ML19037A053
| ML19037A053 | |
| Person / Time | |
|---|---|
| Issue date: | 03/21/2019 |
| From: | Office of Nuclear Material Safety and Safeguards |
| To: | |
| References | |
| OMB 3150-0001 | |
| Download: ML19037A053 (7) | |
Text
NRC FORM 653 U. S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0001 EXPIRES: (MM/DD/YYYY)
(MM-YYYY) Estimated burden per response to comply with this mandatory collection request: 36 10 CFR 32 TRANSFERS OF INDUSTRIAL minutes. NRC requests quarterly reports to keep apprised of device movements. Send comments regarding the burden estimate to the Information Services Branch (O-1 F21), U.S.
DEVICES REPORT Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.gov, and to the Desk Officer, Office of Information and (TO GENERAL LICENSEES) Regulatory Affairs, NEOB-10202, (3150-0001), Office of Management and Budget, Washington, DC 20503. If a means used to impose an information collection does not (Continue on NRC Form 653, 653A or 653B, as appropriate) display a currently valid OMB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.
For each "licensee" to whom a device(s) has been transferred during the reporting period, supply the following:
Name of Vendor Reporting Period From To License Number Intermediate Person(s) (if any)
Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Name of Responsible Individual Business Telephone Number Title of Responsible Individual Information on Device(s) Transferred Date of Transfer Type of Device Model Number Serial Number Isotope Activity and Units Intermediate Person(s) (if any)
Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Name of Responsible Individual Business Telephone Number Title of Responsible Individual Information on Device(s) Transferred Date of Transfer Type of Device Model Number Serial Number Isotope Activity and Units NRC FORM 653 (MM-YYYY) Page of
NRC FORM 653 (Continued) U. S. NUCLEAR REGULATORY COMMISSION (MM-YYYY) 10 CFR 32 TRANSFERS OF INDUSTRIAL DEVICES REPORT (TO GENERAL LICENSEES) (continued)
Intermediate Person(s) (if any)
Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Name of Responsible Individual Business Telephone Number Title of Responsible Individual Information on Device(s) Transferred Date of Transfer Type of Device Model Number Serial Number Isotope Activity and Units Intermediate Person(s) (if any)
Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Name of Responsible Individual Business Telephone Number Title of Responsible Individual Information on Device(s) Transferred Date of Transfer Type of Device Model Number Serial Number Isotope Activity and Units NRC FORM 653 (MM-YYYY) Page of
NRC FORM 653 (Continued) U. S. NUCLEAR REGULATORY COMMISSION (MM-YYYY) 10 CFR 32 TRANSFERS OF INDUSTRIAL DEVICES REPORT (TO GENERAL LICENSEES) (continued)
Intermediate Person(s) (if any)
Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Name of Responsible Individual Business Telephone Number Title of Responsible Individual Information on Device(s) Transferred Date of Transfer Type of Device Model Number Serial Number Isotope Activity and Units Intermediate Person(s) (if any)
Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Name of Responsible Individual Business Telephone Number Title of Responsible Individual Information on Device(s) Transferred Date of Transfer Type of Device Model Number Serial Number Isotope Activity and Units NRC FORM 653 (MM-YYYY) Page of
NRC FORM 653A U. S. NUCLEAR REGULATORY COMMISSION (MM-YYYY) 10 CFR 32 TRANSFERS OF INDUSTRIAL DEVICES REPORT (FROM GENERAL LICENSEES)
For each "licensee" from whom a device(s) has been received during the reporting period, supply the following:
General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)
General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)
General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)
General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)
NRC FORM 653A (MM-YYYY) Page of
NRC FORM 653A (Continued) U. S. NUCLEAR REGULATORY COMMISSION (MM-YYYY) 10 CFR 32 TRANSFERS OF INDUSTRIAL DEVICES REPORT (FROM GENERAL LICENSEES) (continued)
For each "licensee" from whom a device(s) has been received during the reporting period, supply the following:
General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)
General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)
General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)
General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)
NRC FORM 653A (MM-YYYY) Page of
NRC FORM 653B U. S. NUCLEAR REGULATORY COMMISSION (MM-YYYY) 10 CFR 32 TRANSFERS OF INDUSTRIAL DEVICES REPORT (LABEL CHANGES)
For each device for which required label information has been changed, supply the following:
General Licensee User Information Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Previous Serial New Serial Previous New Previous Label Label Activity Type of Device Model Number Number Number Isotope Isotope Activity and Units and Units General Licensee User Information Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Previous Serial New Serial Previous New Previous Label Label Activity Type of Device Model Number Number Number Isotope Isotope Activity and Units and Units General Licensee User Information Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Previous Serial New Serial Previous New Previous Label Label Activity Type of Device Model Number Number Number Isotope Isotope Activity and Units and Units General Licensee User Information Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Previous Serial New Serial Previous New Previous Label Label Activity Type of Device Model Number Number Number Isotope Isotope Activity and Units and Units NRC FORM 653B (MM-YYYY) Page of
NRC FORM 653B (Continued) U. S. NUCLEAR REGULATORY COMMISSION (MM-YYYY) 10 CFR 32 TRANSFERS OF INDUSTRIAL DEVICES REPORT (LABEL CHANGES) (continued)
For each device for which required label information has been changed, supply the following:
General Licensee User Information Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Previous Serial New Serial Previous New Previous Label Label Activity Type of Device Model Number Number Number Isotope Isotope Activity and Units and Units General Licensee User Information Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Previous Serial New Serial Previous New Previous Label Label Activity Type of Device Model Number Number Number Isotope Isotope Activity and Units and Units General Licensee User Information Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Previous Serial New Serial Previous New Previous Label Label Activity Type of Device Model Number Number Number Isotope Isotope Activity and Units and Units General Licensee User Information Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Previous Serial New Serial Previous New Previous Label Label Activity Type of Device Model Number Number Number Isotope Isotope Activity and Units and Units NRC FORM 653B (MM-YYYY)
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