEAR b NUMBER OO WEEKS o
MONTHS FROM TO NAVY FROM TO 1-NUCLEAR POWER PLANT FUNDAMENTALS a
A U
T NU R
UNIT OPERATOR (Classroom) 1 -RD 2-PLANT SYSTENS 2
E REOBW/PPWN CLASSROOM 9267RV-018 3 EWS/PPWS 4 ERS/CRW
.13-OPERATING PRACTICE_________________
CONTROL ROOM OPERATIONS ON SHIFT 5
OTHER (Specify)
SIMULATOR OPERATING (Includes Classroom)
FOSSIL SIMUATO INSTUCTO ADit IONAL FACILIT6 OPERATOR h
SUPERVISOR OPERATOR_.
CERTIFIED STARTUP 0XNYES NEIFICATE Nuclear PPoANT STAFF b.ROGBR OFPL TE R9 OERENuclearPro.
(Specify)
NO. OF REACTIVITY 5AOIPCLATIONS a.MONTANDYER0MBKR a
TAND NLEAR (YIncluding ReUearch/
2CPLANT SEMSU0 Test Reacto OBSER N
- 3.
1 - REACTOR OPERATOR (Licensed) 4-SRO INSTRUCTION 11 - SENIOR OPERATOR (Licensed) 5-EXTRA PERSON ON SHIFT IN CONTROL 12 - SHIFT SUPERVISOR (Licensed)
ROOM (13-WEEK MINIMUM)
TIM E N SHIFTAOVU 0
13 - STAFF/SHIFT ENGINEER (Licensed)
(6-WEEK MINIMUM) 14 - AUX./EQUIP. OPER. (Nonlicensed)
EUALIFICATION 15 -
PLANT STAFF THER (Specify) 16 OTHER (Specify)
NRC FORM 398 (10-90)
- 14. FACILITY OPERATOR TRAINING PROGRAM
- a.
GRADUATE OF INPO ACCREDITED OPERATOR
- b. CERTIFIED ON NRC FORM 474 "SIMULATION TRAINING PROGRAM THAT IS BASED UPON X
YES NO FACILITY CERTIFICATION")
NRC APPROVED X
YES NO A SYSTEMS APPRCACB TOTRAINING SIMULATION FACILITY IS USED IN THE OPERATOR TRAINING FROGRAM
- 15. FM RENEWALS ONLY FACILITY
- b. DATE AND RESULT OF R
LST DE URS PERTED ACIITYRECENT NRC ADMINISTERED I.REQUALIFICATION EXAMINATION1 PASS FAIL
- 16. EaPERIENCE DETAILS
- a. POSITION TITLE FROM TO
- b. FACILITY
- c. DUTIES
- 17. CCMENTS (Specify the item number to which you are elaborating. Attach.additional sheets as necessary.)
- 18. NRC FORM 396, CERTIFICATION OF MEDICAL EAMINATION BY FACILITY LICERSEE, IS ATTACHED ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.
19a. I certify under penalty of perjury that the information in this document and attachments is true and correct.
I further certify that I have notifiea my current emloyer of: (1) all previous employers; (2) any instance where I have been tested by a Health and Human Services (HHS) Cert iied Drug Testing Laboratory or a Licensee's testing facility for alcohol or a controlled substance, and the test results exceeded the cutoff levels established pursuant to 10 CFR Part 26 (3) any instance where I have been arrested for the sale, use or possession of a controllea substance described in 1 CFR Part 26*
and (4) any reasons for removalor revocation of unescorted access at a nuclear facility, I also authorize the NRC to submit the results of examinations to my employers for use in preparing retraining programs, as necessary.
SIGNATURE - APPLICANT
'7 DATE CHEC APPLICABLE BO X
- b. I certify that the above named individual has successfully completed the facility licensees requirements to be licensed as an Operator/Senior Operator pursuant to Title 10, Code of Federal Regulations, Part 55* and that the individual has a need or an Operator/Senior Operator license to perform his/her assigned duties and that the facility will be made available for examination. I also certify under penalty of perjury that the information in this document and attachments is-true and correct.
- c. RENEWAL ONLY - I certify that the above named individual meets the aproved reaualification pro ram (with exceptions noted in Item 17) as required by section 50.54 (i-1) of10 CFR 50, and that eane hwsdischarted his/her licensed resonsibilities competently and safely. I a so certify under penalty of perjury that the information in this document and attachments is true and correct.
TRAINING CXXEDINATZ SENIE MANAGEMENT REPRESENTATIVE C SITE PRINTED OR TYPED NAME PRINTED OR TYPED NAME Robert Clement H. E. HORGAN SIGNATURE
( zi?
A DATE SIGNATURE NO SIGNATUERE UIRED DATE
_Acw;VU3 NON-CERTIFIEDUPLICATION FUR NRC USE WAIVER (Check or complete items, as applicable)
MEETS REQUIREMENTS DOES NOT MEET REQUIREMENTS(Erplain below)
GRANTED BY DENIED BY CATEGORY HEADQUARTERS REGION HEADQUARTERS REGION TEN TING IGIBILITY MEDICAL SIGNATURE
- REVIEWER DATE OTHER NRC FORM 398 (10-90)
NC F::.
296 U S. NUX ER PEGULATORY CCYY!SSICN r',.,5 C t~
EXPRES 14, W CERTIFICATION OF MEDICAL EXAMINATION ES BY FACILITY LICENSEE
"'^""r"k s
Schott, Steven I
.FACILITY DOCKET NUMBER San Onofre Nuclear Generating Station, Unit 1 50-206 A. MEDICAL EXAMINATION CERTIFICATION 5,,s S '700 :iR';.Y -AT
-E -EO\\
AP.'E PLICANTFOR AN ERCTO.NiOR CFERATCR LI^E:SE 4ASE
£ j
C STATE A LICENSE NL:MER EA:AINDT soT CIM L ROLSIN M.D.
EXAMNATICD 3/ f)
. ^/ft-/f/
10-31-91 BASED ON THE RESULTS OF THE EXAMINATION. INCLUDING INFOF.MATION FURN:SHED BY THE APPLICANT, THE PHYSICIAN HAS DETED THAT THE APPLICANT'S PHYSICAL CONDITION AND GENERAL HEALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPERATIONAL ERRORS ENDANGERING PUBLIC HEALTH AND SAFETY I CERTIFY THAT IN REACHING THIS DETERMINATION. THE GUIDANCE CONTAINED IN ANSI/ANS 3.4.1SS3 0R ANS1/ANS 15.4-1977 IN3C0H WAS FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY NRC.
ON THE AS OF THE RECOMMENDATION OF THE PHYSICIAN. I RECOMMEND THAT THE APPLICANT'S OPERATOR LICENSE BE CONDITIONED AS FOLLOW NO RESTRICTIONS 7
- 2. CORRECTIVE LENSES BE'WORNWHEN PERFORMING LICENSED DUTIES
- 3. HEARING AID SE WORN WHEN PERFORMING LICENSED DUTIES
- 4. RESTRICTED LICENSE OR EXCEPTION-Provide details below a*d sasih supporing rnedial evi c for
. $evii 9
S. RESTRICTION CHANGE FROM PREVIOUS SUBMITTAL-Provae dea;Ils below And anlach Luporing medical evidence for NRC revi PROPOSED WCRDING CF RESTRICTION (Block 4ebov].
Corrective lenses be worn when-performing licensed duties.
RELATIONSHIP OF RESTRICTION TO DISOUALIFYING CONDITION IBriefly indcte how rticionwilcorrect the disqualyingoAnditionJ REMARKS FOR RESTRICTION CHANGE (Block 5aboai)
S. NONMEDICAL CERTIFICATION*
THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DUTY REQUIREMENTS OF THIS FACILITY F R LICENSED OPERATORS.
ANY FALSE STATEMENT OR OMISSION INoTHIS DOCUMENT INCLUDING AfACHTENTS.
MAY BE S'BJECT TO CIVIL AND CRIMINAL SANCTIONL I CERTIFY UNDER PENALTY OF PERJU..RY THAT THE INFORM.ATION IN THIS DOCUMENT AND ATTACHMENTS IS TRUE AND CORRECT.
PRINTED NAME AND SIGNATURE et Rtpresmenrriel on SireJ TITLE DATE No Signature Required, Non-Certified H. E. Morgan Application Vice President & Site Manager In accordance with 10 CFR 55.5. Communicat;ons, his form &hall be submineo10 the NRC as follows: BY MAIL ADDRESSED TO:
Regional Aorrm rtreor Refiorn IRei;oral Adminitirsior Regon 11 RP-;or.aI Adminrrsor.
- q~on III U.S. Nuclear Re.gu!tory Commission U.S. Nuclear re'?reory Commiuion U.S. Nuclear Reguliory Commieaon 975 AllaraIr Read 101 Warena Stred. SviI 310R King of Prussia. PA 19406 Atlars. GA 3C323 GlanEs. IL 6R1ad Regional Admnistrator, Region IV.
agolLm nirsr V
Re~r* d~~,io.R~mI p~ra
~~~r~r.Region VD;raKc"or.
D;v4a;om of Licenses Perforrmarnce U.S. Nuclear Pousitory Commission U.S. Nulear Regulatory Commhj~on nd ousliy Evelvelon 611 Ryan Ptll$ Drive. Suite 1000 1450 I/a's Lane. Suite 210 Ann: Ofaloe Lctrisir'g Banch Arlir~noreTI 7011 Walnuti Cerrk.
459.
U.S. NucNeue RRulrtory CrtmorCmmon Wash;mq-.on. DC 20S PRIVACY ACT STATEENT P"rluarll 10 5 U.S.C. 5521(1113).
e.,ld into lawe by,.clion 3 of the Pri,&cy Act of ROUTINE USES: The inforation ma be d;do"I.
to ami appro0j~ais Faorp,o.I Slait, or 1974 IPublic U.9 $3.579). Ihe Iol:o..,r..
r-aber,4rrl ;a Irlu %.iiad toided,~
who local ae.-cy in 1t4 fsan the.rrformaliom ;r4;="a~
A violviiori or Vo l O 1..~')Py
- M f~ rr,.el. 0 10 t 1 he U S. N c e r Pe ~ory C ornr ru.
Son on N eC ar,m Ms aory Co m in l' q t o n 11.4 rforrru 1ion irdcr o oio n o p w0 41 vto r.;
Arli;nors ior X 760 j,,r TIr~,sfralc~ I ~ na sy~ti of ecorda eeei;9-r.. as I.FCI 1 en&d. the c.>_r~ of v' 6drr;ant,,'9 at iwd.caIl pocavd~r.g. In bdrion. th:
frImraton rmay be C a P.11 *ll 3 971 IAp._ar n. rI'nI s rar r.d to an s oro sia Federal. S-Ur.S. ard la R acy o ike rsio t
-on a,C AUTHORITY:
107 a'd 161(.) cf irae Aior-nc Ene,;Y ALt of l4.
a rw.,..ry for an NRCde.%eion ebojl you.
aerefe. '42 USC. ',137 s,.d 701
.wHETHER DISCLOSURE IS MANDATORY OR VOI.UtiTARY. AND EFFECT ON PRINCIPAL P% 1fr'SEtSI: Ir ir.rra~ ee'd o~n IhN formn 4 uird to Cr-ieINDIVIDUAL CF NOT PROVIDING INFORVATIO4. D
'I:s 's voI.riba. If IN,
'1 whalt#a It'$ ;,Ipa tq a I..0it of t n A'S s they -o-r-d m,- cn ;& rnot proe edd ho e.r itr.@
PTo of;Ln fr a 'e,Iy or.Pr e r or',
'.01 caj a *'e.r err ore er~.a;gP.bI;C hirhth arid i,,ey.
Th;% rircrr..a.
or.. "Mot. o4q ior's I;C*-1 may L4a den;.d.
1,011-t's -0~ ty 1 N5 1 NRC raiff 10 eiiri if thg iv,.
,i "ra irt,-~ie SYSTEM.
JA.NAGERIS) AND ADDRESS: C'ra1 Owaeor L'--
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-01~~~~~~~tn O1ao Lofsn 10 ancht at t f10b no4,j jI WN;aint C.
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