ML20006D635

Forwards Revised NRC Forms 398 & 396 Re Personal Qualifications Statement & Certification of Medical Exam by Facility Licensee,Respectively.All Applications for Licenses to Be Submitted on Revised Forms by 900201

ML20006D635
Person / Time
Site:	University of Maryland
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Dieter G MARYLAND, UNIV. OF, COLLEGE PARK, MD
References
NUDOCS 9002140146
Download: ML20006D635 (8)

Text

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4:

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JAN 5 1990 s

Docket-No: 50-166 s

University of Maryland i

. ATTN: Dr. George E. Dieter, Dean College of Engineering

' College Park,' Maryland' 20742

-Gentlemen:

SUBJECT:

REVISED NRC FORMS 3?6 AND 398 Enclosed is'a copy.of the-revised NRC Form-398 (Enclosure 1), Personal Qualifications Statement

~ Licensee and revised.NRC Form-396 (Enclosure 2),

certification of Medical Examination By Facility Licensee.

-All' changes toLthe NRC Form-396 are detailed in Enclosure 3.

Changes to NRC j

Form-398 are detailed-in-Enclosure 4.

- All. applications. for licenses are to ce submitted on. these revised forms no 1

later than February 1, 1990, t

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

.by. contacting Beverly Martin, U.S. Nuclear Regulatory Commission, by. telephone.

1 (301) 492-8138 or by-writing to her, U.S. Nuclear Regulatory Commission, Information and Records Management Branch, Mail Step NMBB-7714, Washington, D.C.-.20555.

'j i

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

l

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

Sincerely, hyggwc SmeaWi

. Robert M. Gallo, Chief.

1 Operations Branch Division of Reactor Safety l

Enclosures:

As stated

((k 1

0FFICIAL RECORD COPY 396 & 398 FORMS - 0059.0.0 ta 12/14/89 900214o146 900103 I

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lUn'iversity of Maryland 21 I

cc w/ enc 1: _

Dr. D. D. Ebert, Reactor Director

~

Dr. Bernard White, IV, Reactor Operations Manager Dr. F. Munno, Director; Nuclear Engineering Program Dr.

M.- L.-- Roush, Chairman, Department of Chemical and Nuclear' Engineering Dr. J; S; Toll, President Dr. William Vernetson, Director of Nuclear Facilities, University'of Florida Public Document Room'(PDR)-

Local Public Document Room (LPDR)

' Nuclear Safety Information Center (NSIC)

State of Maryland (2)_

Lbec w/o encl:

Region I Docket Room (with concurrences)

~ Management: Assistant, DRMA-(w/o enc 1)

L. Tripp, DRP LD.'Haverkamp, DRP D.~Limroth, DRP H. Eichenholz, SRI - Calvert Cliffs-OL Facility File i

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DRS:RI.

Gallo/pb 01/01/00 t

yo f; - p 4, 0FFICIAL RECORD COPY 396 & 398 FORMS - 0060.0.0 12/14/89 L

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INSTCUCTIONS POR COMPLETING NRC P:RM 30B ^

PERSONAL QUALIFICATION STf,TEMENT-LICE 9SEE TO RE1*AIN VALID,THIS FOIM MUST NOT BE ALTERED e

t.:

TYPECF APPLICATION

'2.s NEW "X" IF YOU ARE A NEW Af ?LICANT COMPLETE EACH CATEGORY OF THE FORM COMPLETELY, FOLLOWING THE -

INSTRUCTIONS BELOW. THIS IS TO INCLUDE ALL ECUCATION, TRAINING AND EXPERIENCE TIMT YOU HAVE RECEIVED UP TO THE DATE OF THIS APPLICATJON. NOTE: SEE / TEM 14 - THERE IS AN EXCEPTION. ALSO, THIS BLOCW IS TO BE MARKED IF PREVIOUS NEW APPLICATION WAS WITHDRAWN. PLEASE WRITE." WITHDREW" NEXT.

TO "N EW."

2A thru 2.e-FOR 2h THNU 2.e, COMPLETE EACH CATEGORY COMPLETELY, BUT INDICATE ONLY THE EDUCATION, TRAINING.

AND EXPERIENCE YOU HAVE RECElVLD SINCE YOUR LAST APPLICATION. NOTE: SEE / TEM 74 - THERE IS AN EXCEPTION.

2A RENEWAL "X"IF YOU ARE RENEWING CURRENT LICENSE.

2.e UPGRADE "X"IF YOU HOLD A RO LICENSE AND ARE NOW APPLYING TO UPGRADE YOUR LICENSE TO A SRO, F.d MULTI-UNIT

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

RENT LICENSE TO ADD AN ADDITIONAL UNIT.

2.e REAPPLICATION "X"lF YOU HAVE PREVIOUSLY BEEN DENIED A LICENSE AND ARE REAPPLYING, 2.f IMIVER REQUESTED "X" THE. APPLICABLE WAIVER REQUESTED AND JUSTIFY IN COMMENTS SECTION (ITEM 17).

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

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

TlON 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, t&32,WHICH LED TO THE ISSUANCE OF A LICENSE. THIS DOES NOT INCLUDE INSTRUC'OR CERTIFICATION EXAMINATIONS OR REQUALIFICATION' EXAMINATIONS, 11.

EDUCATION - INDICATE BOTH ACADEMIC AND VOCATIONAL / TECHNICAL POST HIGH SCHOOL EDWATION, FOR MAJOR AREA (S) OF STUDY, INDICATE THE NUMBER OF YEARS SPENT IN FACH COLLEGE CURRICULUM AND THE HIGHEST DEGREE RECEIVED, USING THE DEGREE CODE PROVIDED FOR VOCATIONAL / TECHNICAL EDUCATION,-!NCLUDE 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 DEGREEWAS AW TIONAL SPACE IS NEEDED, CONTINUE UNDER COMMENTS (ITEM 17),

12 TRAINING - lNDICATE THE TRAINING YOU HAVE RECEIVED TO MEET THE REQUIREMENTS OF ANSI N18.1/ANS 3.1. TH BREAKDOWN OF TRAINING IN THIS CATEGORY PARALLELS THE ANS STANDARDS. REFER TO THE STANDARDS IF YOU N FURTHER CLARIFICATION, INCLUDE BOTH BEGINNING AND CJMPLETlON DATES AND THE TOTAL NUMBER OF WEEKS SPENT -

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

TO ACCOUNT FOR INTERMITTENT TRAINING (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 FU'.L. TIME TRAINING. TIME IN TRAINING FOR THE LICCNSE APPLIED FOR CANNOT BE DOUBLE COUNTED U EXPERIENCE (ITEM 13).

Al.L REQUALIFICATION TRAINING TIME IS TO BE ACCOUNTED FOR IN THE REQUALIFICATION ITEM PLEASE DO N LIST" THE TIME SPENT IN REQUALIFICATION TRAINING UNDER I TEM 12.6, REQUALIFICATION, EVEN THOUGH IT MAY INCLUDE -

CLASSROOM OR SIMULATOR TIME.

I '~

EXPERIENCE - A MINIMUM OF 6 MONTHS AT THE SITE FOR WHICH THE LICENSE 13 SOUGHT IS REQUIRED. FO i-13.

HELD, COMPLETE ITEM 16. DO NOT DOU3;.E COUNT TIME. IF YOU HAD OVERLAPPING DUTIES,THE MONTHS SHOULD REFLECT THE PROPORTIONATE AMOUNT OF TIME YOU WERE ASSIGNED TO THOSE PARTICULAR DUTIES. IN N') CASE SH NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEED THE NUMBER OF MONTHS THAT AR l.

TIME PERIOD.

E 14.

. FACILITY OPERATOR 1 RAINING PROGRAM - INDICATE a. GRADUATE OF INPO ACCREDITED OPERATOR TRAI wnh cenwice soy yoc Mm,g n ; Cn NRC APPROVED SIMULATION FACsLITY IS USED IN THE OPERATOR 1HAlNING PRO.

GRAM. IF "YES" IS CHECKED IN BOTH 7TEMS 144 AND 14.b, THEN ITEMS 11 (EDUCATION),12 (TRAINING),13 (EXPERIENCE),

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 ACCREDITAT NATIONAL NUCLEAR ACCREDITING BOARD AND MEANS THAT AT LEAST THE MINIMUM REQUIREMENTS OF REGUL GUIDE 1.8, REV. 2, ARE MET, FOR RENEWALS ONLY - (1) ENTER THE APPROXIMATE NUMBER OF HOURS SINCE PREVIOUS RENEWAL OR IS 15.

LICENSE IF FIRST RENEWAL. (2) ENTER DATE AND RESULT OF MOST RECENT NRC ADMINISTERED REQUALIFICA l

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.

i 17 COMMENTS - USE THIS SPACE TO INCLUDE ANY EXTRA INFCRMATION OR CLARIFICATION FOR OTHER ITEMS CATION FORM. IF THE SPACE PROVIDED IS NOT SUFFICIENT, YOU MAY ATTACH EXTRA INFORMATION WITH YOUR APPLICA.

TION.

18.

NRC FORE 26, CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE - MUST ACCOMPANY THIS APPLICATION.

19.

SIGNATURES - SIGN AND DATE ITEM 19J. OBTAIN YOUR TRAINING COORDINATOR *S S!GNATURE AND THAT OF Y MANAGEMENT REPRESENTATIVE ON SITE.

DETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS 398 (ORIGINAL AND TWO COPlES PRIATE REGIONAL ADMINISTRATOA, m _7,,

_ ~ - - - -

r-7 m u r r e (*-~ ~ ~ m-~* e

j hp ORM 885 U.S. NUCLEAA wEtuLATO Y COnass9510h

- APPROYS Y

NO 31504000 gy, Elk!EE7.

ESTIMATED sunoEN PER R sPONat To COMPLY wlTH THl$ (NFORMATION COLL ECTION REQUESTIfu HRS F ~,RWARD COMMENTS REOARDING BURDEN E STIMATE PERSONAL QUALIFICATION STATEMENT-LICENSEE TO THE iNFORMATiON Aho RECORD: MANAOEMENT DRANCH IP.630). U.S NUCLEAR REOULATORY COMMIS-SlON, WASHINGTON. DC 70t46, AND TO THE PAPERWORIL i

RE QUCTION PROJEC* 13160 0000). OFFICE OF MANAGE.

TO REMAIN VAllO.THis FORM MUST NOT BE ALTERED MENT AND BUDOET, W AsHINOTON. DC 20503.

1. APPLICANT *8 FULL NAME (last, //rst, MNRile) ANO ADDRESS (melude //P CWr)

4. TYPE OF APPLICATION (Cheet app /kabJe boAGS) j l

e. RE APPL 4 CATION A,,

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2. CITl2ENSHIP

3. BIRTH DATE 5.OTHER v

6 UNITVD 8TATES MONTH DAY YEAR

g. DATE PAS $ED OENERIC PUNDA.

MM YY MENT AL3 E K AMIN AT)ON SE CTION j

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6. TYPE OF LICENSE APPLIED FOR

6. PRE VIOUS LICE NSE($) HE LD hh lf A F ACW WET NER ab OPERATOR

s. DOCKET NUMSER RO SRO k LICENSE NUMBER

b. SENIOR OPERATOR I

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I 65 I

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60-

s. LIMITED SRO le a. FeetMeaaners I

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7. NAME AND ADDRESS (includelie Codel OF APPLICANT'S EMPLOYEh

10. CURRENT POSITION AT FACILITY

s. PLANT SUPEHINTENDENT L AUX 8LIARY UNIT OPER.

ATORIT RAINE E/TUR0lNE SUILDINO/EQUtPMEeff k AE318 TAN 1 PLANT $UPERINTENDENT OPE R ATOR INON & dCENS.

e ED OPEllA TORJ

s. SHIFT $UPERVISOR l

& STAFF ENGINEER OTHER (3por/4 l F ACILITY DOCKE T NUMBER 8, N.I.ME Of APPLICANT'S 7 ACILITY e, SHIFT TECHNICAL ADVISOR /$HlFT ENGINEER 3

i, L INS 1,quCTOR l=

9. ADDITION AL F ACILITY OOCK ETS (MutrNaast stet.sedi g SENIOR CONTROL ROOM OPERATOR ik CONTROL S.OOM OPER ATOR lt EDUCATION I;

s HIGH SCHOOL

s. MAJOR AREAISI OF STUDY t,",*7ll, "T"J!'

DEGREE CODES

d. VOCATIONAL / TECHNICAL NgER }g

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NG ORADUATE ING'NIFNING iMLO30 HIGH O GREE *obenonedt D.NONE GEO EOulVA6 ENCY OTHER t. CERTIFICATE

2. ASSOC) ATE NO 3 8ACHELOR k IWSER OF

4. M AST E R

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6 DOCTORAL l

13. TR A1:34tG (SINCE LAST APPLICATION - SEE INSTRUCTIONS)

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i 3d OPERATINO PRACTICE 5 OTHER (specs 4#

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COMMERCIAL NUCLE AR tsasA,e no Ressenn/ Tere Reerm,I 4 -SRO INSTRUCTION

10. R E ACTOR OPE R ATOR (thwnw>

5 - fi$,^,7 "","uf,$8" ' 'N C0"i "O' "

11. SENIOR OPE R ATOR (trenwt -

e. @'gypf,%^&wa an POwen' U. SHIFT SUPERVISOR (teenseds 6 -REQUALIFICATION 13.SIAFF/ SHIFT ENGINEER (tkenseds 7 -0THE R (Speci41 14 AUX] EQUIP. OPE R ATOR INeatsreaant)

15. PLANT STAFF 16 OTHER tsoecsNI NRc 70RM 3es (10491 YEI_T7T:XK '*~I_TE_C:?K*.*% ~-. _,. T T.T ~.WB:~ ' *. AT~n.'

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YES NO, 1010108 #fl00ftAfe TteAT IS SAesD Usoes A YES' pgg.

• ACeuTvseuse APPROACH TO TRAcesise0 -

PRoofiAas

15. FOR RENER ALS ONLY O

h. DATE AND Rt9 ULT OF aA06f I

DATE RBouti

= 000 Ult 40PSRATED F ACILITY.

RECGNT teRC ADutNISTtRED I

EAES Fall fiEQUALiflCATION LKAMINATION l

16. EXPERIENCE DETAILS

& PoteTt006 TITLE PROM TO k # ACILITY

e. DUTIES i

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17. anamatWTS anewsP see nem musener se enne reo me amewestep. ANesh anNesseef shame a sensory./

a 18,88RC PORhl308, CERTIFICATION OF MEDICAL EXAMlesATION SY P ACILITY LICENBEE;IS ATTACHED ANY FALSE STATEMENT OR OMISSION IN THIS DOCUMENT. INCLUDING ATTACHMENTS. MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.

see, a vniev weser seashy os paviusy that the interne en shh aserwnca and esteenmems h irve end soivost. I funher eoruty thei e have nettvies eny eurvem enguever es: (t) en prov6ous anipieyme; tap any tossense esacre i hese been tened oy e Heenth and Hwnen Spymes lHH5) Ceruhed Drue Teettne Lahoretory or e Lesenese's seeiine gesenty fee seashot er e sent:seied eshmense,and the test scouste essessed the outett osan emehhehed pueeuent to 10 CPR part 2s. tai eny samense veheee i have been arveused ser the ease. isee er posesenten et a sentioned subeienes neeerihed in to Cr R cert 26; and 446 eny esamene see semeni er sovession se onesorted essen at e musteoritestiny, I ew outhorue the NRC to euhmM the teauate el earmnetens to my anstre are ter ues m pasportne rareen6ng -

poseems. es saammary SIONATURE-APPL 4CAN( -

DATE ID4ECIC APPLICAOLE SOX

] k e eeniey thee tne eheve named indivusuoi hee sucessefuny eemoseed the seeiniy sneensees eeuvirenants to be heensed a en Operator /senaar Operaer pursuent to Tnie 10, Code et Feder Part est sad test tan ansessehses ties e need eer en C

.T _

Osoreter lesense to periorm teether eeuyied dutmo end (het the esM he mens settehte let segmeneteen. $ sese sanity emter pensity of portury that the intermetien in thee esecumem end attacamente h trwe end correct.

lt RSNEWAL ONLY = l certify that the ehew named indevedual mesis the approwd requeHfiestion program (wifA esceptopes nefed M frwn f M se requerut try egetton 60.6a (bIl of 10 CF M 60. and '

===.s that tw/ine hee sacherged his/her heensed responelbeinme songstanity and utsty, i esso eentoy under peetty of perjury that she Informetton la the document and eHechments.

le true end soffect-

- TRAINING COORGiNATOR SENIOR MANAGEMENT REPRESENTATIVE ON SITE PRONTED ON TYPED NAME PRINTLD OR TYPED NAME lDATb SIGNATURE Daft StGNATURE FOR NRC USE WAIVE R (Check or corrwAere # ems. as appIkeNe) l MEETS RIQUIREMENTS l l DOES NOT MtET REQUIREMENTS ffsadeln 6ebw/

GMANTeDev Denied V

' CAT 500RY Haannu Amf a ns nsaioN HeAcouAnruns neosoN CRITTEN-OPERATING ELIOltlLi1 Y MEDICAL SIGNATURE-REvt4WLR lDA f t OTHER e feRC PORae see (totes -

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8080C40RJ M U $. NUCLE AA RE4ULAleRY COfHelSSilN LeeROv8D 3

t toegge t : - 401 10 Ce P G4 2154 27 ISFtWAT8D SURndN PGR eit yONSE TO COtaPLY WITN ogs te ll twee #NeORuatiON Lot t act sOas R60ut et; 29 MRs CERTIFICATlON OF MEDlCAL EXAMINATION

' gRg o,,c,gll,a,y,g,R ',u,Af o;g pMfg BY FACILITY LICENSEE

.io( wA IP.41ot oC ou.ARANo ro,A,T.ORY,iR.espit.

SRANCH US NUCit REQUL CO

. iNoTON

< u OR RE DUCTION PROJE CT (3140 o0741 08etCE Of WANAGE.

uthf AND sUDot T.n AsHiNOTON DC 20e02 NAME OF APPLIGANT lF ACILITY DOCatET NUMBER F ACILITY A. MEDICAL EXAMINA. TION CERTIFICATION THis is 70 CE RTIF Y THAT THE ABOVE NAVED APPLICANT FOR AN OPERATOR / SENIOR OPERATOR LICENSE HAS BEEN EXAMINED BY A PHYSICIAN.

E K AMINA flON DATE MINTED NAME foran stesenJ lST ATI AND LICENSE NUMBER r

CASED ON THE RESULTS OF THE EXAMINATION INCLUDING INFORMATION FURNISHED BY THE APPLICANT. THE PHY5dCIAN HAS DETERMINED THAT THE APPLICANT'S PHYSICAL CONDITION AND GENER AL HE ALTH ARE NOT SUCH THAT IT MIGH T CAUSE OPE R ATION AL E RRORS ENDANGERING PUBLIC HE ALTH AND SAFETY. I CERTIFY THAT IN RE ACHING TNtS DETEftM! NATION. THE GUIDANCE CONT AINED IN ANSIIANS 3 4-1983, OH ANSl/ANS 16 41977 (N380) WAS FOLLOWED AND THAT DOCUMENT ATION i$ AVAILABLE FOR REvtEW BY NRC.

ON THE Basis OF THE RECOMMCNDATION OF it1CHYSICIAN I RECOMMEND THAT THE APPLICANT'S OPERATOR LICEN3E BE CONDITIONED AS l'O LLOWS.

t. NO RESTRICTIONS

~

2. CORRECTivt LENSES OE WORN WHEN PERFORMING LICENSED DUTIES

3. HEARING AfD BE WOR *)WHEN PERFORMING LICENSED DUTIES

4. RESTRICTED LICE NSE OR E XCEPTION. Provide detus below and attach nuppurimg matical mdence for NRC romw

6. RESTRICTlON CHANGE F ROM PRE VIOUS SUBMITTAL Peovide deia.li beeow and attach supportmo medical ev*sence for NRC emew PROPOSED WORDING OF RESTRICTION (8toct 4 abow!

f.E LAflON$ HIP OF RESTRICTION TO DISOUALIFYING CONDITION (8ereu muscare how rwrncten wr/Icorrect the desoueWrme condsten; r

REMARF.S FOR RESTRICTION CHANGE (8/och 5 aoora B. NONMEDICAL CE RilFICA TION POWE R RE ACTORS.

THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS' AND FITNESS FOR DUTY REQUIREMENTS OF THIS F ACILITY FOR LICENSED OPE R ATORS.

+

NON POWER RE ACTORS THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUNO TO MEET THE SAFEGUARDS' REQUIREMENTS OF THIS F ACILiTY FOR LICENSED OPERATORS. AND i HAVE NO KNOWLEDCE OF THE APPLICANT EXCEEDING THE CUTDFF LEVELS FOR ALCOHOL OR CONTROLLED SUBST ANCES AS ESTABLISHFD PUR$UAMT TO 10 CFR 2C.

my e Aue st AtausNs OH omission iN rMis occumeNr. iNctuoiNu A r r AcMuaN ts u Av ee sumatc ta cavit kND CHiMiNAL 3ANL.tIUN3. I GtH i P Y UNueM Pt NALI v V6 FERJURv TviAf THE INeORMAfiON IN THl3 DOCUMONT AND ATT ACMMENT$ 13 TRUE AND CORRICT.

FRINTED NAME AND SIGNATUNE (Senror Marwgement Mapresenver,w on stres TITLE DATE in accordance witn 80 CF R 55.6, Commumcatsons. imt form shall be submitted to the NRC as follows. 8 Y MAIL ADDRESSED TO.

Regional Administrator. Region i Regenal Admimstrator, Region 11 Regional Admemstrasor. Region til US Nuclear Regulatory Commisuon U.S. Nuclear Requestors Commisaeon U S Nuclear Requiatory Commission 416 Allendase Road 101 Marietta Strut. Suite 3100 199 Roosevert Road King of Prussia. P A 19406 Atlanta GA 30323 Glen Etiyn. IL tio137 Regional Admimitrator. Region lv Reg onal Admmisstator. Region V 81.S. Nuclear Requiaiory Commision U S. Nucmar ftequietory Cornmission 611 Ryan Piada Dow. Suite 1000 1450 Maria Lane. Suite 210 Artmgton. T X 1601i Walnut Crevio CA 94596 PRiv ACY ACT ST ATkMENI Pursuant to 6 U.S.C $52aisif 3L enactes mio ian by section 3 of ths Privacy Act of ROUTINE USES: The informaten may be +icloses to an acornpr. ate Falerei. State. or 1974 (Pubhc Law 93 6791. the followmg statement is turneed to erubviduals who local agency in the event the information irws.caies a vioietion o, purennal vioisten of law

. supply mformaten to the U S Nuclear Regulatory Commiscon en NRC Form 396 aext in the event the informaoon md e.ates a viorat>on or oneential violatine of law arni m This information as suaintained m a system of records designated as NRC 16 and the course of an administrateve or ludicial procealmg in addition, sti.s mformaten may be descr* bed at 61 Fasera' Register 33157 ISeptember 18.1986).

transferred to an appropriate Federal. State, and local agency to the nient ruvant and AUTHORITY Sectens 101 and 1616) of the Atomic Energy Act of 1954. as necmary for en NRC decision at out you.

ammsm1642 V S C. 213/ aad 220161).

WHETHER DISCLOSURE IS YANDATORY OH VOLUNTARY AND EFFECT ON PRINCIPAL PURPOSEISI: Information entered on this form is uwd to determme INDivlDUAL OF NOT PROvlD NG INFORMAflON Disclosure is voluntary, if the whether the pnysical condition and gsneras health of the apoticant are even that they miumted informt on is not provided. however. the aptatication for a facility operator's will not cause operational errotg emlangittmo pubiaC health and sarely This af tforma or Senior operatoe lllCente may be demmi non may be uset by the NRC staff to determme if the mdividual enects the revivire SYSTEM MANAGERIS) AND ADDRESS Chief. Operator L.commg Branch Office of meets of 10 CF R 56 to tar.e an eneminsten or to :,e issued an operator's hcenw.

Nuclear Reactor AmMaten U.S Nucwar Repdatory Commiwon. Washmgion. DC 20555

%ne mnu inn on av

I i

IllC460RE 3 i

l SmenRY OF QWGS 10 NIC FORT 396 l

N val Examination Certification Added block "flestriction Change From Prwicus Sunanittal" plus Ranarts section.

Han-Medical Certificatier.

Changed non-carlinal certification statament to: Peuer Insectors-This oortifies that the applicant has been found to meet the safeguards

• and fitness for drty requirementa of this this facility for liounsed operators.

Nonpower-This certifies that the applicant has been found to meet the safesuards' requirementa of this facility for 14a====d operators and I have no knowledge of the applicant d iar the autoff levels for alochol or aantrolled substanama as es+=h14 M pursuant to 10 CFR 26.

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EHCIA805 4 I

Suttel OF QWM510180 FORf 398 j

Item 4.d Added clarifying statammt to indiasta this is to be l

checked only if appliantion is to amend liamnee to add additianal mit(s).

Item 4.f

- Added "(Category)" to Operating.

i Added " Medical",

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

• Item 12.3 Changed wording to " Certified Startup Patsrom Ccupleted" i

for clarification.

I Itan 12.5 Changed wording to " Extra Perman Ch Shift In Control Room (13-week miniaam)" for clarification.

Ita 12.5a Added a nos item "Tian On Stift Above 20E Pouer (6-week minima)".

1 Item 14.a Added the words "1 hat Is Bened Upon A Systeem Approach to Training" for clarification.

I Itam 15 Added "Dete and Result of Noet Recent MRC Administered i

Degualifiestica Rosmination".

Item 19 a Added the wording "I further certify that I have notified sr current employer of t (1) all.pewious employers (2) asp instance wherw I have been tested by a Health and ihnen Servions (HRB) Certified Dnat Testing taboratory or a Licensee's testing facility for alochol or a ocatrolled substanoe, and the test resulta esconded the autoff 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 substemos described la 10 CFR Part 26 and

+

(4) any reasons for removal or twoonation of unescortad access at a smaclear facility".

Item 19.b and Item 19.c Moved 19.b and 19.c tesother. Applicable box aust now be checked. Also added black for typed nees of Training Coordinator and Sa.ior Manap===t Representative On Site.

l FOR NRC DSR Under waiver cetesarr added " Medical".

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