ML20006D641

Forwards Revised NRC Forms 396 & 398 Re Certifications of Medical Exam by Facility Licensee & Personal Qualifications Statement,Respectively.All Applications for Licenses Should Be Submitted on Revised Forms No Later than 900201

ML20006D641
Person / Time
Site:	Rhode Island Atomic Energy Commission
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Dimeglio A RHODE ISLAND, STATE OF
References
NUDOCS 9002140157
Download: ML20006D641 (8)

Text

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JAN

$W Docket No: 50-193 Rhode Island Atomic Energy Commission

-ATTN: Mr. A. Francis DiMeglio, Director Nuclear Science Center South Ferry Road Harragansett, Rhode Island 02882 Gentlemen:

SUBJECT:

REVISED NRC FORMS 396 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.

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

Changes to NRC I

Form-398-are detailed in Enclosure 4.

p All applications for licenses are to be submitted or, these revised forms no later than February 1, 1990.

The enclosed applications are for your use. Additional copies can be obtained by contacting Beverly Martin, U.S. Nuclear Regulatory Commission, by telephone (301) 492-8138 or by writing to her, U.S. Nuclear Regulatory Commi.ssion, Information and Records Management Branch, Mail Stop NMBB 7734, Washington, D.C.

20555.

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

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

Sincerely, B

Criginal Signed By 8 4

Robert M. Gallo, Chief Operations Branch Division of Reactor Safety 7

Enclosures:

As stated h6O b 4

20 MAL MD M 396 & 398 E - 00M.0.0 9002140157 900100 12/I4/89 PDR ADOCK 05000193 s

V PDC

(

6 I

Rhode' Island Atomic Energy-2 Commission cc w/ enc 1:

Professor George Seidel, Chairman, RIAEC Dr. Stephen Mecca, Commissioner, RIAEC John S. Pascalides, Commissioner, RIAEC Dr. Vincent C. Rose, Commissioner, RIAEC Dr. Stanley J. Pickart, Physics Department 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 Rhode Island bec w/o enc 1:

Region I Docket Room (with concurrences)

Management Assistant, DRMA (w/o enc 1)

E. McCabe, DRP W. Raymond, SRI - Millstone 1 P. Kauffman, DRP D. Haverkamp, DRP OL Facility File l

DRS:RI l

Gallo/pb 01/02/9Ih,N V6 f'4 0FFICIAL RECORD COPY 396 & 398 FORMS - 0052.0.0 12/14/89 l

co 1

INST;UCTIONS P R 00MPLETING NIC.4RM 388 PEROONAL CUAltFICATION STATEMENT-LICENSEE TO REMAIN VAllD,THIS FORM MUST NOT BE ALTERED 4

TYPE OF APPLICATION 23 NEW "X" IF YOU ARE A NEW APPLICANT, COMPLETE EACH CATEGORY OF THE FORM COMPLETELY, FOLLOWING THE j

INSTRUCTIONS BELOW, THIS IS TO INCLUDE ALL EDUCATION, TRAINING AND EXPERIENCE THAT YOU HAVE RECEIVED UP TO THE DATE OF THIS APPLICAT4ON, NOTE: SEE / TEM f 4 - THERE IS AN EXCEPTION, ALSO, THIS BLOCK IS TO BE MARKED IF PREVIOUS NEW APPLICATION WAS WITHDRAWN, PLEASE WRITE " WITHDREW" NEXT TO "NEW,"

2,b thru 2.s - FOR 2 b THRU 2.e, COMPLETE E ACH CATEGORY COMPLETELY, BUT INDICATE ONLY THE EDUCATION, TRAINING, AND EXPEFJENCE YOU HAVE RECEIVED SINCE YOUR LAST APPLICATION, NOTE SEE ITEM 74 - THERE IS AN EXCEPTION, 2.b RENEWAL

• X"lF YOU ARE RENEWING CURRENT LICENSE, 2.c UPGRADE

'X"IF YOU HOLD A RO LICENSE AND ARE NOW APPLYlyG TO UPGRADE YOUR LICENSE TO A SRO, 2,d MULT1, UNIT "X" IF YOU CURRENTLY HOLD A LICENSE AT YOUR FACILITY AND ARE APPLYING TO AMEND YOUR CUR, RENT LICENSF.TO ADD AN ADDITIONAL UNIT, 2.e REAPPLICATION "X"IF YOU HAVE PREVIOUSLY BEEN DENIED A LICENSE AND ARE REAPPLYING, 2.f WAIVER REQUESTED "X"THLAPPLICABLE WAlVER REQUESTED AND JUSTIFY IN COMMENTS SECTION (ITEM 17),

2.g DATE PASSED GENERIC FUNDA*AENTALS EXAMINATION SECTION (GFES).

THl$ 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 GFESWAS 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 INCLUDF INSTRUCTOR CERTIFICATION EXAMINATIONS OR REQUALIFICATION EXAMlW TIONS,

- 11.

EDUCATION - lNDICAi! LTH ACADEMIC AND VOCATIONAIJTECHNICAL POST HIGH SCHOOL EDUCATION, FOR MAJOR AREA (S) OF STUDY, INDdATE THE NUMBER OF YEARS SPENT 'N 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 CONDITIOfelNClREFRIGER ATION, DIESEL MECHANIC SCHOOL, ETC, INDICATE THE NUMBkiR OF MONTHS IN EACH PROGRAM AND WHETHER A CEPTIFICATE OR DEGREE WAS AWARDED, IF ADDI.

TIONAL 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 1,1, THE BREAKDOWN OF TRAINING IN THIS CATEGCi V PARALLELS THE 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 TY?E OF TRAINING THE NUMBER OF WEEKS IS PROVIDED,IN ADDITION TO BEGINNING AND COMPLETION DATES, TO ACCOUNT FOR INTERMITTENT TRAINING (FOR EXAMPLE,4 WEEKS OF CLASSROOM TRAINING SPREAD OVER A 2 MONTH PEROD), THEREFORE, THE DATE COLUMNS MAY INDICATE A LARGER TIME SPAN THAN THE ACTUAL NUMBER OF WEEKS I

SPENT IN FULL. TIME TRAINING TIME IN TRAINING FOR THE LICENSE APPLIED FOR CANNOT BE DOUSLE COUNTED UNDER EXPERIENCE (ITEM 13),

j j

ALL REQUALIFICATION TRAINING TIME IS TO BE ACCOUNTED FOR IN THE REQUALIFICATION ITEN, PLEASE DO NOT " DOUBLE LIST" THE TIME SPENT IN REQUAllFICATION TRAINING UNDER ITEM 12,6, REQUALIFICATION, EVEN THOUGH IT MAY INCLUDE CLASSROOM OR SIMULATOR TIME, 13.

EXPERIENCE - A MINIMUM OF 6 MONTHS AT THE SITE FOR WHICH THE LICENSE IS SOUGHT IS REQUIRED, FOR EACH POSITION HELD, COMPLETE ITEM 16. DO NOT DOUBLE COUNT TIME. IF YOL' HAD OVERLAPPING DUTIES,THE MONTHS SHOULD REFLECT THE PROPORTIONATE AMOUNT OF TIME YOU WERE ASSIGNED TO THOSE PARTICULAR DUTIES, lid NO CASE SHOULD THE NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEED THE NUMBER OF MONTHS THAT ARE IN THAT TIME PERIOD, FACILITY OPERATON TRAINING PROGRAM - INDICATE a. GRADUATE OF INPO ACCREDITED OPERATOR TRAINING PRO 14 AND b. CERTIFIED (ON NRC FORM 474) On NnC APPROVED GIMULATION FACILITY 45 U5ED IN IHe OPERATOR TRAINING PRO.

GRAM, IF "YES" IS CHkCKED IN BOTH ITEMS 14a AND 14,b, THEN ITEMS 11 (EDUCATION),12 (TRAINING),13 (EXPERIENCE),

- AND 16 (EXPERIENCE DETAILS) DO NOT etAVE TO GE DOCUMENTED, NEW APPLICATIONS MUST STILL INCLUDE lHE NUMBER OF SIGNIFICANT CONTROL MANIPULATIONS UNDER ITEM 12,3, NOTE: INPO ACCREDITED MEANS ACCREDITATION BY THE NATIONAL NUCLEAR ACCREDITING BOARD AND MEANS THAT AT LEAST THE MINIMUM REQUIREMENTS OF REGULATORY GUIDE 12, REV,2, ARE MET, 45, FOR RENEWALS ONLY - (1) ENTEH THE APPROXIMATE NUMBER OF HOURS SINCE PREvlOUS RENEWAL OR ISSUANCE OF LICENSE IF FIRST RENEWAL, (2) ENTER DATU AMD RESULT OF MOST RECENT NRC ADMINISTERED REQUAllFICATION EXAMI.

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 APPLl.

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

TION, 18.

NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE - MUST ACCOMPANY THIS APPLICATION, 19, SIGNATURES - SIGN AND DATE ITEM 194. ODTAIN 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 A PRIATE REGIONAL ADMINISTRATOR,

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U.A nucle AR katub410RT C0amsimeON APPROVE)SV com NO 31504000.

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n, E xPiRES 143 e2 M.47,sa8 M AP e

ESTlMATSD SURDEN P6R RESPONSE TO COMPLY WITH TH18 INFORMATION COLLECTION REOutti 2D HR$

FORWARD COMMENTS REGARDING BURDEN ESTIMATE PERSONAL QUALIFICATION STATEMENT-LICENSEE TD THE INFOaMAtiON AND RECORDS MANAoEMENT SMANCH (P-53N. U S NUCLE AR REOULATORY COMMIS.

SiON. WASHINGTON. DC 20bts. AND TO THE PAPERviORK REDUCTION PROJECT (31604000L OFFICE OF MANAGE.

TO REMAIN VALID,THIS FORM MUST NOT DE ALTERED MENT AND SUDOET, WASHINGTON.DC 20503.

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1. APPLICANT'S FULL NAME (Last, f/rst, Mdst e) AND ADORESS (includelip QNJrJ

4. TYPE OF APPLICATION (ChecA amticable bomaal I *A8VI A NIOVI81ED 1

S. HOT l

e.,RE APPLICATION l

t nuett& en neuererp

--2. COLD i.FIRST 1MRIT1E NICelayery)

s. NEW 3.SECOND I.OPEpATrNGlCom 16 MENEWAL

3. T HIRD 8'T f

e, UPORADE 3 6L10ltiLITY 6 MULTI. UNIT IAMENO TOINCLVDE ADOITIONAL

4. MEDICAL

2. CIT 12E NSHir

3. BIRTH DATE UNIT)

S.OTHER

& UNITED STATES MONTH DAY YEAR S. DATE PASSED OENERIC PUNDA.

MM YY ME NT ALS E X AMIN ATION SECTION

b. OTHER fSneel&D l

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Ir9 APPtlCnelEl

5. TYPE OF LICENSE APPLIED FOR

6. PREVIOUS LICENSE (S) HE LD 1

. OPERATOR

s. DOCKET NUMBER R0 SRO k LICENSE NUMBER

[v et F ACILITY DOCKET NUMSER uo n a us

~

b SENIOR OPERATOR I

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e. LIMITED SRO te s. ruro xendnert g

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7. NAME AND ADDRESS (inc4sdellPgdrJ OF APPLICANT'S EMPLOYER

10. CURRENT POSITION AT FACILITY

a. PLANT SUPERINTENDENT 6 AuxsLIARv UN110PER.

ATOR/TRAINE E /TURSINE

h. AS$1ST ANT PLANT SUPERINTENDENT SUILDINO/ EQUIPMENT OPER ATOR INON LICENS.

s. SHIFT SUPERylSOR LO OPERA TOMI el STAFF ENGINEER I. OTHER (saert&f l F ACILITY DOCKET NUMsER 8, NAME Of APPLICANT'S F ACILITY

o. SHIFT TECHNICAL ADylSOR/8HIFT ENGINEER

f. INSTRUCTOR

9. ADDITION AL F ACILITY DOCKETS fMettevan t* ease 81 s SENIOR CONTROL ROOM OPERATOR lt CONTROL 'AOOM OPE R ATOR

11. EDUCATION i

j s HilHSCHOOL

e. MAJOR AREAfSIOP STUDY e,", !,*,

77,l'!!.'

DEGREE CODES

1. VOCATIONALITE"HNICAL NYR ge g,

j no ENGINE E RING (f'rb,DsJ I ' " O' I " * 'N '* O M kTH8

• E8 NO ORADUATE pf g p ggggaobtemsWJ OED $0UlvALENCY

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0.NONE OTHER

1. CE RTifICATE

7. ASSOCIATE NO 3 9ACHELOR kNggOpF MSER

4. M AST E R S. DOCTOR AL

12. T R AININO (SINCE L AST APPllCA TION - SEE INSTRUCTIONS)

13. E MPERIENCE 100 NO T DOUBLE COUNT-SEE INSTRUCTIONSI

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. woNr aNo va an ICAsse.

' aN NAVY

• aou to

• • ""'a 1 -NUCLEAR POWER PLANT FUNOAMENTALS tooms 1 RO 2 -PLANT SYSTEMS

2. EOOW/PPWO CLASSROOM

3. EWS/PPWS OBSERVATION

4. E RS/CRW 3-OPERATING PRACTICE 5.OTHE R (spes,&)

' CONTROL ROOM OPERATIONS ON SHIFT SIMULATOR OPER ATING (inesudes Nasroom/

FOSS1L SIMULATOR NAMES A*

6 OPERATOR M,

JM,g 7 SUPERVISOR a.

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8. PLANT STAF F

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10. REACTOR OPERATOR Itscenards 6 *sxima Pe nsON ON SmF T IN CONTn06 ROOu j ). SENIOR OPE R ATOR iticenseds (tiwEEK MMtintuw

,, j4u,e4Nygg*yys aos rower 12 SHIFT SUPERVISOR (teceaeds 6 -REQUALIFICATION

13. STAFF / SHIFT ENGINEER ILJesassas 7 -0THE R (soset&J 14 AUX./ EQUIP. OPE RATC#s (Noniscenseds

15. PLANT STAFF 16. OTHE R (soset&A

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14. FACILITY OPERATOR TRAWING PROORAM o*GRADUATOOP 1890 600TSD OPSRATOR -

k CERT 4FIED ON NRC PORGA 474 ("$ftfdL A T804 FACftiT r TO Cf;TFP#CATftMr*? OR IGRC APPROVED Sit #UL ATION YES-NO.

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T IS Utto IN THE 089RATOR TRAlseieso

15. POR RENEWALS ONLY -

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teDume OPORATSD F ACILITY RSCENT NRC ADhitNt$TERED MSQUALIFICATION EstAtesNAT10N pggg.

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18. EXPERIENCE DETAILS --

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18, MRC pores SAS, CERTIFICATION OF MEDICAL EXAMINATION SY F ACILITY LIC ACHED r

ANY F ALSE STATEMENT OR OMisB60N IN THis DOCUMENT. INCLUDING ATTACHMENTS MAY BE sutJECT TO CivlL AND CRIMINAL SANCTIONS.

tem a sanity unser seenny of periury that the informenton in the desumem end ensehmenes to true end sorrect. I further omttfy test I neve notshed my surveni ensuever es: t11 en growous enenseywi

12) any eneessee mRom i have mesa tones av e Heesth eel Humen terweses (HHS) Cert 48ted Drue Tesi6ng Lamerstory or e Leseness g testeg tesidety for eleohol or e controleed mAnanos,and the test i

vesules enseeded tem autett Isuste assenfished pureuset to 10 ( F R Fort 26. (3) eny annense where I have been arvesnes ter the este, use er possession of e sentressed submense doesMbed m 10 CF R Port 26; -

- enel (4l any vessene ter sonstel or esvosesion of unsuported asesse et e ausseeritseeiny, i esso authortae the NRC te phant the remdte et saanmestions to my emotoyers for use m pseuererg retreemng pengene, as sensesery 80006ATURE.AFPLICANT DATg CHGCE APPUCASLE BOX h i sortify thet the shows named ind6 vessel has successfully completed the feelllIV lerensses reeutrements to tie licensed es en Operseor/ senior Omerosor pursumat to Tale 10. Code of Federes Reeuestene.

Port %elef 90est the inesulehsel hoe e need for an t'._ _ _.__ O r Ouestor emense to perform hestner sessened dutese end that the - - " te morte euensbee for eneminsteen, a seen seri6fy omner penefey of pertury that the intermetion in thee docuntent end attachmente to ense graf servest.

' & RENSWAL ONLY - I sortify that the above named indivhluel meets the aponned sechseltfustton proerem (wirA esesprdene morest m from pp) se required by emetoon 50.54 (&4) of to CP R 50. and -

thet he/she has dietherged lus/her heensed *esponeihilnese competently and asfety. 4 steo certify umser pensity of pertury that the informetton in th6s _^

.: and attachments le true end sorrect.

TRAINING COORDINATOR SENIOR MANAGEMENT REPRESENTATIVE ON SITE -

PRINTED OR TYPED NAtf 6 PRINTED OR TYPED NAME lOATE SeoNATURE-ElONATURE DATE FOR NRC USE WAtVE R (Check or Cbnedere freens, as applica6de/

l MEET 5 HEQU(REMENTS l l DOES NOT MEET REQUIREMENTS (fsadese tem una reoev one.iac ev

,g7 gony HeADQUARTeRB Re QlON HEADQUARTER 5 R e G ION ERITTEN OPERATING ELIGIBILITY MEDICAL -

stoNATURE. Reviewer DATE OTHER ssRC PoRen aos siosos

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feRC s'Omas 36 U S NUCLE AW Lt wuLAluY COMsAISSION Asenovep ev ones No 3166c0J4 ETd10$$ l-3s44 ggg iO Ce8 66 23 64 27 tefluaff0 Sumoth tem sterompt to conspLv ertyH ane t4 87 TMIS smo OmuAt eom coLLactiom m 80us et: 25 Mas CERTIFICATION OF MEDICAL EXAMINATION g%o,,cy;".4y,La',0,^aogo L =,3 o

SRANCM iP 43DI US NUCLEAR REQULATOmv coasult BY FMape agCgMegg la b

" rW h SION. WASHtNOTON OC tohtt AND to TME e Aptnwonet as puCTION PROJE CT 131904 D741 Of elCE 08 MANAGS-waN f ANO SUDGE1. n AswiNr.1om DC 20e03 NAME OF APPLICANT F ACILIT Y lF ACILITY DOCKET NUMBER A. MEDICAL EXAMINATION CERTIFICATION THIS IS TO CE Rf tF Y THAT THE ABOVE NAMED APPLICANT FOR AN OPERATOR' SENIOR OPERATOR LICENSE MAS DEEN E XAMINED BY A PHYSICIAN 7 MIN TED NAME tot pa ate.en) l$1 ATE AND LICENSL NUMBER l EXAMINAllON DATE r

BASED ON THE RESUtilOF THE E RAMINAllON INCLUDING INFORMAtlON F URNISHED 8v THE APPLICANT. THE PHv$1CIAN HAS DETERMINED THAT THE APPLICANT'S PHYSICAL CONDITION AND GENERAL HE ALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPE RATION AL ERRORS ENDANGERING PUBLIC HE ALTH AND SAFETY. I CE RTIFY THAT IN RE ACHING THis DETERMINATION THE GUIDANCE CDNT AINED IN ANSI /ANS 3 41983.OR ANil/ANE 15 4-1877 AN380) WAS FOLLOWED AND THAT DOCUMENTATION IS Av AILABLE FOR REVIEW BY NRC, ON THE Basis OF THE RECOMMENDATION OF f tifHYSICIAN. I RECOMMEND THAT THE APPLICANT'S OPER ATOR LICENSE BE CONDITIONED AS FOLLOWS.

i' 1, NO RESTRtCTIONS

2. CORRECTIVE LENSES 8E WORN WHEN PERFORMING LICENSED DUTIES

3. HE ARING AID BE WORN WHEN PERFORMING LICENSED DUTIES

4. RESTRICTED LICENSE OR E XCEPTION Provide estails Deiow and attach supac tmg medical evidence for NRC review 5 RE ST RICTION CH ANGE F ROM PRE VIOUS SU8 MITT AL-Provede deta is below and attach supportmq men cal evinence for NRC revi,

PROPOSED WOROING OF RESTRICTION f8/oca d aooves RE LATIONSHIP OF RESTRICTION TO DISQUALIFYING CONDITION I8naftP mWeste how restricten wdf correct tne maqueMyme condirens k

REMARKS FOR RESTRICTION CHANGE (8Acca 5 ahotel I

B. NONM LOICAL CE R T IFICA T ION POWER RE ACTORS.

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

NON POWER RE ACTORS THIS CERTIFIES THAT THE APPLICANT HAS SEEN FOUND TO MEET THE SAFEGUARDS

• REQUtREMENTS OF THIS F ACILITY FOR LICENSED OPER ATORS, AND I HAVE NO KNOWLEDGE OF THE APPLICANT EXCEEDING THE CUTOFF LEVELS FOR A(COHOL OR (DNTROLLF.D SUBSTANCES AS ESTABLISHED PURSUANT TO 10 CFR 26 l

Ahv sats st A r aueNt on owissioN iN rms occuwtNt iNctuoiNu Ar t AcMutN rs u Av et suaatci to civit Ahu cMIMiNAL &ANd dVNk i GkM li>

• UNutR PtNALi v of l

PERJURY tMAI TNG INFOmuAtioN im TMil DOCUMENT AND ATT ACMMENf 5 IS TRUE AND CORRECT.

PRINTED N AME AND SIGN ATURE (Sentor Management Neoresenter,ve on S,rei TlTLE DATE 1

in accoraance witn 10 CF R 55.5. Communicatens,inis form snail be suomitted to tne NRC as totlows. SY Mall ADDRESSED 10:

Regiones Admmistrator. Region i Regenal Admmntrator. Region 11 Regional Aummistrator, Region all U S. Nuclear Regulatory Commessen U.S. Nucker Requestory Communen U.S Nuclear Requeatory Commissert

- 476 Allendare Road 101 Marietta Street. Suite 3100 799 Rooseveit Road King of Pruiva. P A 19406 Atlanta. G A 30323 Glen Eltyn. IL 6Cl37 Regional Administfator, Reipon IV Regenen Adminntrator Region V U S. Nyctear Rep 4latory Commission U.S. Nuclear Requeatory Commission 611 Ryan Plan Dnve Suite 1000 1a50 Maru Lane. Suite 210 Arimgton. TX 76011 Walnut Craen. CA 94596 PRiv ACY ACT ST ATEMENT Pursuant to 5 U.S.C. 552ateH3). enactes into law by action 3 of the Pnvacy Act of ROUTINE USES The mformaten may be dnclosed to an appropriate Federai. State. or 1974 (Pubhe Law 93579). the sollowmg statement is turnnhet to mdividuais wno locad agency in the event the mtormation niidicates a viciaten or potentsai viusation of law supply mformation to the U.S Nuclear Regulatory Commnuon on NRC Form 396.

and m the event the enformation moscates a violaten or potential violatea of law and m the cou se of an admmistrative or audicial proceedmg in addition tti.s informaten may be This mformaien is mainta.ned m a system of reaards designated as NRC 16 and r

coscribed at 518clera6 Register 33157 (September 18.19861 tiJosferred to an appropriate Federas. State. and local agency to tne entent reievant and AUTHORITY-Sectens 107 and 16111 of the Atomic Energy Act of 1954, as narenefy for an NRC necision anout you.

amenned (42 U S C. 2137 and ??01141 WHETHER DISCLOSURE is MANDATORY OR VOLUNTARY AND EFFECT ON PRINCIPAL PURPOSELSl: Information entered on this form n used to determine INDIVtDUAL OF NOT PROVIDING INFORMATION D se:osure is wwuntary. 6f the enether tne pnys<al corviiton and general het'th of the apodicant are such that (Pey mluetted informat on is not provided. however the appbCation for a facility operator's will not cause operatenal errors ennangenng puccic health and safety This mforma or sener operator s license may be dea ed

)

ten may be used by the NRC statt to determine et ttie mdevidual meets tne require SYSTEM MANAGERIS) AND ADDRESS Cheef Operator Licensing Biamn. Ottice of 1

ments of 10 CF R 55 to taae an enammation or to be issued an operator's hcenna Nucie.r Reactor Requieren. U S. Nuclear Requietory Commiwon. Washington. DC 20555 Naesam v ina onam n

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1 IIN I G iU R E 3

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SilflARY OF CHANGES '!O 100 Polt! 396 l

t-Medical Examination Certification Added block " Restriction Change Frta Prwicus Submittal" plus Ramants i

section, q

Non-Medical Certification Changed nonwi=1 certification.

statement tor Power Reactors-Thia J

oortifies that the applicant has been found to aset the safeguards' and i

L fitnese for dirty requirements of this l

this. facility for licensed operators.

Hanpower-ThAs certifies that the -

t applicant has been found to meet the safeguards' requirements of this fa:ility for lih operators and I have no knowledge of the applicant emoeeding the autoff levels for alcohol' or controlled substances as es+=hliM pursuant to 10 CFR 26.

O 5

/.

x ID Q DSORE 4 St2t1ARY OF CHAN3ES 'l0 NBC FOGM 396 Item 4.d Added clarifying statement to indb=ta this is to be checked only if application is to amend license to add additional unit (s),

h Itam 4.f

' Added "(Catescry)" to Operating.

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

Item 12.3 Changed wording to " Certified Startup Program Consileted" y

for clarification.

Item 12.5 Changed wortiing to "Itxtra Person On Shift In Centrol Boom (13-week minimum)" for clarification.

L Item 12.5a Added a new item " Time On Shift Above 205 Power (6-week minimum)".

Itam 14.a Added the wortis "That Is Bened Upon A Systeam Awie to Traiaia=" for clarification.

Item 15 Added "Date and Beault of Most Recent NBC Administered 6144'icatica Examination".

.e Item 19.a Added the wortiing "I further certify that I have notified my current employer of: (1) all previous esplayers (2) any.

instance where I have been tested by a Health and Human Services (HBB) Certified Drug Testing Lat-wii or a Licanese's testing facility for mimhal or a ocatrolled substance, and the teet results M the cutoff 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 substanos described in 10 CFR Part 26: and.

(4) any reescas for removal or twoocation of unecoorted access at a nuclear facility".

-Item 19 b and Item 19.c Moved 19.b and 19.c together. Applicable box must now be checked. Also added block for typed name of Tr=4a4=r Coordinator and Senior Management Representative On Site.

POR NRC USE Under waiver category added " Medical".

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