ML18096A984

Forwards Revised NRC Form-396,certification of Medical Exam by Facility Licensee & Revised NRC Form-398,personal Qualifications Statement - Licensee

ML18096A984
Person / Time
Site:	Salem, Hope Creek
Issue date:	09/17/1992
From:	Bettenhausen L NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Miltenberger S Public Service Enterprise Group
References
NUDOCS 9209220037
Download: ML18096A984 (7)

Text

.e Docket No. 50-272

• 50-311 50-354 Mr. Steven E. Miltenberger Vice President and.

Chief Nuclear Officer SEP 1 7 199Z Public Service Electric & Gas Company P. o. Box 236 Hancocks Bridge, New Jersey 08038 *

• Gentlemen:

SUBJECT:

REVISED NRC FORMS 396 AND 398 Enclosed is a copy of the reyised 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 off ice can obtain additional copies of these forms by contacting Beverly Martin. by telephone on (301) 49-2-8138 or by writi11g 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,'

lriginal SigneC. 'BY~

Lee H. Bettenhausen, Chief Operations Branch Division of Reactor Safety

Enclosures:

As stated 9209220037 6;866~72 PDR ADOCK PDR p

Public Service Electric & Gas cc w/enclosures:

A. Orticelle, Manager - Nuclear Training G. Mecchi, Principal - Operations Training J. Lloyd, Principal Training Supervisor (Salem)

W. Gott, Principal Training Supervisor (Hope Creek) cc w/o enclosures:

s. LaBruna, Vice President - Nuclear Operations J. Isabella, Director, Generation Projects Department, Atlantic Electric Company J. Hagan, General Manager -

Hope Creek Operations F. Thomson, Manager, Licensing and Regulation J. Robb, Director, Joint Ov.iner Affairs A. Tapert, ~rogram Administrator R. Fryling, Jr., Esquire M. Wetterhahn, Esquire Lower Alloways Creek Township

c. Schaefer, External Operations, Nuclear, Delmarva Power & Light

c. Vondra,.General Manager -

Salem Operations L. Reiter, General Manager, QA.and Nuclear Safety Review NRC Resident Inspector (HC arid Salem)

Public Document Room (w/encl)

Local Public Document Room (w/encl)

Nuclear Safety Information Center (w/encl)

State of New Jersey bee w/enclosures:

OL Facility File RI:DRS Curley VC-09/1:>/92 RI:DRS B~ausen 09//6-/92 Official Record Copy

NRC FORM 396 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0024 (6*92)

EXPIRES: 1*31-94 1 O CFR 55.23, 55.25, ESTIMATED BURDEN PER

RESPONSE

TO COMPLY WITH THIS 55.27, 55.31. 55.33 INFORMATION COLLECTION REQUEST:

15 MINUTES.

FORWARD 55.57 COMMENTS REGARDING BURDEN ESTIMATE TO THE INFORMATION AND CERTIFICATION OF MEDICAL EXAMINATION RECORDS MANAGEMENT BRANCH (MNBB 7714),

U.S.

NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555--0001, AND TO THE BY FACILITY LICENSEE PAPERWORK REDUCTION PROJECT (3150-0024),

OFFICE OF MANAGEMENT AND BUDGET, WASHINGTON, DI:; 20503.

NAME OF APPLICANT FACILl1Y I 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 BY A PHYSICIAN.

PRINTED NAME (of physician)

I STATE AND LICENSE NUMBER I EXAMINATION DATE 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 SUCH THAT THE APPLICANT WOULD NOT BE EXPECTED TO CAUSE OPERATIONAL ERRORS ENDANGERING PUBLIC HEALTH AND SAFE1Y. I CERTIFY THAT IN REACHING THIS DETERMINATION, THE GUIDANCE CONTAINED IN ANSI/ANS 3.4-1983, OR ANSI/ANS 15.4-1988 (N380) WAS FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY NRG. IF THE GUIDANCE IN THE APPROPRIATE ANSI/ANS DOCUMENT IS NOT COMPLIED WITH, AN ACCEPTABLE ALTERNATIVE 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:

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 NRG review.

PROPOSED WORDING OF RESTRICTION {Block 4 above)

RELATIONSHIP OF RESTRICTION TO DISQUALIFYING CONDITION (Briefly indicate how restricuon will coffect the disqualifying condiUon)

REMARKS FOR RESTRICTION CHANGE (Block 5 above)

8. NONMEDICAL CERTIFICATION THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS AND FITNESS FOR DU1Y REQUIREMENTS 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 PEriAL 1Y OF PERJURY THAT HiE INFORMATION IN THIS DOCUMENT AND ATTACHMENTS IS TRUE AND CORRECT.

PRINTED NAME AND TITLE (Senior Management Representabve on Site)

I SIGNATURE I DATE In accordance with 10 CFR 55.5, Communications, this form shall be submitted to the NRG as follows: BY MAIL ADDRESSED TO:

REGIONAL ADMINISTRATOR, REGION I REGIONAL ADMINISTRATOR, REGION II REGIONAL ADMINISTRATOR, REGION Ill U.S. NUCLEAR REGULATORY COMMISSION U.S. NUCLEAR REGULATORY COMMISSION U.S. NUCLEAR REGULATORY COMMISSION 475 ALLENDALE ROAD 101 MARIETTA STREET NW, SUITE 2900 799 ROOSEVELT ROAD KING OF PRUSSIA PA 19406-1415 ATILANTA,GA 30323 GLEN ELLYN, IL 60137 REGIONAL ADMINISTRATOR, REGION IV REGIONAL ADMINISTRATOR, REGION V OPERATOR LICENSING BRANCH U.S. NUCLEAR REGULATORY COMMISSION U.S. NUCLEAR REGULATORY COMMISSION DIVISION OF LICENSEE PERFORMANCE 611 RYAN PLAZA DRIVE, SUITE 400 1450 MARIA LANE AND QUALITY EVALUATION ARLINGTON, TX 6011-8064 WALNUT CREEK, CA 94596-5368 U.S. NUCLEAR REGULATORY COMMISSION WASHINGTON, DC 20555-0001 PRIVACY ACT STATEMENT Pursuant TO 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law ROUTINE USE(S): The informatiOn may be disclosed to an appropriate Federal, State and 93-579), the following statement is furnished to individuals who supply Information to the U.S. Nuclear local agency in the event the information indicates a violation or potential violation of law and Regulatory Commis~ion on NRG 'Form 396. This i~formation is maintained in a system of records in the courae of an administrative or judicial proceeding. In addition, this information may be transferred to an appropriate Federal, State, or local agency to the extent relevant and designated as NRC-16 and described at 55 Federal Register 33978 (August 20, 1990), or the most necessary for an NRC decision about you.

recent Federal Register publication of the Nuclear Regulatory Commission's *Republication of Systems WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF of Records Notices* that is available at the NRG Public Document Room, Gelman Building, Lower NOT PROVIDING INFORMATION:

Disclosure is voluntary. lf the requested information is not Level, 2120 L S1reet NW, Washington, D.C.

provided, however, the application for a facility operator's or senior operator's license may be AUTHORl1Y:

Section 107 and 161 (i) of the Atomic Energy Act of 1954, as amended (42 U.S.C. 2137 denied.

and 2201 (i)).

SYSTEM MANAGER(S) AND ADDRESS:

Chief, Operator Licensing Branch PRINCIPAL PURPOSE(S):

1ntormation entered on this form is used to determine whether the physical Office of Nuclear Reactor Regulation U.S. Nuclear Regulatory Commission condition and general health of the applicant are such that they will not cause operational errors Washington, DC 20555-0001.

endangering public health and safety.

The information may be used by the NRG staff.to determine if the individual meets the requirements of i O CFR 55 to take an examination or to be issued an operator's license.

NRC FORM 396 (6*92)

INSTRUCTIONS FOR COM.'ING NRC FORM 398, PERSONAL QUALIFICATIATATEMENT-LICENSEE T~EMAIN VALID, THIS FORM MUST NOT BE AL TERP'

4.

TYPE. OF APPLICATION

a.

NEW-

"X" IF YOU ARE A NEW APPLICANT.

COMPLETE EACH CATEGORY OF THE FORM COMPLETELY, FOLLOWING THE

. INSTRUCTIONS BELOW. THIS IS TO INCLUDE ALL EDUCATION, TRAINING AND EXPERIENCE THAT YOU HAVE RECEIVED UP TO THE DATE OF THIS APPLICATION. NOTE: SEE ITEM 12 - THERE IS AN EXCEPTION. ALSO, THIS BLOCK IS TO BE MARKED IF PREVIOUS NEW APPLICATION WAS WITHDRAWN. PLEASE WRITE "WITHDREW' NEXT TO "NEW."

FOR 4.b THROUGH 4.e, COMPLETE EACH CATEGORY COMPLETELY, BUT INDICATE ONLY THE EDUCATION, TRAINING, AND EXPERIENCE YOU HAVE RECEIVED SINCE YOUR LAST APPLICATION. NOTE: SEE ITEM 12-THERE IS AN EXCEPTION.

b.

RENEWAL - "X" IF YOU ARE RENEWING CURRENT LICENSE.

c.

UPGRADE - "X" IF YOU HOLD A RO LICENSE AND ARE NOW APPL YING TO UPGRADE YOUR LICENSE TO A SRO.

d.

MULTI-UNIT - "X" IF YOU CURRENTLY HOLD A LICENSE AT YOUR FACILITY AND ARE APPLYING TO AMEND YOUR CURRENT LICENSE TO ADD AN ADDITIONAL UNIT.

e.

REAPPLICATION - "X" IF YOU HAVE PREVIOUSLY BEEN DENIED A LICENSE AND ARE REAPPLYING.*

f.

WAIVER REQUESTED - "X" THE APPLICABLE WAIVER REQUESTED AND JUSTIFY IN COMMENTS SECTION (ITEM 17).

g.

DATE PASSED GENERIC FUNDAMENTALS EXAMINATION SECTION (GFES) - THIS IS NOT APPLICAB.LE TO RESEARC_H REACTORS OR LICENSES LIMITED TO FUEL HANDLING. ENTER THE MONTH AND YEAR THE GENERIC FUNDAMENTALS EXAMINATION SECTION OF THE WRITIEN EXAMINATION WAS PASSED.. IF THE GFES WAS NOT TAKEN, YOU MUST HAVE PASSED AN NRG LICENSlf\\!G EXAMINATION ON THE APPLICABLE REACTOR TYPE (PWR OR BWR) AFTER FEBRUARY 1, 1982, WHICH LED TO THE ISSUANCE OF A LICENSE. THIS DOES NOT INCLUDE INSTRUCTOR CERTIFICATION EXAMINATIONS OR REQUALIFICATION EXAMINATIONS.

11.

EDUCATION - INDICATE BOTH ACADEMIC AND VOCATIONAL/TECHNICAL POST HIGH SCHOOL EDUCATION. FOR MAJOR AREA(S) OF STUDY,

. INDICATE THE NUMBER OF YEARS SPENT IN EACH COLLEGE CURRICULUM AND THE HIGHEST DEGREE RECEIVED, USING THE DEGREE CODE PROVIDED. FOR VOCATIONAL/TECHNICAL EDUCATION, INCLUDING PROGRAMS SUCH AS NUCLEAR POWER SCHOOL, MILITARY TRAINING, AIR CONDITIONING/REFRIGERATION, DIESEL MECHANIC SCHOOL, ETC. INDICATE THE NUMBER OF MONTHS IN EACH PROGRAM AND WHETHER A CERTIFICATE OR DEGREE WAS AWARDED. IF ADDITIONAL SPACE IS NEEDED, CONTINUE UNDER COMMENTS (ITEM 17).

12.

FACILITY OPERATOR TRAINING PROGRAM - CHECK THE APPROPRIATE BOX IN ITEMS 12.a AND 12.b. IF "YES" IS CHECKED IN BOTH ITEMS 12.aAND 12.b, THEN ITEMS 13 (TRAiNING), 14 (EXPERIENCE), AND 15 (EXPERIENCE DETAILS) DO NOT HAVE TO BE DOCUMENTED, WITH THE EXCEPTION OF BLOCK 13.3.c. NEW APPLICATIONS MUST STILL INCLUDE THE NUMBER OF SIGNIFICANT CONTROL MANIPULATIONS WHICH AFFECT REACTIVITY OR POWER LEVEL UNDER ITEM 13.3.c. NOTE: INPO ACCREDITED MEANS ACCREDITATION BY THE NATIONAL NUCLEAR ACCREDITING BOARD AND THAT THE MINIMUM REQUIREMENTS OF REGULATORY GUIDE 1.8, REV. 2, ARE MET..

13.

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 TRA.INING 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 TOTAL NUMBER OF WEEKS SPENT IN EACH TYPE OF TRAINING. THE NUMBER OF WEEKS IS PROVIDED.IN ADDITION TO BEGINNING AND COMPLETl,ON DATES, TO ACCOUNT FOR INTERMITIENT TRAIN.ING (FOR EXAMPLE, 4 WEEKS OF CLASSROOM TRAINING SPREAD OVER A 2-MONTH PERIOD).

THEREFORE, THE DATE COLUMNS MAY INDICATE A LARGER TIME SPAN THAN THE ACTUAL NUMBER OF WEEKS SPENT IN FULL-TIME TRAINING. TIME IN TRAINING FOR THE LICENSE APPLIED FOR CANNOT BE DOUBLE COUNTED UNDER EXPERIENCE (ITEM 14).

ALL REQUALIFICATION TRAINING TIME IS TO BE ACCOUNTED FOR IN THE REQUALIFICATION ITEM 13.6. PLEASE DO NOT "DOUBLE LIST" THE.

TIME SPENT IN REQUALIFICATION TRAINING FOR CLASSROOM OR SIMULATOR TIME UNDER ITEMS 13.1, 13.2, OR 13.3.

14.

EXPERIENCE - A MINIMUM OF 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 AMOUNT OF TIME YOU WERE ASSIGNED TO THOSE PARTICULAR DUTIES. IN NO CASE SHOULD THE NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEED THE NUMBER OF MONTHS THAT ARE IN THAT TIME PERIOD.

15.

EXPERIENCE DETAILS - INCLUDE POSITION TITLE, TIME PERIOD-FROM/TO, FACILITY, AND A BRIEF DESCRIPTION OF DUTIES PERFORMED WHILE SERVING IN THAT POSITION. IF MORE SPACE IS NEEDED.USE COMMENTS (ITEM 17), OR IF NECESSARY, ATIACH ADDITIONAL INFORMATION.

16.

FOR RENEWALS ONLY - (1) ENTER THE APPROXIMATE NUMBER OF HOURS SINCE PREVIOUS Rf;:NEWAL OR ISSUANCE OF LICENSE IF FIRST RENEWAL. (2) ENTER DATE AND RESULT OF MOST RECENT NRG ADMINISTERED REQUALIFICATION EXAMINATION.

17.

COMMENTS - USE THIS SPACE TO INCLUDE ANY EXTRA INFORMATION OR CLARIFICATION FOR OTHER ITEMS ON THE APPLICATION FORM.

IF THE SPACE PROVIDED IS NOT SUFFICIENT, YOU MAY ATIACH EXTRA INFORMATION WITH YOUR APPLICATION.

18.

NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE - MUST ACCOMPANY THIS APPLICATION.

19.

SIGNATURES SIGN AND DATE ITEM 19.a.

OBTAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YOUR SENIOR MANAGEMENT REPRESENTATIVE ON SITE.

DETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS 398 AND 396 (ORIGINAL AND TWO COPIES EACH) TO THE APPROPRIATE REGIONAL ADMINISTRATOR. (SEE REVERSE SIDE FOR PRIVACY ACT STATEMENT AND ADDRESSES)

NRC FOAM 398 (6-92)

PRIVACY ACT STATEMENT Pursuant to U.3.C. 552a(e}(3). enacted into law by Section 3 of the Privacy Act of 1974 IPublic Law 93-!:79), the foliowing is furnished to individuals who

upply information to the U.~. Nuclear Regulatory Commission on NRC form 398. This information i;; main'iained i;i a System of Records designated as NRC i6 and described at 55 Federal Register 33978 (August 20, 1990), or the most recent Fed?.ral 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 will be collected anci evaluated for determining licensing eligibility and to generate statistical data and reports on licensing actions.

3.

ROUTINE USES. Information entered on this form may be used to: (a) determine if the ii~dividual meets the requirements of 10 CFR Part 55 to be issued an opP.rator's license, (b) provide researchers with information for statisticc.I evaluations related to selection, training, and examination ot facility operators; (cl p1ovide facility management with sufficient information to 9nroll the indi,1iduals in the licensed operator requalification program; (d) provide for examination and testing material and obtain results from contractors.

4.

WHETHER DISCLOSURE IS MANDATORY Otl VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION. Disclosure is voluntary. f-iowever, if the information requested is not provided, NRC will not be able to !!valuate whether the application meets the requirements of 10 CFR Part 55.

5.

SYSTEMS MANAGER(S) AND ADDRESS. Chief, Operator Licensing Branch, Office of Nuclear Reactor Regulation, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.

6.

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 U. S. NUCLEAR REGULATORY COMMISSION 475 ALLENDALE ROAD KING OF PRUSSIA, PA 19406-1415 REGIONAL ADMINISTRATOR, REGION IV U. S. NUCLEAR REGULATORY COMMISSION 611 RYAN PLAZA DRIVE, SUITE 400 ARLINGTON, TX 76011-8064 REGIONAL ADMINISTRATOR, REGION II U. S. NUCLEAR REGULATORY COMMISSION 101 MARIETTA STREET NW, SUITE 2900 ATLANTA, GA 30323 REGIONAL ADMINISTRATOR, REGION V U. S. NUCLEAR REGULATORY COMMISSION 1450 MARIA LANE WALNUT CREEK, CA 94596-5368 REGIONAL ADMINISTRATOR, REGION Ill

• U. S. NUCLEAR REGULATORY COMMISSION 799 ROOSEVELT ROAD GLEN ELLYN, IL 60137 OPERATOR LICENSING BRANCH DIVISION OF LICENSEE PERFORMANCE AND QUALITY EVALUATION U.S. NUCLEAR REGULATORY COMMISSION WASHINGTON, DC 20555-0001

NRC FORM 398 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0090 DATE RECEIVED 16-92)

EXPIRES: 12-31-94

!To be completed by NRCJ 10 CFR 55.31. 55.35.

ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS 55.47. and 55.57 INFORMATION COLLECTION REQUEST: 2.0 HRS. FORWARD PERSONAL QUALIFICATION STATEMENT-LICENSEE COMMENTS REGARDING BURDEN ESTIMATE TO THE INFORMATION AND RECORDS MANAGEMENT BRANCH IMNBB 77141. U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555-0001, AND TO TO REMAIN VALID, THIS FORM MUST NOT BE ALTERED THE PAPERWORK REDUCTION PROJECT 13150-0090), OFFICE OF MANAGEMENT AND BUDGET. WASHINGTON, DC 20503

1. APPLICANrS FULL NAME (Last, First, Middle) ANO ADDRESS (include ZIP Code) 4'. TYPE OF APPLICATION !Check applicable boxes! I HOT I I COLD

a. NEW I

f. WAIVER REQUESTED (Justify on Reverse!

b. RENEWAL 1 - WRITIEN (Categoryj

c. UPGRADE 2 - OPERATING (Category)

d. MULTI-UNIT (AMEND TO INCLUDE ADDITIONAL UNIT/

e. REAPPLICATION 3 - ELIGIBILITY f--

1 -FIRST 4 - MEDICAL f--

2. CITTZENSHIP

3. BIRTH DATE 2-.SECOND 5 - OTHER MONTH I DAY YEAR I_ 9. DATE PASSED GENERIC FUNDA-

~**

UNITED STATES 3-THIRD MENTALS EXAMINATION SECTION FF

b. OTHER (Specify!

I I I (IF APPLICABLE!

5. TYPE OF LICENSE APPLIED FOR

6. PREVIOUS LICENSE(SI HELO

a. OPERATOR

a. DOCKET NUMBER RO SRO

b. LICENCE NUMBER

c. EXPIRATION DATE

d. FACILITY DOCKET NUMBER MONTH DAV VEAR r--

b. SENIOR OPERATOR I

I I

55-I I

I 50-

c. LIMITED SRO (e.g.. Fuel Handler!

I I

I

7. NAME AND ADDRESS OF APPLICANT"S EMPLOYER (Include ZIP Code!

10. CURRENT POSITION AT.FACILITY

a. PLANT SUPERINTENDENT LJ i. AUXILIARY UNIT OPER-A TOR/TRAINEE/TURBINE

b. ASSISTANT PLANT SUPERINTENDENT BUILDING/EQUIPMENT f--

OPERATOR !NON LICENS-

c. SHIFT SUPERVISOR ED OPERA TORI

d. STAFF ENGINEER D j. OTHER (Specify!

8. NAME OF APPLICANT'S FACILITY I FACILITY DOCKET NUMBER

e. SHIFT TECHNICAL ADVISOR/SHIFT ENGINEER

f.

INSTRUCTOR

9. ADDITIONAL FACILITY DOCKETS (Multi-unit Licensees!

g. SENIOR CONTROL ROOM OPERATOR

h. CONTROL ROOM OPERATOR

11. EDUCATION

a. HIGH SCHOOL

c. MAJOR AREAIS) OF STUDY NUMBER HIGHEST DEGREE CODES

d. VOCATION_AL/TECHNICAL NUMBER CERTIFICATE

- OF YEARS DEGREE rTo be used for "HIGHEST OF RECEIVED ENGINEERING (FIELDS!

1useCoc1es1 DEGREE" obtained!

I YPE Uc I HAININli MONTHS

• oo NU GRADUATE 0-NONE GED EQUIVALENCY OTHER 1 *CERTIFICATE 2 - ASSOCIATE NO 3 - BACHELOR

b. NUMBER OF 4 - MASTER YEARS OF COLLEGE 5-DOCTORAL

12. FACILITY OPERATOR TRAINING PROGRAM

a. GRADUATE OF INPO ACCREDITED OPERATOR I

I I

b. CERTIFIED ON NRC FORM 474 i"SIMULA TION FACILITY I

TRAINING PROGRAM THAT IS BASED UPON A YES NO CERTIFICATION") OR NRC APPROVED SIMULATION FACILITY IS YES NO SYSTEMS APpROACH TO TRAINING USED IN THE OPERATOR TRAINING PROGRAM

13. TRAINING !SINCE LAST APPL/CATION - SEE INSTRUCTIONS)

14. EXPERIENCE (00 NOT DOUBLE COUNT - SEE INSTRUCTIONS!

a. IYIVl'I I H Ml*LI 1:1"\\~

b. NUMBER

a.

HAllL.>

b. NUMBER FROM TO OF WEEKS NAVY FROM TO OF WEEKS 1 -

NUCLEAR POWER PLANT FUNDAMENTALS

/Class*

1oom1 1-RO 2 -

PLANT SYSTEMS 2 - EOOWfPPWO CLASSROOM 3-EWSfPPWS OBSERVATION 4-ERS/CRW 3 -

OPERATING PRACTICE 5 - OTHER !Specify)

CONTROL ROOM OPERATIONS ON SHIFT SIMULATOR OPERATING !Includes Classroom)

COMMERCIAL NUCLEAR (Including Research;Test Reactor!

10 - REACTOR OPERATOR (Licensed!

SIMULATOR NAMES 11 - SENIOR OPERATOR (Licensed!

a.

12 - SHIFT SUPERVISOR (Licensed)

b.

13 - STAFF/SHIFT ENGINEER (Licensed!

CERTIFIED ST AATUP I

I YES i

INO PROGRAM COMPLETED 14-AUX./EQUIP. OPERATOR !NonlicensedJ c NUMBER OF SIGNIFICANT CONTROL MANIPULATIONS PLANT SIMULATOR 15 - PLANT STAFF I

16 - OTHER (Specify!

4 -

SRO INSTRUCTION 5 _ EXTRA PERSON ON SHIFT IN CONTROL ROOM FOSSIL

/ 13*WEEK MINIMUMJ TIME ON SHIFT ABOVE 20°"o POWER 6-0PERATOR a 16-WEEK MINIMUMJ 6 -

REQUALIFICATION 7 - SUPERVISOR 8 - PLANT STAFF 7 -

OTHER (Specify!

9 - OTHEfl (Specify)

NRC FORM 398 16-92)

NRC Form Numb.er 396 398 Item Number

1. 12

1. 13

1. 14

1. 15

1. 16

1. .18 DESCRIPTION OF CHANGES Change The 10 CFR Part 55 referenced in the upper left hand corner was corrected.

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

1. 12 is NOW "Facility Operator Training Program."

This was "Experience."

Item #13 is NOW "Training."

This was "Facility Operator Training Program."

Item

1. 14 is NOW "Experience."

This section was reorganized but not renumbered.

This was "For Renewals Only." Item

.#15 is NOW "Experience Details."

This was "Experience Details." Item

1. 16 is.NOW "For Renewals Only."

"Attach" should be "attached."