ML17056C003
| ML17056C003 | |
| Person / Time | |
|---|---|
| Site: | Nine Mile Point  |
| Issue date: | 09/17/1992 |
| From: | Bettenhausen L NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | Sylvia B NIAGARA MOHAWK POWER CORP. |
| References | |
| NUDOCS 9209220020 | |
| Download: ML17056C003 (16) | |
Text
Docket Nos.
50-220 50-410 SEP 17 1992 Mr. B. Ralph Sylvia Executive Vice President Nuclear Operations Niagara Mohawk Power Corporation 301 Plainfield Road
- Syracuse, New York 13212 Gentlemen:
SUBJECT:
REVISED NRC FORMS 396 AND 398 Enclosed-is a
copy of the revised NRC Form-396 (Enclosure 1),
Certification of Medical Examination By Facility Licensee and revised NRC Form-398 (Enclosure 2),
Personal Qualifications Statement Licensee.
All changes to the NRC Form-396 and the NRC Form-398 are detailed in Enclosure 3.
All applications for licenses are to be submitted on these revised forms as soon as possible but no later than November 1, 1992.
The enclosed applications are for your use.
Your office can obtain additional copies of these forms by contacting Beverly Martin by telephone on (301) 492-8138 or by writing to her, U.S.
Nuclear Regulatory Commission, Information and Records Management
- Branch, Mail Stop MNBB-7714, Washington, D.C.
20555.
If you have any questions regarding these
- forms, please contact Richard J.
Conte at (215) 337-5210 or Glenn W. Meyer at (215) 337-5211.
Sincerely,
Enclosures:
As stated
~iainal Signed By:
Lee H. Bettenhausen, Chief Operations Branch Division of Reactor Safety 9209220020 920917 PDR ADOCK 05000220 P
Nine Mile Nuclear Power Station cc w/enclosures:
R. Smith, Manager Training F. White, Supervisor Training R. Sanaker,
~ General Supervisor Operations Training (NMP1)
R. Slade, General Supervisor Operations Training (NMP2) cc w/o enclosures:
J. Firlit, Vice President Nuclear Support C. Terry, Vice President Nuclear Engineering J. Perry, Vice President Quality Assurance N. Cams, Vice President Nuclear Generation K. Dahlberg, Unit 1 Plant Manager M. McCormick, Unit 2 Plant Manager D. Greene,
- Manager, Licensing J.
- Warden, New York Consumer Protection Branch G. Wilson, Senior Attorney M. Wetterhahn, Winston and Strawn
- Director, Power Division, Dept. of Public Service, State of NY C. Donaldson, Esquire, Assistant Attorney General, NY Dept. of Law NRC Resident Inspector State of New York, SLO Designee bcc w/ enclosures:
OL Facility File RI: DRS Curley Y>
09/ 5 /92 RI DRS Be hausen 09/~92 Official Record Copy
NRC FORM 396 (6.92) 10 CFR 55.23, 55.25, 55.27, 55.31, 55.33 55.57 U.S. NUCLEAR REGULATORY COMMISSION CERTIFICATION OF MEDICALEXAMINATION.
BY FACILITYLICENSEE NAMEOF APPUCANT APPROVED BY 0MB: No. 3150.0024 EXPIRES: 1.31-84 ESTIMATED BURDEN PER
RESPONSE
TO COMPLY WAH THIS INFORMATION COLLECilON REOUEST:
15 MINUTES.
FORWARD COMMENTS REGARDING BURDEN ESTIMATETO THE INFORMATIOMAND RECORDS MANAGEMEhT BRANCH (MNBB 7714),
U.S.
NUCLEAR REGULATORYCOMMISSION, WASHWGTON, OC 205550001, ANDTO THE PAPERWORK REDUCTION PROJECT (3150.0024),
OFFICE OF MANAGEMENTAND BUDGET, WASHINGTON, DC 20503.
FACiLlTY FA(XtflYDOCKET NUMBER A MEDICALEXAMINATIONCERTIFICATION THIS IS TO CERTIFY THATTHE ABOVE NAMEDAPPUCAMT FOR AN OPERATOR/SENIOR OPERATOA UCENSc HAS BEEN EXAMINEDBY A PHYSCIAN.
PRINTED NAME(orPfrysfcien)
STATE ANDUCENSE NUMBER EXAM!NATlON DATE BASED ON THE RESULTS OF THE EXAMINATION,INCLUDINGINFORMATIONFURNISHED BYTHE APPUCANT, THE PHYSCIAN HAS DETERMINED THATTHE APPUCANl'S PHYSCALCONDfnON AND GENERAL HEALTH ARE SUCH THAT THE APPUCANT WOULD NOT BE EXPECTED TO CAUSE OPERATIONAL ERRORS ENDANGEFcNG PUBUC HEALTH AND SAFElY.
I CERRFY THAT IN REACHING THIS DETERMINATION,THE GUIDAlfCE CONTAINEDIN ANSI/ANS 3.4 1983, OR ANSI/ANS 15.4 1988 (N380) WAS FOLLOWEDANDTHATDOCUMENTATIONIS AVAILABLEFOR REVIEW BY NRC.
IF THE GUIDANCE IN THE APPROPRIATE ANSI/ANS DOCUMENT IS NOT COMPUED WITH, AM ACCEPTABLE ALTERNATlvE METHOD, WHICH HAS BEEN APPROVED BY NRC, WAS USED.
ON THE BASIS OF THE RECOMMENDATION OF THE PHYSICIAN, I RECOMMEND THAT THE APPLICANT'S OPERATOR LICENSE BE CONDITIONED AS FOLLOWS:
t; NO RESTRICTIONS 2.
CORRECTIVE LENSES BE WORN WHEN PERFORMING LICENSED DUTIES 3.
HEARING AID BE WORN WHEN PERFORMING LICENSED DUTIES 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.
PROPOSEO WORDING OF RESTRICTION (BICCk 4 above)
RELATICNsHIpoF AEsTRIGTIDNTo DisovAUFYINGcoNDITloN(Brieliyindicate how restrictio willccnect rrre ddovviryrng condition)
REMARKS FOR RESTRICTION CHANGE (Block 5 shove)
B. NONMEDICALCERTIFICATION THIS CERTIFIES THATTHE APPUCAMT HAS BEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DUrYREOVIREMEMTS OF THIS FACIUlYFOR UCENSED OPERATORS.
ANY FALSE STATEllENT OR OMiSSION IM THIS DOCUMENT, INCLUDINGATTACHMENTS, MAYBE SUBJECT TO CIVILAND CRIMINALSANCTIONS. I CERTIFY VNDFR PENALTY OF PERJURY THATTHE INFORMATIONIN THIS DOCUMENT AND ATfACHMENTSIS TRUE AND CORRECT.
PRINTED NAME ANDTrrLE (senior Management Representative on sire)
SGNATVRE DATE In accordance with 10 CFR 55.5, Communications, this form shall be submitted to the NRC as follows: BY MAILADDRESSED TO:
REGIONALADMIN'ISTRATOR,REGION I U.S. NUCLEAR AEGULATORYCOMMISSION 475 ALLENOALEROAD IONG OF PRUSSIA PA 19406 1415 REGIONALADMINISTRATOR,REGION IV U.S, NUCLEARREGULATORYCOMMISSION 611 RYAN PLAEA DRIVE, SUITE 400 ARUMGTOM,TX 601 14064 REGIONALADMINISTRATOR,REGION II U.S. NUCLEAR REGIJLATORY COMMISSOM 101 MARIETTASTREET NW, SuriE 2900 ATLANTA,GA 30323 REGIONALADMINtSTRATOR,REGION V ~
U.S. NUCLEARREGULATORY COMMISSION 1450 MARIALANE WALNUTCREEK CA 94596-5368 REGIONALADMINISTRATOR,REGION Ii'I U.S. NUCLEAR REGULATORYCOMMISSION 799 ROOSEVELT ROAD GLEN ELLYN IL 60137 OPERATOR UCENSIMG BRANCH DIVISIONOF UCENSEE PERFORMANCE AND OVAUIYEVALUATION U.S. NUCLEAR REGULATORYCOMMISSOM WASHINGTON, DC 20555400 t TATEMENT ROUTINE USE(S):
The Information may be disclosed lo an appropriate Federal. Sta',e and local agency in the event the Information indicates a viotation or potential violation of law and In the course of an administrative or judicial proceeding, In addcion, this information may be transferred to an appropriate
- Federal, Sta!e, or local agency to the extent reIevant and necessary for an NRC decbion about yov.
WHETHER (XSCLOSURE IS MANDATORYOR VOLUNTARYAND EFFECT ON INDIVIDUALOF NOT PROVIDIMG INFORMATION: DisrJosure b votuntary.
If the reqvested information is not prrnfded, however, the application for a facilny operators or senior operators license may be denied.
PRIVACYACT S Pureuant TO 5 V.S.C. 552a(e) (3), enaCted InIO laW by SeCtiOn 3 Of the Prixaey ACt Of 1974 (Public LaW 93-579), the following statement is furnished to IndMduals who supply Information to the U.S. Nuclear Regulatory Commission on NRC Form 396.
Thb Information is maintained in a system of records designated as NRC-16 and descnbed at 55 Federal Register 33978 (August 20, 1990), or Ihe most recent Federal Register publication of Ihe Nuclear Regutatory Commission's Republication of Systems of Records Notices'hat b avaitable at the NRC Public Document Room, Gelman Building, Lower Level, 2120 L Sreet NW, Washington, D.C.
AUTHORITY: Section 107 and 161 i of the Atomic Ener Act ot 1954, as amended 42 U.S.C. 2137 the individual meets the requirements ot 10 CFR 55 to tave an examination oi to be bsued an operators license.
and 2201(i)).
0 gy
(
SYSTEM MANAGER(S) AND ADDRESS:
Chief, Operator Ueensing Branch Office ot Nuclear Reactor Regulation PAIMOIPALPURPosE(s):
Information eniered on this form b vsed to determine whether the physical condcion and general health of the applicant are such that they wilt not cause operabonal errors endangering pubhc health and safety The Information may be used by the NRc staff lo determine lf NRC FORM 396 (6.92)
12.
14.
15.
16.
18.
t INSTRUCTIONS FOR COMPLETING NRC FOAM 398, PERSONAL QUALIFICATIO ATEMENT-LICENSEE TO REMAINVALID,THIS FORM MUST NOT BE ALTERED TYPE OF APPLICATION a.
NEW-X" IF YOU ARE A NEW APPUCANT.
COMPLETE EACH CATEGORY OF THE FORM COMPLETELY, FOLLOWING THE INSTRUCTIONS BELOW. THIS IS TO INCLUDEALLEDUCATION, TRAININGAND EXPERIENCE THAT YOU HAVE RECEIVED UP TO THE DATE OF THIS APPUCATION. NOTE: SEE ITEM 12 - THERE IS AN EXCEPTION. ALSO, THIS BLOCK IS TO BE MARKED IF PREVIOUS NEW APPUCATION WAS WITHDRAWN. PLEASE WRITE WITHDREW" NEXT TQ NEW.
FOR 4.b THROUGH 4.e, COMPLETE EACH CATEGORY COMPLETELY,BUT INDICATEONLYTHE EDUCATION,TRAINING,ANDEXPERIENCE YOU HAVE RECEIVED SINCE YOUR LAST APPUCATION. NOTE: SEE ITEM 12-THERE IS AN EXCEPTION.
b.
AENEWAL- 'X'F YOU ARE RENEWING CURRENT LICENSE.
c.
UPGRADE - X IF YOU HOLD A RO UCENSE AND ARE NOW APPLYING TO UPGRADE YOUR LICENSE TO A SRO.
d.
MULTI-UNIT- 'X IF YQU CURRENTLY HOLD A LICENSE AT YOUR FACILITYAND ARE APPLYING TO AMENDYOUR CURRENT LICENSE TO ADD AN ADDITIONALUNIT.
o.
REAPPLICATION - "X" IF YOU HAVE PREVIOUSLY BEEN DENIED A UCENSE AND ARE REAPPLYING.
f.
WAIVER REQUESTED - "X THE APPLICABLEWAIVER REQUESTED AND JUSTIFY IN COMMENTS SECTION (ITEM 17).
g.
DATE PASSED GENERIC FUNDAMENTALSEXAMINATIONSECTION (GFES) - THIS IS NOT APPLICABLETO RESEARCH REACTORS QR LICENSES LIMITEDTO FUEL HANDLING. ENTER THE MONTHANDYEARTHE GENERIC FUNDAMENTALSEXAMINATIONSECTION OF THE WRITTEN EXAMINATIONWAS PASSED.
IF THE GFES WAS NOT TAKEN,YOU MUST HAVEPASSED AN NRC LICENSING EXAMINATIONON THE APPLICABLEREACTOR TYPE (PWR OR BWR) AFTER FEBRUARY 1, 1982, WHICH LED TO THE ISSUANCE OF A LICENSE. THIS DOES NOT INCLUDE INSTRUCTOR CERTIFICATION EXAMINATIONSOR REQUALIFICATIONEXAMINATIONS.
EDUCATION - INDICATEBOTH ACADEMICANDVOCATIONAL/TECHNICALPOST HIGH SCHOOL EDUCATION. FOR MAJORAREA(S) OF STUDY.
INDICATETHE NUMBER QF YEARS SPENT IN EACH COLLEGE CURRICULUMAND THE HIGHEST DEGREE RECEIVED, USING THE DEGREE CQDE PROVIDED.
FOR VOCATIONAL/TECHNICALEDUCATION, INCLUDING PROGRAMS SUCH AS NUCLEAR POWER SCHOOL, MIUTARY TRAINING,AIRCONDITIONING/REFRIGERATION,DIESEL MECHANICSCHOOL, ETC. INDICATETHE NUMBEROF MONTHS IN EACH PROGRAM AND WHETHER A CERTIFICATE OR DEGREE WAS AWAADED. IF ADDITIONALSPACE IS NEEDED, CONTINUE UNDER COMMENTS (ITEM 17).
FACILITYOPERATOR TRAININGPROGRAM - CHECK THE APPROPRIATE BOX IN ITEMS'12 a AND 12 b. IF YES'S CHECKED IN BOTH ITEMS 12.a AND 12.b, THEN ITEMS 13 (TRAINING), 14 (EXPERIENCE), AND 15 (EXPERIENCE DETAILS) DO NOT HAVETO BE DOCUMENTED, WITHTHE EXCEPTION OF BLOCK 13.3.c. NEW APPLICATIONS MUST STILLINCLUDETHE NUMBEROF SIGNIFICANTCONTROL MANIPULATIONSWHICH AFFECT'REACTIVITYOR POWER LEVELUNDER ITEM 13.3.c. NOTE: INPO ACCREDITED MEANS ACCREDITATIONBYTHE NATIONALNUCLEAR ACCREDITING BOARD AND THAT THE MINIMUMREQUIREMENTS OF REGULATORY GUIDE 1.8, REV. 2, ARE MET.
TRAINING -
INDICATE THE TRAINING YOU HAVE RECEIVED TO MEET THE GUIDELINES OF ANSI N18.1/ANS 3.1
~ AS ENDORSED BY REGULATORY GUIDE 1.8, REV. 2. THE BREAKDOWN OF TRAINING IN THIS CATEGORY PARALLELS THE ANSI/ANS STANDARDS. REFER TO THE STANDARDS IF YOU NEED FURTHER CLARIFICATION. INCLUDE BOTH BEGINNING AND COMPLETION DATES AND THE TOTALNUMBER OF WEEKS SPENT IN EACH TYPE OF TRAINING. THE NUMBER OF WEEKS IS PROVIDED,IN ADDITIONTO BEGINNING AND COMPLETION DATES, TO ACCOUNT FQR INTERMITTENTTRAINING(FOR EXAMPLE,4 WEEKS OF CLASSROOM TRAININGSPAEAD OVER A2-MONTHPERIOD).
THEREFORE, THE DATE COLUMNS MAY INDICATEA LARGER TIME SPAN THAN THE ACTUAL NUMBER OF WEEKS SPENT IN FULL-TIME TRAINING. TIME IN TRAINING FOR THE UCENSE APPLIED FOR CANNOT BE DOUBLE COUNTED UNDER EXPERIENCE (ITEM 14).
ALLREQUALIFICATIONTRAININGTIMEIS TO BE ACCOUNTED FOR IN THE REQUALIFICATIONITEM 13.6. PLEASE DO NOT DOUBLE LIST THE TIME SPENT IN REQUALIFICATIONTRAINING FOR CLASSROOM OR SIMULATORTIME UNDER ITEMS 13.1, 13,2, OR 13.3.
EXPERIENCE - A MINIMUMOF 6 MONTHS AT THE SITE FOR WHICH THE LICENSE IS SOUGHT IS REQUIRED. FOR EACH POSITION HELD, COMPLETE ITEM 15.
DO NOT DOUBLE COUNT TIME.
IF YOU HAD OVERLAPPING DUTIES, THE MONTHS SHOULD REFLECT THE PROPORTIONATE AMOUNTOF TIMEYOUWERE ASSIGNED TO THOSE PARTICULARDUTIES. IN NO CASE SHOULD THE NUMBEROF MONTHS REPORTED FOR A PARTICULARTIME PERIOD EXCEED THE NUMBER OF MONTHS THAT ARE IN THAT TIME PERIOD.
EXPERIENCE DETAILS - INCLUDEPOSITION TITLE,TIMEPERIOD-FROM/TQ, FACILITY,ANDA BRIEF DESCRIPTION OF DUTIES PERFORMED WHILE SERVING IN THAT POSITION.
IF MORE SPACE IS NEEDED,USE COMMENTS (ITEM 17), OR IF NECESSARY, ATTACH ADDITIONAL INFORMATION.
FOR AENEWALSONLY - (1) ENTER THE APPROXIMATENUMBEROF HOURS SINCE PREVIOUS RENEWALOR ISSUANCE OF LICENSE IF FIRST RENEWAL. (2) ENTER DATE AND RESULT OF MOST RECENT NRC ADMINISTEREDREQUAUFICATIONEXAMINATION.
COMMENTS - USE THIS SPACE TQ INCLUDEANYEXTRAINFORMATIONOR CLARIFICATIONFOR OTHER ITEMS ON THE APPLICATIONFORM.
IF THE SPACE PROVIDED IS NOT SUFFICIENT, YOU MAYATTACH EXTRA INFORMATIONWITHYOUR APPLICATION.
NRC FORM 396, CEATIFICATIDNOF MEDICALEXAMINATIONBY FACILITYLICENSEE - MUST ACCOMPANYTHIS APPUCATION.
SIGNATURES SIGN AND DATE ITEM 19.a.
OBTAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YOUR SENIOR MANAGEMENTREPRESENTATIVE ON SITE.
DETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NAC FOAMS 398 AND 396 (OAIGINALAND TWO COPIES EACH) TO THE APPAOPRIATE REGIONALADMINISTRATOA. (SEE AEVERSE SIDE FOR PRIVACYACT STATEMENT AND ADDRESSES)
NRC FORM 398 (8-92)
~'
PRIVACYACT STATEMENT Pursuant to U.S.C. 552a(e){3). enacted into law by Section 3 of tho Privacy Act of 1974!Public Law 93. 79), the Ioliowing is furnished to individuals who supply information to the U.S. Nuclear Regulatory Commission on NRC Form 398. Ihis information is maintained in a System of Records designated as NRC 16 and described at 55 Federal Register 33978 (August 20, 1990), or the most recent Federal Register publication of the Nuclear Regulatory Commission's 'Republication of Systems of Records Notices" that is available at the NRC Public Document Room, Gelman Building, Lower Level, 2120 L Street NW, Washington, D.C.
1.
AUTHORITY. Section 107 AND 161(i) of the Atomic Energy Act of 1954, as amended (42 U.S.C. 2137 and 2201 (i)).
2.
PRINCIPAL PURPOSES.
The information willbe collected and evaluated for determining licensing eligibilityand to generate statistical data and reports on licensing actions.
3.
ROUTINE USES.
Information entered on this form may be used to:
(a) determine ifthe ir.di"idual meets the requirements of 10 CFR Part 55 to be issued an operator's license; (b) provide researchers with information for statistical ovaluaticns related to selection, training, and examination Of faCility OperatcrS; (C) piOVIde faCility management With SuffiCient infOrmatiOn tO enrOII the indlvidualS in the liCenSed OperatOr requalifiCatiOn program; (d) provide for examination and testing material and obtain results from contractors.
4.
WHETHER DISCLOSURE IS MANDATORYOR VOLUNTARYAND EFFECT ON I".IDIVIDUALOF NOT PROVIDING INFORMATION. Disclosure is voluntary. However, ifthe information requested is not provided, NRC willnot be aole to evaluate whether the application meets the requirements of 10 CFR Part 55.
5.
SYSTEMS MANAGER(S) AND ADDRESS.
Chief, Operator Ucensing Branch, Office of Nuclear Reactor Regulation, U.S. Nuclear Regulatory Commission, Washington, DC 205554001.
6.
In accordance with 10 CFR 55,5, Communications, this form shall be submitted to the NRC as follows: BY MAILADDRESSED TO:
REGIONALADMINISTRATOR,REGION I U. S. NUCLEAR REGULATORY COMMISSION 475 ALLENDALEROAD KING OF PRUSSIA, PA 19406-1415 REGIONAL ADMINISTRATOR,REGION IV U. S. NUCLEAR REGULATORY COMMISSION 611 RYAN PLAZA DRIVE, SUITE 400 ARLINGTON,TX 7601M064 REGIONALADMINISTRATOR,REGION II U. S. NUCLEAR REGULATORY COMMISSION 101 MARIETTASTREET NW, SUITE 2900 ATLANTA,GA 30323 REGIONAL ADMINISTRATOR,REGION V U. S. NUCLEAR REGULATORY COMMISSION 1450 MARIAlANE WALNUTCREEK, CA 94596-5368 REGIONAL ADMINISTRATOR,REGION III U. S. NUCLEARREGULATORYCOMMISSION 799 ROOSEVELT ROAD GLEN ELLYN, IL 60137 OPERATOR LICENSING BRANCH DIVISION OF LICENSEE PERFORMANCE AND QUALITYEVALUATION U.S. NUCLEAR REGULATORYCOMMISSION WASHINGTON, DC 205554001
NRC FORM 398 (6-92) 10 CFR 55.31. 55.35.
is/5.47, and 55.57 U.S. NUCLEAR REGULATORYCOMMISSION PERSONAL QUALIFICATIONSTATEMENT-LICENSEE TO REMAINVALID,THIS FORM MUST NOT BE ALTERED APPROVEO BY0MB:NO. 31500090 EXPIRES: 12-31.94 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 2.0 HRS. FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE INFORMATION AND RECORDS MANAGEMENTBRANCH IMNBB7714), U.S. NUCLEAR REGUIATORY COMMISSION. WASHINGTON. DC 20555(m01. AND TO THE PAPERWORK REDUCTION PROJECT (3150 0090). OFFICE OF MANAGEMENTANDBUDGET, WASHINGTON,DC 20503 DATE RECEIVED (To be completed by N/ICI
- l. APPUCANT'S FULLNAME (Last, First. h(idd(ei ANDADDRESS (include Z(P Codel
- 4. TYPE OF APPLICATION (Cbeck applicable boxesl HOT COLD
- 2. CITIZENSHIP
- a. UNITED STATES
- b. OTHER (Specify)
- 5. TYPE OF UCENSE APPLIED FOR
- 3. BIRTH DATE MONTH DAY YIAR
- a. NEW
- b. RENEWAL
- c. UPGRADE
- d. MULTI.UNIT(AMEf(DTO
/NCLUDEADD(7(DNAL UN/7)
- e. REAPPUCATION 1 ~ FIRST 2 ~ SECOND 3 ~ THIRD B. PREVIOUS LICENSE(s) HELD I. WAIVERREQUESTED (Justify on Reverse) 1
~ WRIT(EN (Cstegoryl 2 - OPERATING (Categoryl 3
EUGIBIUTY 4 ~ MEDICAL 5 ~ OTHER
- 9. DATE PASSED GENERIC FUNDA.
MENTALSEXAMINATIONSECTION (IFAPPLICABLE)
- a. OPERATOR
- b. SENIOR OPERATOR c, LIMITEDSRO (e.g., Fuel Handierl a, OOCKETNUMBER RO 55.
- b. LICENCE NUMBER O
Ai N A
MONIII OAP I
I I'.
FACILITYDOCKET NUMBER 50.
- 7. NAMEAND ADDRESS OF APPLICANT'S EMPLOYER (include Z/P Codel
- 10. CURRENT POSITION AT FACILITY
- 8. NAMEOF APPLICANT'5 FACILITY
- 9. ADDITIONALFACILITYDOCKETS (Multiunit Licenseesl FACILITYDOCKET NUMBER
- a. PLANT SUPERINTENDENT
- b. ASSISTANT PLANTSUPERINTENDENT
- c. SHIFT SUPERVISOR
- d. STAFF ENGINEER
- e. SHIFT TECHNICALADVISOR/SHIFTENGINEER I.
INSTRUCTOR
- 0. SENIOR CONTROL ROOM OPERATOR
- h. CONTROL ROOM OPERATOR I, AUXILIARYUNITOPER ATOR/TRAINEE/TURBINE BUILDING/EQUIPMENT OPERATOR (NON LICENS.
ED OPERA TOAI
- j. OTHER (Specify/
11.
EDUCATION
~. HIGH SCHOOL GRADUATE GED EQUIVALENCY NO
- b. NUMBER OF YEARS Of COLLTGL
- c. MAJOR AREA(5) OF STUDY ENG'INEERING (FIELDS/
OTHER MIMOIP Ol YIAP5 Mrpa st OICAII IIAPCfrtu DEGREE CODES (To be used /or H/GHEST DEGREE obtainedl 0 ~ NONE 1 ~ CERTIFICATE 2 ~ ASSOCIATE 3 ~ BACHELOR 4 ~ MASTER 5 ~ OOCTORAL
- d. VOCATIONAL/TECHNICAL NVMBTR Of MONTHS C RI I It RICTIV(D
- 12. FACILITYOPERATO R TRAININGPROGRAM P. GRADUATE Of INPO ACCRTDITTD OPt RATOR TRAININGPROGRAM THAT IS BASED UPON A SYSTEMS APPROACH TQ TRAINING YES NO
- b. CTRTIFITDON NRC FORM ~Is I'SIMVIATIOVFACltlty CFRDFICAFCIN IQR NRC APPROVE O SIMULATIONFACIVTYIS VSTD IN THE OPTRATOR TRAININGPROGRAM YES NO 1 NUCLEAR POWER PlANTFUNDAMENTALS 2 PLANT SYSTEMS CLASSROOM OBSERVATION IR M
3 OPERATING PRACTICE CONTROL ROOM OPERATIONS ON SHIFT SIMULATOROPERATING ltnC/udha Classroom/
SIMULATORNAMES a,
I I A
V PROGRAM COMPLETED YES NO NVMBIRQf SIGNI I Nt QI4IRQ MANIPVLATIQNS I
V 4 SRO INSTRUCTION EXTRA PERSON ON SIOFT IN CONTROL RQQM IIS IVFFKMIIVIMUMI 5 TIME ON SHIFT ABQVS TMPOWT R I I MI 6 REQUALIFICATION 7 OTHER (Speci fyl
- 13. TRAINING (SINCE LASTAPPLICAT(ON-SEE INSTRUCT(ONSI b.
V Of Wt(KS
- 14. EXPERIENCE (OO (VOTDOUBLECOUNT-SEE INSTRUCT(0(VSI NAVY 1 ~ RO 2 ~ EOOW/PPWO 3 ~ 5WS/PPWS 4 ~ ERS/CRW 5 ~ OTHER (Speci fyl COMMERCIALNUCLEAR (/nc/uding Reseals/I/Test Reactor) 10 ~ REACTOR OPERATOR (L(censedt 11-SENIOR OPERATOR (Licensedl 12 ~ SHIFT SUPERVISOR (Licensed/
13 ~ STAFF/SHIFT ENGINEER (Licensed/
Il~ AUX./EQUIP.OPERATOR (f/antiCenSed/
15 ~ PLANT STAFF 16 ~ OTHER (Specify/
FOSSIL 6 ~ OPERATOR 7 ~ SUPERVISOR 8
PLANTSTAFF 9 ~ OTHER (Specify)
O.
V Of VITTXS IRC FORM 398 (6-92)
5&
. j
- a. POSITION TITLE FROM TO
- 15. EXPERIENCE DETAILS
- b. FACILITY
- c. DUTIES 15.
FOR RENEWALS ONLY
'OURS OPERATED FACILITY:
- b. DATE AND RESULT OF MOST RECENT NRC ADMINISTERED REQUALIFICATIONEXAMiNATiON PASS FAIL
- 17. COMMENTS lSpecify theitem number to which you are elaborating. Anach additional sheetsif necessary l
- 18. NRC FORM 39B. CERTIFICATION OF MEDICALEXAMINATIONBY FACILITYLICENSEE, IS ATTACH ANYFALSE STATEMENTOR'DMISS)DN IN THIS DOCUMENT, INCLUD)ttGATTACHMENTS.MAYBE SUBJECT TO CIVILANDCRIMINALSANCTIONS.
194 I certify under penaqy of osriury that the information in this document and attachments is true and correct. I further certify that I have notified my cunent employer of: II)all previous employertq l2) any instance wnere I have ueen tested oy 4 tealth and Human Services IHHSI Cerlif ed Drug Testing Laboratory or 4 Licensee's testing f4cilltyfof 4lcoliol or 4 controlled substance, and the test rSauna ~XCeeded the Cutalf leVelr eStabiiahed Ourauanl tu 10 CFR Part 26; I3I xny inrtanCe Where I haVe been arreated rOr the Sale, uce Or pocaeaarqn Of 4 COntrOlled SubrtanCe deSCribed in 10 CFR perl 26: inid!4) any reasons for removal or revocauon ol unescorted access at a nuclear faohty, I also authorire the NRc to submit the results of examinalions to my employers for use in preparing rctrmning programs. as necessary, SIGNATURE-APPLICANT DATE CHECK APPLICABLEBOX I
- b. I certify that the above named ind vidual has successfully completed the iacrlity licensees requirements to be hcensed as an Operatorrsenior Operator pursuant to Title 10. Code of Federal Regulations. Part 55; and that the individual has 4 need tor an Operator/senior operator license to perform hisrher assigned duties and that the facilitywillbe made available for examination.
I also certify under penalty of perjury that the information in this document and attachments is true and correct.
C. RENEwALONLv-I certify that tt'4 above n4med individual meets tire approved requahhcation program rwirhexcepporia no(ed in Item tlras requueo by section 50 54 li I) of 10 CFR 50. and that rrershe has discharged hisiher licensed responsibilities competently and safely. I also certify under penalty of perjury that the information in this document and attachments is true and correclh PRINTED GR TYPED NAME TRAININGCOORDINATOR SENIOR MANAGEMENTREPRESENTATIVE ON SITE PRINTED OR TYPED NAME DATE SIGNATURE DATE CATEGORV WRITTEN OPERATING WAIVERlChecfr or Complete items. as epplicablel rri v
FOR NRC UBE
'EETS REQUIREMENTS
'OES NOT MEET REQUIREMENTS rExplain pekiw)
ELIGIBII.ITY MEDICAL OTHER
>RC FORM 398 l6.92)
SIGNATURE-REVIEWER DATE
Enclosure 3
DESCRIPTION OF CHANGES NRC Form Number Item Number Change 396 The 10 CFR Part 55 referenced in the upper left hand corner was corrected.
398 412 The parapraph in Section A "Medical Examination Certification,"
was changed to include the statement regarding ANSI/ANS 3.4-1983, or ANSI/ANS 15.4-1988(N380) was followed or an acceptable alternative
- method, which has been approved by NRC, was used.
This was "Training."
Item 412 is NOW "Facility Operator Training Program.>>
g13 f14 816 This was "Experience."
Item 413 is NOW "Training."
This was "Facility Operator Training Program."
Item gl4 is NOW "Experience."
This section was reorganized but not renumbered.
This was "For Renewals Only." Item 415 is NOW "Experience Details.".
This was "Experience Details."
Item gl6 is NOW "For Renewals Only."
518 "Attach" should be "attached."
0 e