ML20006D627

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

ML20006D627
Person / Time
Site:	Pilgrim
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Bird R BOSTON EDISON CO.
References
NUDOCS 9002140137
Download: ML20006D627 (8)

Text

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g JAN 5 1990 s

Docket No'. 50-293' l

q" Boston' Edison Company'

~ p' ATTN:- Mr. Ralph G. Bird

' Senior Vice President - Nuclear h

. Pilgrim Nuclear Power Station RFD #1 Rocky-Hill Road Plymouth,: Massachusetts 02360 Gentlemen:

q

SUBJECT:

REVISED NRC, FORMS 396:AND 398 Enclosed is a copyc of the revised NRC Form-398'(Enclosure 1), Personal e

Qualification's Statement-'- Licensee and revised NRC Form-396 (Enclosure 2),-

LCertificationiof Medical Examination By Facility Licensee.

1 a

All' changes,.to the NRC Form-396 are detailed in Enclosure 3.

Changes'to NRC o

Form-398 are detailed'in Enclosure 4.

..t.i All' applications for-licenses are to'be submitted on these revised forms no u

later than February 1, 1990L

.The enclosed applications are' for your use..- Additional copies can be obtained.

1 by contacting.Beverly Martin, U.S. Nuclear Regulatory Commission,-by telephone (301) 492-8138 or by writing to her, U.S. Nuclear Regulatory Commission,

Information and. Records Management Branch,' Mail Stop NMBB17714, Washington, D.C; L20555.

If,you have:any questions regarding-these forms, please: contact Richard J.

-r C

Conte at=(215) 337-5120 or, Peter W. Eselgroth at (215) 337-5211.

M Sincerely, p

e,gginni5,1@0 N Robert M. Gallo, Chief Operations Branch Division of. Reactor Safety

Enclosures:

As stated j

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q OFFICIAL RECORD C0pY 396 & 398 FORMS - 0011.0.0

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12/14/89

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Bostori Edison Company 2'

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.cc w/o encl' K. Highfill,.Vice President, Nuclear Operations.

R. Anderson, Plant Manager b

J. Dietrich, Licensing Division Manager

/

E. Robinson, Nuclear Information Manager R. Swanson, Nuclear Engineering Department Manager

~The' Honorable John:F. Kerry q

'The Honorable Edward J. Markey

-The. Honorable Edward P. Kirby The Honorable Peter V. Forman The Honorable Lawrence R. Alexander

. The Honorable Nicholas J. Costello B. McIntyre, Chairman, Department of Public Utilities D.' Lt Gillipie, Nuclear Training Manager (w/ enclosures)

Chairman, Plymouth, Board of Selectmen Chairman, Duxbury Board of Selectmen Plymouth' Civil' Defense Director R. Hallisey,. Department of Public Health, Commonwealth of Massachusetts R. - Adams, Department of Labor. and Industries, Commonwealth of Massachusetts D. :Tibbetts, Acting Massachusetts Secretary of ' Energy Resources Sarah Woodhouse,: Legislative-Assistant

-A.

Nogee. MASSPIRG.

Public Document Room'(PDR)

~

Local Public Document Room (LPDR)

Nuclear Safety-Information Center (NSIC)

NRC Resident Inspector-q

. Commonwealth of_ Massachusetts, SLO Designee j

bec w/o enc 1:

Region I Docke't Room (with concurrences)

Management Assistant, DRMA (w/o-encl)

I W.ERussell.'RA

'J. Dyer, E00

'R. Wessman, NRR cD. Mcdonald, NRR

j

J.~ Johnson, DRP R

R. Blough,'DRP'

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C. Marshcall, SRI - Pilgrim (with concurrences) l

~0L Facility File j.

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Gallo/pb/l/ (f l

01/02/90 Td OFFICIAL RECORD COPY 396 & 398 FORMS - 0012.0,0 f

12/14/89

INST;UCTIONS POR COMPLETING NRC FORD 300 O

PERSONAL OUALIFICATION STATEMENT-LICENSEE im 41 TO REMAIN VALID,THIS FORM MUST NOT BE ALTERED 4.'

TYPE CF APPLICATION '

2.e,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 J

RECElVED UP TO THE DATE OF THIS APPLICATION NOTE: SEE / TEM 74 - THERE IS AN EXCEPTION. ALSO, THIS BLOCK 18 TO BE MARKED IF PREVIOUS NEW APPLICATION WAS WITHDRAWN. PLEASE WRITE " WITHDREW" NEXT j

TO "NEW/'

1 2.b thru 2.e-FOR 2.b THRU 2.e, COMPLETE EACH CATEGORY COMPLETELY, BUT INDICATE ONLY THE EDUCATION, TRAINING, AND EXPERIENCE YOU HAVE RECEIVED SINCE YOUR LAST APPLICATION, NOTE: SEE / TEM 14 - THERE IS AN EXCEPTION.

1

- 2.b RENEWAL

• X"IF YOU ARE RENEWING CURRENT LICENSE, 2.s UPGRADE

'X"IF YOU HOLD A RO LICENSE AND ARE NOW APPLYlNG TO UPGRADE YOUR LICENSE TO A SRO, 2.d MULTI. UNIT

• X" IF YOU CURRENTLY HOLD A LICENSE AT YOUR FACILITY AND ARE APPLYlNG TO AMEND YOUR CUR.

j RENT LICENSE TO ADD AN ADDITIONAL UNIT, l

2.e REAPPLICATION "X"IF NOU HAVE PREVIOUSLY BEEN DENIED A LICENSE AND ARE REAPPLYING, 2.f WAlVER REQUESTED "X"THLAPPLICABLE WAIVER REQUESTED AND JU$TIFY IN COMMENTS SECTION (ITEM 17),

2.s DATE PASSED GENERIC FUNDAMENTALE EXAMINATION SECTION (GFES).

THIS IS NOT APf LICABLE TO RESEARCH REACTORS. ENTER THE MONTH AND YEAR THE GENERIC FUNDAMENTALS EXAMINA.

TION SECTION OF THE WRITTEN EXAMINATION WAS PASSED, IF THE GFES WAS NOT TAKEN,YOU MUST HAVE PASSED AN NRC LICENSING 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 - lNDICATE 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, INCLUDE PROGRAMS SUCH AS NUCLEAR POWER SCHOOL, MILITARY TRAINING, AIR CONDITIONING /REFRIGERATlON, OlESEL MECHANIC SCHOOL, ETC, 1

INDICATE THE NUMBER OF MONTHS IN EACH PROGRAM AND WHETHER A CERTIFICATE OR DEGREE WAS AWARDED, IF ADDI.

- TlONAL SPACE IS NEEDED, CONTINUE UNDER COMMENTS (ITEM 17),

12.

TRAINING - INDICATE THE TRAINING YOU HAVE RECEIVED TO MEET THE REQUIREMENTS OF ANSI N18,1/ANS 3.1, THE BREAKDOWN OF TRAINING IN THIS CATEGORY PARALLELS THE ANS STANDARDS. REFER TO THE STANDARDS lF YOU NEED FURTHER CLARIFICATION. INCLUDE BOTH BEGINNING AND COMPLETION DATES AND THE TOTAL NUMBCR OF WEEKS SPENT l

IN EACH TYPE OF TRAINING. THE NUMBER OF WEEKS IS PROVIDED,IN ADDITION TO BEGINNING AND COMPLETION DATES, l

i TO ACCOUNT FOR INTERMITTENT TRAINING (FOR EXAMPLE,4 WEEKS OF CLASSROOM TRAINING SPREAD OVER A 2. MONTH 11 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 13),

i ALL REQUALIFICATION TRAINING TIME IS TO BE ACCOUNTED FOR IN THE REQUALIFICATION ITEM. PLEASE DO NOT " DOUBLE LIST" THE TIME SPENT IN REQUALIFICATION TRAINING UNDER ITEM 12.6, REQUALIFICATION, EVEN THOUGH IT MAY INCLUDE CLASSROOM OR SIMULATOR TIME, j

13.

EXPERIENCE - A MINIMUM OF 6 NONTHS AT THE SITE FOR WHICH THE LICENSE IS SOUGHT IS REQUIRED, FOR EACH POSITION l

HELD, COMPLETE ITEM 16. 00 NOT DOUBLE COUNT TIME, IF YOU HAD OVERLAPPING DUTIES, THE MONTHS SHOULD REFLECT l

THE PROPORTIONATE AMOUNT OF TIME YOU WERE ASSIGNED TO THOSE PARTICULAR DUTIES. IN NO CASE SHOULD THE N'JMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEED THE NUMBER OF MONTHS THAT ARE IN THAT TIME PERIOD, 1

4 l'

FACILITY OPERATOR TRAINING PROGRAM - INDICATE e. GRADUATE OF INPO ACCREDITED OPERATOR TRAINING PROGRAM:

14. -

AND b. CERTIFIED (ON NRC ton'M M On *lnC MTOOVO CMULATiGN rei r #S USED IN THE OPERATOR TRAINING l'HO.

GRAM, IF "YES" IS CHECKED-IN BOTH ITEMS Ida AND 14.b, THEN ITEMS 11 (EDUCATION),12 (TRAINING),13 (EXPERIENCE),

j-AND 16 (EXPERIENCE DETAILS) DO NOT HAVE TO BE DOCUMENTED. NEW APPLICATIONS MUST STILL INCLUDE THE NUMBER OF SIGNIFICANT CONTROL MANIPULATIONS UNDER ITEM 12.3. NOTE: INPO ACCREDITED MEANS ACCREDITATION BY THE I

j NATIONAL NUCLEAR ACCREDITING BOARD AND MEANS THAT AT LEAST THE MINIMUM REQUIREMENTS OF REGULATORY l

GUIDE 1.8, REV 2, ARE MET, 1

i

.15, FOR RENEWALS ONLY - (1) ENTER THE APPROXIMATE NUMBER OF HOURS SINCE PREVIOUS RENEWAL OR ISSUANCE OF LICENSE lF FIRST RENEWAL, (2) ENTER DATE AND RESULT OF MOST RECENT NRC ADMINISTERED REQUALIFICATION EXAMI.

i 1

p NATION.

16.

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, ATTACH ADDITIONAL INFORMATION.

17.

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

CATION FORM. IF THE SPACE PROVIDED IS NOT SUFFICIENT, YOU MAY ATTACH EXTRA INFORMATION WITH YOUR APPLICA.

TlON, 18.

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

' 19.

SIGNATURES - SIGN AND DAtt! 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 (ORIGINAL AND TWO COPIES EACH) TO THE APPRO.

PRIATE REGIONAL ADMINISTRATOR,

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F oaf t mECElvtD ORM SW -

U.L slucLt AA ILE oVLAT4mV COneslNIOsl APP!.OVE3 9Y OMS) NO. 31N 8KP8Hf 8 1'31 U to CPA N.31. 64.36, M A7, esul t6.87 ESTIMATED SURDEN PER RESPOe89E TO COMPLY WITH THIS INFORMATION COLLECTION Rf00EST; 20 HR$

FORWARD COMMENTS REGARDING BURDEN (STIMATE i'ER80NAL QUALIFICATION STATEMENT-LICENSEE TO THe INFORMATION AND RECOaDs MANAOSMENT DR ANCH IP 63DI. U.S. talCLE AR REOULATORY COMM IS-SiON. WASHINGTON OC 20666. AND TO THE PAPERWORK REDUCTION PROJtdT (31600000l. OFFICE OF MANAGE.

TO REMAIN VALID,THIS FOMM MUST NOT BE ALTERED MEN T AND puOGET, W A$HINGTON. DC 20603,

1. APPLICANT'S FULL NAME (Last,first,MnMief AND ADORESS (hactudeI/PCode/

4. TYPE OF APPLICATION (CPMck app /kable 6vass)

4. HOT l

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1. FIRST WRMENICegoy)

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3. E LIOlalLITY

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d. MULTI.UnlT LAufNO T0 /NCLVDE ADDITIONAL 4. MEDtCAL

2. CITIZENSHIP

3. BIRTH DATE UNIll 6 0THER 6 IJNITED STATES MONTH DAY YEAR g DATE PASSED GENERIC FUNDA.

MM YY MENT ALS E X AMIN ATION SECTION

k. OTHER ISeec!No l

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6. TYPE OF LICENSE APPLIED FOR

6. PREVIOUS LICENSE (S) HELD 6 06ER ATCR,

s. DOCKET NUMSLR RO 3RO k LICENSE NUMBER

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d, F ACILITY DOCKET NUMGER y

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7. NAME AND ADDRESS (ItscAspe l/P Codel OF APPLICANT'S EMPLOYE R

10. CURRENT POSITION Al FACILITY

a. PLANT SUPERINTENDENT L AUXILIARY UNil OPER.

ATOR/ TRAINEE /TURSINE k ASS 18 TANT PLANT SUPERINTENOtNT BUILDING! EQUIPMENT OPERCTOR INON LICENS.

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a. SHIFT 80PERVISOR qL STAFF ENGINEER

l. OTHER f3meev&/

6. NAME OF APPLICANT'S F ACILITY F ACILITV DOCKET NUMUER g 3HlFT TECHNICAL ADVISOR /5HIFT ENGINEER f.

INSTRUCTOR 9

S. ADDITIONAL F ACILITY DOCKET 8 (Mutteens teenses>

$ SENIOR CONTROL ROOM OPERATOR

h. CONTROL ROOM OPER ATOR

11. EDUCATION

& H11HSCHOOL s, MAJOR AREA (56 OF STUDY J'".".'!!.

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DEGREE CODES

d. VOCATIONAL / TECHNICAL NT'" T,"[,'M Y*IQ'N QRADUATE ENGINE ERINO tFItt03)

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GED EQUIVALENCY OTHER RilF ICAT E 2 ASSOCIATE gg J.8ACHELOR

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12. T R AlNINO (SINCE L AST APPLICA TION - $EE INSTRUCTIONS)

13. E XPE F,1ENCE 100 NO T DOUBLE COUNT-SEE INS TRUCT10NSI j

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1-NUCLEAR POWER PLANT FUNDAMENTALS mmi 1.RO 2 -PLANT SYSTEMS

2. EOOW/PPWO CLASSROOM

3. EWS/PPWS OBSERVATION 4 ERS/CRW 3-OPERATING PRACTICE 5 0THER (specJNA CONTROL ROOM OPERATIONS ON SHIFT

- SIMULATOR OPER ATING Itacasue:Cuenoemt ppgggg 6 OPERATOR i

SIMULATOR NAMES 4

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3 COMMERCIAL NUCLE AR (inesentine nesseren/ Test Avectorf l-4 6RO INSTRUCTION

10. RE ACTOR OPERATOR (tsceaants lI 5 dUt$r*Fh'UO"a,$,'" '" ' "'" ' " "

11 SENIOR OPERATOR (teenents l

a. / g,ye"r4,% 4',v # " 3 " '

12 SHIFT SUPERVISOR (teeasedJ 8

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l 6.REQUALIFICATION 13 STAFF / SHIFT ENGINEER (teensess 7-0THER IsaavNs -

34. AUXJEQUIP. OPE RATOR INonteceasedi

15. PLANT STAFF 16 OTHERisoectNo

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- 14. FACILITY OPERATOR TRAINING PROGRAM -

t k CERTtF tED Ok NRC PORM e14 t*St ULA TIOk sAClLIT Y k Wied'EEflTS7d7-ygg NO}

CairsssOArfOer~s OR NRC AprROvsD susutATeo" YES' NO!

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? Sv5fm Af8ROACN TO TRA00stNO S NO m THE NATOR TRAmmo.

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16. FOR RENEWALS ONLY

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16. EXPERIENCE DETAILS e6 POtifl0N TITLE PROM 70

b. F ActLITY

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17,00m8 mpose see deem aesneer se igura rue are sameresses. AmesA annenes eneses se assemaryJ -

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y tt NRC PORM SOS, CERTlPICATION OF MEDICAL EXAMINAllON SY F ACILITY LICENSEE,18 ATTACHED

-ANY F ALSE STATEMENT OR OMISSION IN THIS DOCUMENT. INCLUDING ATTACHMENTS MAY BE SUSJECT TO CivlL AND CRIMINAL SANCTIONS.

19e. - I certify useler ponesey of pequry that the information in the datumem end ettschmems le true and correst. I further cert 4fy that i have notified my current employer of: (1) all grouteus entievert;

- (21 any instance sessere I have been tested by e Hashh eral Human terw6ees (HMG) Cert 4 feed Drug Tem 6ng Lemntenory or e Licensee's testing leci46ty for eleahot or e contreited asestense. end the t at seguns emesseed the autoff sevets seienhahms pursuant to 10 CPR Port 26;(3) say instones vehere I have been enested for the sete, use or posesseen of a comvened asbetense deserthed in 10 CPR Port 26; :

esel d4l any sessene ter remotel or revesetton of unserorted sceses at a nucieerttecHhy, I sino authottae the NRC to submit the result $ of emanunetk.as to my employerg for use en preparing retreimne -

4 peepense,3 Ie4

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SIONATURE. APPLICANT oAtg CH8CK APPLICABLE BOX

b. I eartify thee the above named indsviduel hee succest0ully sempleted the tecihty leseneses requ6tement4 to be licensed es en Operater/$enior Operator encuent to Th's 10. Code of Federet Roguisttons,-

Port 05: esel that the indsweshael fine e need for en Operator /Senter Operetor tirenes to perform Ne/9.or eeugned dutses and that the essene.enn be made suedemie for esaminetson, i eien certify under -

j J poeshy of pegury that the intormation in thee document end etischmems h true and conect.

. e6 RENEWAL ONLY - I certify that ene enove named indiv6 dust meets the apomwed requenfication peogram twies escopress seenfin trern f 71 en reautred by section 60.54 H.8) of to CFR 60, and ;

that he/she has deschargut his/her heensed responsitWnses competently and estety, I also certify under pensity of pequry that the tnformation in thss escument and ettschenents i

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6 h true end correct.

TRAINING COORDINATOR '

SENIOR MANAGEMENT REPRESENTATIVE ON SITE l

PRINTED OR TYPED fsAME PRINTED OR TYPED NAME l

Sa0 NATURE DATE SiONATURE l TATE

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FOR NRC LEE j

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o WAIVER ICheeA or Qwrpre # ems, as apsWiceWel l MEET 5 HEQUIREMENTS l l DOES NOT MEET REQUIREMENTS (isodera temw I

GRANreDev DeNetD e*

CATEGORY..

Ma anco A R T E RS RE GION He ADQU ARTE Re Mr GION Y:RITTEN OPERATING Ellll81LITY l

MEOICAL.

s4GNATURE REVIEWER DATE OTHE3 n 8IRC PORM 300 t1040)

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.s iNeo A loh uem CERTIFICATION OF MEDICAL EXAMINATION P gam o,,c,,g=ay&,"*,taf eggp;'og,=

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enANCH 4P S IDI. US NvCLEAM REOutatomy coesasis BY FACIb UCENSgg un tF=

SiON,nASHiNGYDN DC 7o666. AND TO THE P APERueOAM mtDuction enoJeet ainocc2al osseCs or mANAos.

MENT AND $UDGE1, uirASHINGToN OC 2o0cJ NAMt OF APPLIGANT lF ACILITY DOCKET NUtA8ER F ACILIT Y A. MEDICAL E XAMIN ATION CERTIFICATION i

THIS 15 TO CERTif Y THAT THE ABOVE N AMED APPLICANT FOR AN OPER ATOR/ SENIOR OPE RATOR LICENSE M AS BE EN E XAMINED BY A PHYSICIAN P^tNTED NAME to/pe srewn) l STATE AND LICENSE NUMBER l EM AMINATION DATE r

BASED ON THE RESULTS OF THE E XAMINATION INCdlDING INFORMATION FURNISHED BY THE APPLICANT. THE PHYSICIAN HAS DETERMINED THAT THE APPLICANT'S PHYSICAL G)NDITION AND GENER AL HE ALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPE RATION AL E RRORS ENDANGERING PUBLIC HE ALTH AND SAFETY. I CERTIFY THAT IN RE ACHING THIS DETERMINATION. THE GUIDANCE CONTAINED IN ANSI /ANS 3 44983.OR ANSI /ANS 15 419U (N3801 WAS FOLLOWED AND THAT DOCUMENTATIONIS AVAILABLE FOR REVIEW 8Y NRC ON THE BASIS OF THE RECOMMENDATION OF ItilfHYSICIAN 1 RECOMMEND THAT THE APPLICANT *S OPERATOR LICENSE BE CONDITIONED AS FOLLOWS.

1. NO RESTRICTIONS

~

2. CORRECTIVE LENSES OE WORN WHEN PERFORMING LICENSED DUTIE3

3. HEARING AlD SE WORN WHEN PERFORMING LICENSED DUTIES 4 RESTRICTED LICENSE OR E xCEPTION.Provitse details beson and attach supporimg medical evidence for NRC rewww 5 RESTRICTION CHANGE F ROM PRE VtOUS SUBMITT AL-Provide details betow and attach supportmq medical evertence for NRC review.

NOPOSED WORDING OF RESTRICTION (Stock 4 abowel LE LATIONSHIP DF R E STRICTION TO DISOUALIF YING CONDtTION (8 netty mdocate how restenTen woH correct sne wsoueistyrne conrtiren)

FitMARKS FOR RESTRICTION CHANGE (8/ock 5 above)

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8. NOfWEDICAL CERTIFICA EION l

POWE R RE ACTORS-THl3 CERTIFIES THAT THJ APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS

• AND FITNESS FOR DUTY REOUIREMENTS OF THis F ACILITY FOR LICENSED OPERATORS l

NON POWE R RE ACTOR $.

THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS' REQUIREMENTS OF THIS F ACILITY FOh LICENSED OPERATORS. AND I HAVE NO KNOWLEDGE OF THE APPLICANT EXCEEDING THE CUTOFF LEVELS FOR ALCOHOL i

OR CONTROLLED SUBSTANCES AS ESTABLISHED PURSUANT 70 to CFR 26 s_Ny e atse sva reueNr un ouissiuN iN ewis oucumeNr iNc6uoiNu ar racHutNis wAv se sueJact ro civit awo cnisiNA6 sANctivNs, s ctH t e* r umukH etna 6 t v ue

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leRJunv rwAT Tws sNsonwarioN iN THea poCUMENT AND ATT ACHwtNTS IS TRUE AND CORRECT.

l lDATE PRINTED NAME AND SIGN ATURE (Sener Menevement Representarsee on Serel TIT LE In accorcance witn 10 CF R 55.5 Communications, tms form snad be submitted to the NRC as follows. 8 Y MAIL ADDRESSED TO; 1

Regional Administrator, Region i Regional Admemstrator. Region 11 Regionai Administrator, Reipon 111 US Nuclear Regulatory Commission U.S. Nuclear Regulatory Comemssen U S Nuclear Requiatory Commessen 475 Alleedaie Road 101 Marietta Street. Susie 3100 799 Rooseveit Road King of Prusue. PA YO6 Atlanta GA 30323 Gien Ellyn. IL 60137 Regenas Admmntrator. Region tv Regional Admimstrator. Region V U S. Nuclear Regulatory Commnsen U.S. Nuclear Regulatory Cornmission 611 Ryan Plaza Drive. Suite 1000 1450 Maria Lane. Suite 210 Arlington. Tx 76011 Watnut Creen, CA 94596 PRIVACY ACT STATEMENT Pursuant to 5 UAC 5524(eH3L enactas mto law by section 3 of the Pnvacy Act of ROUTINE USES The informaten may be disclosed to an appropriate Feceras. State. er 1974 IPobhc Law 93579L ine feitowmg statement is umisnad to mdmduais eno local agency m tne event tne m#armation mrsicates a viciaten or potentia violaten of law r

Supply enformation to the U.S. Nuclear Regulatory Cornmsssion on NRC Form 396 ants in the event the mformation irocates a vioiaten or oneentias violation of law and n This mtormation is mamtamed m a system of records designated as NRC 16 and tne course of an acmmistratwe or tudicial proceer0nq in addition. In.s mformaten may be described at 6I FWserai Regater 33t57 (Septemper 18.1986L transferred to en appropriate Federai. State. and locas 49ency to the extent relevant and AUTHORITY: Sectens 107 and 16tM of the Atomic Energy Act of 1954. as necessary for an NRC decnion about you.

amended 142 U S.C. 2137 ants 2201s il WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON PRINCIPAL PURPOSEISI: Informaton enterns on tms form is used to determme INDIVIDUAL OF NOT PROVIDING INFORMAflON Onciosure es voiuntary, if trie wnetner the anys. cal condition and general hesitn of the apphcant are such tnat they requested rntorenation rs not provided, nowever. the appiecation for a tecihty operator s will not cause coerational errors endangermq public neeltn and safety in6s mforma-or senior operator s hcense may be uemed fort may be used by tfie NRC 4taff to daermme of he mdividuai meetsinbequire-SYSTEM MANAGER (Sl AND ADDRESS Chief. Operefor Licenung Biancn. Office of t

ments of 10 CF R 55 to taae an esammaten or to be asued an opereror i hce Nucseer Reactor Regulation. U.S. Nuclear Regulatory Commusion Wasnmqton. DC 20555 heief 808U 194 'Hf Am i

.j' IIN CIA SURE 3 a

SMelARY OF QiAIGES To tGC PORT 396 i

Medir21'Exanination' Certification Added block "Bestriction Change Fren Prwious Submittal" plus Remarks section.

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' Han-Mari4a*1 Certification Changed nondir=1 certification statement to:' Bauer Sanctors-lhis I

certifies that the applicant has been fmnd to most the==fwm@' and fitnese for duty requirements of this this facility for licensed operators, y.

Nonpower-This certifies that the

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applicant has been found to meet the l_

safeguards' requirements of this 1

facility for 14t====rl operators and I have no knowledge of the applicant i

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--=arline the cutoff levels for al*1 L

or controlled substances as es+=h14= hart pursuant to 10 CFR 26.

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1 EHCIASURE 4 1

SUtttARY OF CHAN3115 'to NBC PORI 396

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Ites 4.d Added clarifying statement to indicate this is to be checked only if application is to===nd license to add additional unit (e).

Item 4.f Added "(Category)" to Operating.

p Added - e.i.

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Item 4.s Added a new item "Date Passed Generic Fundamentals Examination Section".

Item 12.3 Changed wording to " Certified Startup N.

Ocupleted" for clarificatica.

Item 12.5

- Changed wording to " Extra Person On Shift In Control Roca (13-week minima)" for clarificatica.

Item 12.5a Added a new item "Tian On Shift Above 20E Power (6-week

.ini.

3.

Item 14.a Added the words '"! hat Is Bened Upon A Systems Asvavech to Tr=4aia " for clarification.-

- Item 15 Added "Date and Result of Host Beoant NBC Achainistered Reqpalificatico Ibramination".

Item 19.a'.

Added the wording "I further certify that I have notified my current esplayer of: (1) all previous esployers; (2) any instance where I have been tested by a" Health and Human Services (HHB) Osttified Dnar Testing Lt.-.Wei or a Licensee's testias facility for alochol or a centrolled substance, and the test resulta==a== tad the cutoff levels established pursuant to 10 LTR Part 26; (3) any instance where I have been arrested for the sale, use or possession

-of a centrolled substance described in 10 CFR Part 26; and.

(4) any reasons for removal.or revocation of unescorted aremaa at a nuclear facility".

Item 19.b and Item 19.c Moved 19.b and 19.c tesother. Applicable bcoc must now be checked. Also added block for typed name of Training Coordinator and-Senior Manneesent Representative On Site.

PCR NRC USE Under waiver catesory added "MmMeal".

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