ML20006D651

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

ML20006D651
Person / Time
Site:	University of Lowell
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Beghian L MASSACHUSETTS, UNIV. OF, LOWELL, MA (FORMERLY LOWELL
References
NUDOCS 9002140172
Download: ML20006D651 (8)

Text

..

i -

+

,y 1

JAN 51990 Docket No: 50-223 University'oflL'owell ATTN:

Dr.. Leon E. Beghian Associate Vice President' for--Research 1 University Avenue-Lowell,-Massachusetts 01854 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.

All changes-to the NRC Form-396-are detailed in Enclosure 3. -Changes to'NRC Form-398 are detailed in Enclosure 4.

All: applications for licenses are to be submitted on 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 Commission, Information'and Records Management Branch, Mail.Stop NMBB 7714, 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, Original Signed By1 Robert M. Gallo, Chief Operations Branch Division of Reac or Safety

Enclosures:

As stated b

Jgg2 $3bcd $00bh[3 e o

\\

o 9

0FFICIAL RECORD COPY 396 & 398 FORMS - 0043.0.0 12/14/89 m

m 2

c M

b 1.'

~~

it J

I.)

Unt'versity of-Lowell 2-l n

cc w/ enc 1:.

e Dr. J. Phelps, Chairman, Reactor Safety Subcommittee lT. Wallace, Reactor Supervisor 1

Leo Bobek,-Chief Reactor Operator 1-

-Dr.' William'Vernetson, Director of Nuclear Facilities,-

University of Florida Public Document Room (PDR)

. Local Public Document noom (LPDR)-

l

~ Nuclear Safety Information, Center (NSIC)

Commonwealth of Massachusetts (2)

-bec w/o encli J

~

Region I Docket Room (with concurrences)

~;

Management Assistant; DRMA'(w/o enc 1) g2

-D. Haverkamp,'DRP SRI - Seabrook L.-Doerflein, DRP OL' Facility-File t

.c i

' N

}

c 3

i k

DRS:RI Gallo/pb.

01/02/S0 ((

par F

, 4 TD l

0FFICIAL RECORD COPY 396 & 398 FORMS - 0044.0.0 12/14/89 I

m

~

i INSTRUCTIONS FOR COMPLETING NRC FORM 388

[

PERSONAL QUALIFICATION STATEMENT-LICENSEE TO GEMAIN VALID,THIS FCRM MUST NOT BE ALTERED -

l 4.

TYPE CF APPLICATION 2.s 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 / TEM 14 - THERE 18 AN EXCEPTION. ALSO, THIS BLOCK IS TO BE MARKED 1F PREVIOUS NEW APPLICATION WAS WITHDRAWN, PLEASE WRITE " WITHDREW" NEXT TO "NEW,"

i '

'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 RECElVED SINCE YOUR LAST APPLICATION, NOTE: SEE / TEM 14 - THERE IS AN EXCEPTION, 2.b RENEWAL "X"lF YOU ARE RENEWING CURRENT LICENSE.

2.c UPGRADE "X"IF YOU HOl.D A RO LICENSE AND ARE NOW APPLYING TO UPGRADE YOUR LICENSE TO A SRO.

2A MULTI. UNIT "X" IF YOU CURRENTLY HOLD A LICENSE AT YOUR FACILITY AND ARE APPLYING TO AMEND YOUR CUR.

RENT LICENSE TO ADD AN ADDITIONAL UNIT.

2.e REAPPLICATION "X"lF YOU HAVE PREVIOUSLY BEEN DEN 1ED A LICENSE AND ARE REAPPLYING, i

2.f WAIVER REOUESTED "X"THEAPPLICABLE WAIVER REQUESTED AND JUSTlFY IN COMMENTS SECTION (ITEM 17),

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

THIS IS NOT APPLICABLE 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 AREAlS) OF STUDY, INDICATE THE NUMBER OF YEARS SPENT IN EACH COLLEGE CURRICULUM AND THE HIGHEST DEGHEE RECElVED, USING THE DEGREE CODE PROVIDED, FOR VOCATIONAL / TECHNICAL EDUCATION, INCLUDE PROGRAMS SUCH AS NUCLEAR POWER SCHOOL, MillTARY TRAINING, AIR CONDITIONING / REFRIGERATION, DIESEL MECHANIC SCHOOL, ETC, INDICATE THE NUMBER OF MONTHS IN EACH PROGRAM AND WHETHER A CERTIFICATE OR DEGREE WAS AWARUED, IF ADDl.

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. THE BREAKDOWN OF TRAINING IN THIS CATEGORY 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 S IN EACH TYPE 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 PERIOD), THEREFORE, THE DATE COLUMNS MAY INDICATE A LARGER TIME SPAN THAN THE ACTUAL NUM8ER OF WEEKS SPENT IN FULL. TIME TRAINING. TIME IN TRAINING FOR THE LICENSE APPLIED FOR CANNOT BE DOUBLE COUNTED UNDER EXPERIENCE (ITEM 13),

ALL REQUALIFICt. TION TRAINING TIME IS TO BE ACCOUNTED FOR IN THE REQUALIFICATION ITEM. PLEASE DO NOT " DO LIST" THE TIME SPENT IN REQUALIFICATION TRAINING UNDER ITEM 12.6, REQUALIFICATION, EVEN THOUGH IT MAY INCLUDE

/

CLASSROOM OR SIMULATOR flME.

13.

EXPERIENCE - A MINIMUM OF 6 MONTHS AT THE SITE FOR WHICH THE LICENSE IS SOUGHT IS REQUIRED, FOR EACH POSITION HELD, COMPLETE ITEM 18. DO NOT DOUBLE COUNT T!ME. IF YOU HAD OVERLAPPING DUTIES,THE MONTH! SHOULD REFLECT '

1 l

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

14 FACILITY OPERATOR TRAINING PROGRAM - INDICATE a. GRADUATE OF INPO ACCREDITED OPERATOR TRAINING PROG

. AND b. CERTlS '0" ".; ".~ ~.N; OR NRC APPROVED SIMULATION FACILITY iS USED IN THE vrennivH (NAINING PHO.

GRAM, IF "YES" IS CHECKED IN BOTH ITEMS 14a 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 NUMS OF SIGNIFICANT CONTROL MANIPULATIONS UNDER ITEM 12.3 NOTE: INPO ACCREDITED MEANS ACCREDITATION BY TH NATIONAL NUCLEAR ACCREDITING BOARD AND MEANS THAT AT LEAST THE MINIMUM REQUIREMENTS OF REGULATORY GUIDE 1.8, REV. 2, ARE MET.

15.

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

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 CLARIFICATICN FOR OTHER ITEMS ON TH 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. OBTAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YOU MANAGEMENT REPRESENTATIVE ON SITE,

' DETACH THESE INSTRUCTIONS AND SU8MIT THE COMPLETED NRC FORMS 398 (ORIGINAL AND TWO COPIES EACH PRIATE REGIONAL ADMINISTRATOR.

(

.n_n--.,-

~-~

~ ~

~ ~ ~

~

,p PORM SW U.L NUCLE AA REOULATORY COMMISSION APPIOVE19Y oms: NO. 31604090 DAlt RECEIM l

40 i E xil3 E S: 13tC2 Uo be anwe MCA d.CPJ b6 J1. 64.36, t

i ESTIMATED DURDEN PER RESPONDE TO COMPLY WITH i

ef. enil t4N#

THL 4 INFORMATION COLLECTION REOUEST: 24 HR$.

)

PEN 80NAL QUALIFICATION STATEMENT-LICENSEE FORW ARD COMMtNTS REGARDING BURDEN ESTIMATE 10 THE INPORMATION AND RECORD $ MANAGEMENT BRANCH (P.S.1. 01. U $ 160 CLEAR REOULATORY COMME SaON, WASHINGTON. DC 20bt6. AND TO THf PAf'LRWWORK REDUCTION PROJECT (31604000). OFFICE OF MANAGE. e TO REMAIN VALlD,TH18 FORM MUST NOT DE ALTERED MENT AND SUDGET. WASHINGTON. DC 20603.

j.

i

1. APPLICANT'S FULL NAME (Last, E/rst, AWdJe) AND ADDRESS (hclude /IP Codel

4. TYPE OF APPLICATION (OUck atPlar# 'abosas)

t. HOT l

e. RE APPLICATION I,

[g UE,y D

1 2 COLD l. F 1R$T lWRITTENICessysryl

e. NEW 7 8ECOND

2. OPE R All% fCaer

b. RENEWAL

3. THIRD '

W

c. UPORADE 3 < ',LIOltiLIT Y t MULTI. UNIT LAht(NO TOINCLVDE ADOITIONAL

2. CITIZE NSHIP

3. BIRTH DATE

~

~

e. utDICAL 5.OTHER

& UNITED 8(ATES MONTH DAY YEAR

g. DATE PASSED OENERIC FUNDA.

MM YY MENT ALS E K AMIN ATION 6ECTION

b. OTHER ISeastiNo l

l l

I:9 A99tICAclth I

5. TYPE OF LICENSE APPLIED FOR

6. PREVIOUS LICENSE 18) HE LD

a. OPERATOR

e. DOCKET NUMBER RO SRO b LICENSE NUMetR 4 F ACILITY DOCKET NUMBER y

y,,

E6 SE NIOR OPERATOR I

I I

)

$6 1

I I

60,

s. LIMff ED SRO le e.. Fuel NonsfJerf l

9

)

)

7. NAME AND ADDRESS (/ncAude I/P CDdel OF APPLICANT'S EMPLOYER

10. CURRENT POSITION AT F ActLIiY a FLANT SUPERINTENDENT 4 AUXIUARY UNIT OPER.

ATOR/T RAINE E/TUR$1NE

b. ASSilf ANT PLANT $UPERINTENDENT SUILDING/ EQUIPMENT OPE R ATOR INON & tC(NS

s. $HIFT SUPtRVISOR iO OP(NA TORA EL STAFF ENGINEER

1. OTH4 R (Specify)

8. ellME OF APPLICANT'8 F ACdLITY F ACILITY OQCKET NUMBER e6 $Hff f TECHNICAL ADVISOR /5HIPT ENGINEER

f. INSTRUCTOR

3. ADDITIONAL F ACluTY DOCK E T8 IMetteet tarensess g SENIOR CONTROL ROOM OPERATOR IL CONTROL ROOM OPf R ATOR

11. EDUCATION g HIGH SCHOOL

s. MAJOR ARE AISI OF ETUDY a.","/1f.

",T,;L*.'

DEOREE COCES t VOCATIONALnECHNICAL NU ER R F OnJ.OUATE E NGINE ERINQ tFif tO$J

"'"6""'

v vet o. T Ra#NING MONTHS ygg go y,gy pgg gg y.' obteened)

OED EQUIVALENCY RTIFICATE go

2. A850CIATE 3,NUM ER UF d. MAST E R 7 8ACHELOH

. g $ O,P

6. DOCTOR AL g

12. TR AtNING (SINCE L AST APPLICA TION - SEE INSTRUCTIONS) 13 E XPERIENCE (DO NOTDOUBLE COUNT-SEE INSTRUCTIONS) e vos v., 490 v e n a g >=rnanovaan

,,,,,,,J;-'

eaow to m.m.

NAyy show to

• "ani a*

t gew,,

i 1-NUCLEAR PGWER PLANT FUNOAMENTALS ems 1.RO 2 -PLANT SYSTEMS

2. EOOW/PPWO CLASSROOM

3. EWS/PPWS OBSERVATION

4. E RS/CRW 3-OPERATING PR ACTICE 5.OTHER (saved &s CONTROL ROOM OPER ATIONS ON SHIFT SIMULATOR OPER ATING Isnedusin Cwwoom/

pogget SIMhATOR NAMES fn.

6. OPE RATO R

.h, \\ hh.hhh,g

7. SUPE RVISOR a.

- g -. -

q.

p N n7wYo'u'*TeYs0 l l YES l l NO

9. OTHE n tspece47 5. i dm ' 9 93

.A.

4 5

%Uuee n os ma actmr v wameute rio%s MANT 51 WU L A T U P

'y' E I' l

(s 90 ' ',

COMMERCIAL NUCLE AR (incAntsne nesmen/resr aeverorf 4 -SRO INST RUCTION 10 - AE ACTOR OPERATOR Itecenards 6-MS,^r7E,"MI,,*""'"'0"'"""O" 11 SENIOR Ov'ERATOR (ttrenants

a. $',pgs, ayva aos PowsR

12. SHIFT SUPERVISOR (teeneri 6 -REQUAllFICATION

13. ST AFF/ SHIFT CNGINEER Itarensass 7 -0 THE R (spect4A I 4. AUX./ EQUIP. OPER ATOR INontecenants

15. PLANT STAFF 16 CTHE R (spect&A m.

NRC FORM 3EE (1049)

. + - - -

7~..-.,.-...-__,

.-,n..~-

-~y,n

u.. e

=- =;

~t my + _-

4r t

n

14. FACILITY OPERATOR TRAINING PROGRAM -

Te ce sespo e ochoolv.o OPERATOR a canier sed ON NRc roRM 414 f"3WULA TJOHACfMF F g psostene PeloeRAM TNAT et saano uPoM A -

YES -

NO:

CFMihCA TJOF7 03 NRC APPROYED $5MULAT104 YES '

NO l y;t WYSTOGS APPflOAcNTO TRA#NIN3

, Actttiv is us&D IN 1HE OPERA 10R TRAINiteQ PRooRAM

16. FOR RENEWALS ONLY A

b, DATE AND RESULT Of MOtt DATE Re8 4 '

REQUAllFICAllON EXAMINATION PAIE '

E AIL -.

i t

' tIOU81S OPGRATED F ActLITY# -

R$CEN1 NRC ADMINISTERED 4

16. EXPERIENCE DETAILS 6 P001T00N TITLt -

FROM

.TO

b. f ACILITY

s. DUTIES l

l 1

t

.I 1

1 17, N8 muswe see nem numan se essea yea, m saane,efeap. Aeerea senseeener osisere se sessenesty.s

)

r i

i

.i r

.I

18. NRC PORM 800, CERTIFICATION OIMEDICAL EMAMINATION BY P ACILITY LICENSEE, SS ATTACHED ANY F ALSE staff MENT OR OMISSION IN THIS DOCUMENT. INCLUDING ATTACHMENTS, MAY BE SUOJECT TO civil AND CRIMINAL SANCTIONS.

4 me. i eenwy weser penshy es emiury that the infamenton m this desumwe ord wiechmens h true put sorrect, i furthw senHy thm I how notHm! my surrent engWover of; (1) WI prewmue engleyerg; (3) eny enseense gefeste I hees been tested by e Hestth end Human astvtese IMH$) Cenef'ed Drug Teming LahoretOry Or e Licenese's teetm9 fettlity for eiCOhol er a controlled meteenee, and the test tenufte enegaded ties outoff levole estabheheel swoueni to 10 CF A Port 24 (3) any insience where I how been ervesese lor the sese, use er posesseson of a controHed substanc,e and t4: any veneens ter veme i a revo euen et unseconed emeese m e aucesset asenny, i eien authorin the NRc to memn the rotune os eumirmene io my emoseven so un in propenine rarma..e peegrenas se nesseesty

$10 NATURE APPL 8 CANT.

Daft CHECK APPLICABLE POX h I eartify that the above named indtvedual hee eutcessfully somgWetal the tecihty fireneses reluoromente 10 he Iscemed as en Operaterl6enior Operator pursuant to Title 80, Code of Federal Regulatens.

, Port 05:and that the indeveduel hos e need hit en Operefor/tseneer Opererer essenes to perform hee /her eeugned outeso end that the tendetpin be messe owedeDee for esameneten, i eleo certify under peneRy of portury that the letermetton in thee tescument ensi ettechmerite to true end correct.

r

& RENEWAL ONLY I conify that the shows named Indnredual meets the sporewed requallistetten psogram (wita escoptisms soved M from f 7) es fesulted by section 50.54 4 il of 10 CFR 60, and that he/she has discharged h6e/her licensed toeponeitWineg sempmently end echty. j elgo centh undw pensity of perjury thet the informetton in (hte document end ettschmentt..

is true and correct.

TRAINING COOCDINATOR SENIOR MANAGEMENT REPRESENTATIVE ON SITE PReNTED OR TYPED NAML PRINTED OR TYPED NAME S$GNATURE DATE SiONATURE DAfg FOR NRC USE WAIVER (Chdek or Complete items, as applica6/e/

l MEtts ngoulHEMENTS l l DOES NOT MEET REQUIREMENT 4 ttosevn eeJo

"^"

D' "' ' U "

CATEGORY HE ADQU A R T E Rs " U '

R E GION HE ADQU ARTE R$

R e GION Y.7ITTEN OPERATING ELilitlLITY MEDICAL.

sloNATURE-NEVI &WEH lDATE l

_THE3 O

- feRC PORM 30s 110491

.ih-e

U A. NUCLt Aa ets ovkAtout (,.onsenseOJe asamm t og eso sito.aoa4 e,s,a..c.s.ome 26

'a 4

ae..n u.

m, m.i.... e.u... e... e.,o..,o m,,i,, e.,.,,

mem... usu.nio

..ou m e CEMIFICATION OF MEDICAL EXAMINAh0N gaq' *,,c,y:*ays, " *f,af..o;g en.,y,g's.

au..eiic,mc.no o m.e m.o.u..

$Y FACluTY UCENSEE

..a=c..u 3ai,os oc=aci.

us t

r

.io=

is.o

=

al DuCTiOh en0Jt CT 131604KV4 Oeeict Oe esah404 ulti aseD SuDOL1. mabenh4 tom DC Mo3 geeine N64' M APP UGAev t k(( '

lI ACILt TY OOCAt T NVhett R e-

.. e,..u A. MEDICAL EXAMIN ATION CERTIFICATION m

Tetl$ t$ TO Cdif7Y THAT THE. ABOvt NAMED aPPLiG t.T F OR AN OPL R ATOR" SENIOR opt R ATOft LICEN5t HA5 8EEN E R AMINtD BY A PHYstCI AN m

PRINitD NAMt inf a%remens g ST Af t. AND LILLN$t NUMBLR lt AAMINATION DAf t' I

$ ANLD ON THE ht SULTS Of tut t x AMIN ATION INCLUDING INSURMATIC;.TURNISHE D DV THE Al'PLICANT THE PM)SICIAN MAS Dtil RMINE D TH AT THt APPLICANT'S PHYSIC AL CONDifl014 ANO GtNLR AL HL ALTH Aftt NOT SUCH THAT If MIGist CAUSE OPER ATION AL L rotor 5 ENDANGt RING PUBLic Mt ALTH AND LAF ETY i CE RTIF Y THAT IN itf ACHING 1 hts DCTI RMIN AtiON. THE GUIDANCt CON T AINLD IN AN51, AN5 3 41983. OR AN51/AN516 4197 7 (N3110t W As POLLOWt0 AND tHAT DOCUME NT ATION il AV AILASLI FOR fit vitW SY NRC.

ON THE BA$l$ CF THE Rf COMMENDATION OF f tiL.fHYSICIAN. I RECOMME ND THAT THC APPLICANT'S OPERATOR LICENSt 6E CONDITIONED AS

._OLLOWS P

1. NO RtSTRICTIONS

2. COR$st CTtyt LtNst$ $t WORN WHEN PERFORMINO LICENSED OUTitS

s. HE ARING AfD 8% WORN WHEN PE RFORMING LICtNSID Duf ttS 4 RLST Rict ED LICE NSt OR E KCtPTION Pmvine meia N heio acus enach saouartme medical eveente tot NRC rmew

% R(ST *iCTION CHANGt F ROM PRt vlOUS $UBMitt AL Penv,oe oeia is tieme ami ettath succwt.no mouices mnente to NRC ene*

PRO *DNL D WORCING Of RESTRICTIC'e 18'in e d ateves R E LAtlONSHIP 08 811ST RICTION T O DISOUALIF YING CONDit lON (preet& erancere #ew reserNn swu cor, ort the rhaow,4mp comritsont Rt M ARK 5 FOR RitT RICTION CHANGC (8sota 6 afeves tl. NONMt. DICAL Ct Hilf ICA IlON POWL R Rt ACTDR$

THIS CLRTIF:t5 THAT THE Aff'LICANT HAS BtEN FOUND TO Mt ti THE SAF LGUARDS' AND FliNESS FOR DUTY REQUIREMENT 5 0F THis F ACILITY FOR LtCEN5ED opt nATORS y

NON POWE R Rt ACTORS THIS CtatiFits THAT THE CLICANT HAS btf N FOUND TO Mt ti THE SAFEGUARD $' v4tOUiREMLNTS OF THis F ACILif Y 80R LittN5t0 OP8 R ATOitt iND l HAVE NO KNOWLCDGE OF THE APPLICANT LXCitDING THE CUTOF F LtyELS FOR ALCOHOL OR CONTROLLED $USST ANCl$ AS iET ABLl$HtD FUR $UAN f TO 10 CF R 26 F

an v e a ssi s t a t e ue n t um uwisuuh in t nis pucuuim t ihnuceNu at t auvim in wa s et sumatc t Tu civit aku tniwie.at aaNu iuht a ct* i d v unutu riNai.t v ut L

POMJyotg f eeA t TMG INeGMMa tKih.N THi$ DOCUMt NT AND ATT ACHWtNtli$ IMU$ aND CORRlCT, PRINitD N AME AND SIGN ATURL I3enw Meregemeert meprewntarne on $, ret f!TLt Daft in actoraance a in 10 (,F R 66 6 Apmenumcate'ni inns form theti be suomnted to It e NRC as foisows 8 Y MAIL ADDRt $54D TO.

Regional Adm mstrator. Regiun i Regenai Admmetrator, Region il liegionai Aammistrator. Regen til U S. Nuciose Requietory Commision U S Naci+ar Reo.iiatory Commessen U S Nuclear Reeviston Commimon 47% Alterniete Road 101 Mar.etta St'tet Suite 3100 7119 Auowveit Road Kmg of Pruwe PA 19404 Attauta. G A 30323 Gwn (livn. IL tiO137 tieg onal Admmiittator, Recon IV Regenai Administratoe. Reg.on V U S. Nutiese Requiaiovy Commnica U 5 Nuclear Requistory Comm won 611 Ryan Pisia Dr.ve y,, iono e sgo Ma,is Lane, suita gio r

Aomgton. 7Je 76011 Wemut Caen. CA 94596 PRiv ACY ACT %I A n tME NT Pursuant to 6 V EC 552ateH31. enacted mte lee by secten 3 of the Privacy Act of AOUTINE U$ts The etoematen may tw 04ciowo to en soumorwie Feoerc, State. o e 1974 (Pubi.c Lee 91579L the intameg notement 6 ' wen.she to moie ouaii who locat egenev m the event the inbemation indicates a veisten at lesential veisten of law sup uy miormaten to IM U $ Nectear Regulato'v Comm%on on NRC Form 396 ano m the event t's information intlicates a seistion os potentiai voiaten of iew anu m the mfoemaw m memtemeo m a ivstem of eomos angnated as NRC 16 ead the coune of an ademisteetive or iuoicie procevome in edes< ten tha informaten enav te deictitwo at $1 Fotle'ei Reg' fief 33157 ISeptem:sre 18 19861 tramiter'ed to an appropeiste Feoerat Steie. ano iocat a anncv to the entent reieverit eno AUT HOfilT Y Sectoni 107 and 16114 of the Aturmc Enegv Act of '954. ei neceitary for an NRC oocinion ateut you amenonf ia7 U S C ?t3f ew n01bn WHE THE R OtSCLOSUPE t$ VANDATORY ~) R VOLUNTARY AND EFitCT ON PRiNC; PAL PURPOttts). letoematen enie ed on this bem 4 i..) to oetermme INDIVIDUAL OF NOT PROviDING INFORMATION D wasure 4 voiuntarv. It the ewther the rmvocai coreition and genetai hesith o' the arpucent are such that thev 'effuetted *'o"elion 4 "ot D' ovide't ho*e'e'. ihe aci"'cas on toe a f acility otu 'atori

.41 not cause operatenas er' ort emianserint p4buc heetth and sa'ety the mtorma-or uner opetam s i cenu mav be cen.m.

ten may tw meo by the NRC staH to dettemine it the imoiviouat meets the requot

$YSitM MANAGERts) AND ADDatSS Chiet Oteratur Licenimg Branch O't ee of l

nwnts et 10 CF R $6 to tsee en nemmeteen or to be maued an operator t 6.cenw Naciese Peactor Re,4iaten. U S. Nucieer Regu.atorv Commaien. AainmiPo% DC 20556 Nef* eqiegi via i$ agt

l 1

I 1

IN3480RE 3 l

smear or aunas m me nom m Medical Examination Certificatica Added block " Restriction Qanse Frta l

Pawious Sutunittal" plus Remarts i

section.

Non-Medical Certification

- Chansed non-marHaal certification i

statement to: Power Beactore-This i

certifies that the applicant has been 2

fo n d to most the maf e m % ' and fitness for chrty requirementa of this this facility for licensed operators.

Hanpower-This certifies that the applicant has been found to meet the enfesuards' rwauirements of this i

facility for lih operators and I have no knowledge of the applicant

====rHw the autoff levels for slanhal or controlled substances as es+=M w pummaant to 10 CFR 26.

t-l l

l i

l-l-

i l'

l DUASURE 4 i

l StttW@! 0F CHAtMS 10 IEC IGM 396 Item 4.d Added clarifying statement to 4M% this is to be checked only if application is to amend limenes to add additianal tait (s).

Item 4.f Added "(Catasory)" to Cperating, i

Added "MarHam1".

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

Ensaination Section".

Item 12.3 Changed wording to " Certified Startup Program Completed" for clarification.

~

t Item 12.5 Changed wording to " Extra Person on Shift In Control Room I

(13-week minima)" for clarification.

1 Item 12.5a Added a new item "Tian Cks Stdft Above 205 Power (6-week miniaan)".

Item 14.a Added the words "That Is Bened Upon A Systems Approach to Tr=4aia=" for clarifiestion.

Item 15 Added "Date and Result of Host Aeoant NRC Administered Begualification h==ination".

4 Item 19 a Added the wording "I further certify that I have notified my current employer of t (1) all prwious employers: (2) any instance where I have been tested by a Health and Human Services (HBS) Certified Deus Testing L-Wr/ or a Licensee's testing facility for alcohol or a ountrolled eubstance, and the test results====v4=ri 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 reasons for removal or zwvocatica of unescorted aoones at a nuclear facility".

Item 19.b and Item 19.c Moved 19.b and 19.c tesother. Applicable box must now be checked. Aleo added block for typed name of Training Coordinator and Rania* Management Representative th Site.

PGt NRC USE thder waiver category added " Medical".

-s ve w

---

e----n,

-w,--w.

p.

,--,+,,------,-,n

.-n

-,-,,n--

. - + - - - ~ -

,.