ML20006D656

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

ML20006D656
Person / Time
Site:	Indian Point
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Bram S CONSOLIDATED EDISON CO. OF NEW YORK, INC.
References
NUDOCS 9002140177
Download: ML20006D656 (8)

Text

.--

s 7;,

J.*

[

i l

.lAN 51990 l

Docket No. 50-247 l

Consolidated Edison Company of

-i New York, Inc.

3' ATTN: Mr. Stephen Bram n' -

Vice President, Nuclear Power Indian Point Station i

Broadway and Bleakley Avenues Buchanan, New York 10511 Gentlemen:

l

SUBJECT:

REVISED NRC FORMS 396 AND 398 j

Enclosed is a copy of the revised NRC Form-398 (Enclosure 1), Personal Qualifications Statement - Licensee and revised NRC Form-396 (Enclosure 2),

i 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.

1 The enclosed applications-ere 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.

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

Sincerely, Ori lun1 S$sned byg" C

Robert M. Gallo, Chief Operations Branch

)

Division of Reactor Safety

Enclosures:

As stated y

h

gg2qggggg.gaggg7 h

1(

Y OFFICIAL RECORD COPY 396 & 398 FORMS - 0019.0.0 12/14/89

r g

Consolidated Edison Company of 2-1 New York, Inc.

't cc w/o enci J. Del Percio, Manager, Regulatory Affairs B. Brandenburg, Assistant General Counsel i

P. Kokolakis, Director, Nuclear Licensing M. Peckham, Assistant to Resident Manager A. Budnick, General Manager, Administrative Services F. Inzirello, Training Manager (w/ enclosures)

Department of Public Service, State of New York State of New York, Der:rtment of Law W. Stein, Secretary - NFSC Public Document Room (POR)

Local Public Document Room (LPDR)

Nuclear Safety Information Center (NSIC)

NRC Resident Inspect.or (w/SGI) i State of New York bec w/o enc 1:

Region I Docket Room (with concurrences)

Management Assistant, DRMA (w/o enc 1)

J. Wiggins, DRP L. Tripp, DRP D. Limroth, DRP K. Lathrop, DRP l

0. Brinkman, NRR J. Dyer, EDO OL Facility File 4

DRS:RI Gallo/1pb,8g, 01/ 2 SO 9D 1

0FFICIAL RECORD COPY 396 & 398 FORMS - 0020.0.0 12/I4/89

INSTRUCTlDNS FOR ODMPLETING NRC PORM 30B l

PERBONAL QUALIFICAflON STATEMENT-LICE 9SEE a'

T3 CEMAIN VALID,THIS FORM MUST NOT BE ALTE!JD 4.

TYPE OF APPLICAT4ON 3.e NEW "X" IF YOU ARE A NEW APPLICANT, COMPLETE EACH CATEGORY OF THE FORM COMPLETELY, FOLLOWING THE I

' INSTRUCTIONS BELOW. THIS IS TO INCLUDE ALL EDUCATION, TRAINING AND EXPERIENCE THAT YOU HAVE RECEIVED UP TO THE DATE OF THIS APPLICAT4ON. NOTE: SEE ITEM f 4 - THERE IS AN EXCEPTION. ALSO, THis i

BLOCK IS TO BE MARKED IF PREVIOUS NEW APPLICATION WAS WITHDRAWN. PLEASE WRITE " WITHDREW" NEXT l

TO "N EW."

(

2.b tlw 2.e-FOR 2.b THRU 2.e. COMPLETE E ACH CATEGORY COMPLETELY, BUT INDICATE ONLY THE EDUCATION, TRAINING, AND EXPERIENCE YOU HAVE RECEIVED SINCE YOUR LAST APPLICATION, NOTE: SEE ITEM f4 - THERE IS AN EXCEPTION.

l l

l 2.b RENEWAL "X"lF YOU ARE RENEWING CURRENT LICENSE.

l 2.s UPGRADE "X"IF YOU HOLD A RO LICENSE AND ARE NOW APPLYING TO UPGRADE YOUR LICENSE TO A SRO, 2.el MULT1. UNIT "X" IF YOU CURRENTLY HOLD A LICENSE AT YOUR F ACILITY AND ARE APPLYING TO AMEND YOUR CUR.

RENT LICENSE TO ADD AN ADDITIONAL UNIT.

2.e REAPPLICATION "X"IF YOU HAVE PREVIOUSLY BEEN DENIED A LICENSE AND ARE REAPPLYING.

2.f WhlVER REQUESTED "X"THLAPPLICABLE WAlVER REQUESTED AND JUSTIFY IN COMMENTS SECTION (ITEM 17).

2.s DATE PASSED GENEMlC FUNDAMENTALS EXAMINATION SECTION (GFESL I

l 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 1,1Dn2,WHICH LED TO THE.

ISSUANCE OF A LICENSE, THIS DOES NOT INCLUDE INSTRUCTOR CERTIFICATION EXAMINATIONS OR REQUALIFICATION l

EXAMINATIONS.

I 11.

EDUCATION - INDICATE BOTH ACADEMIC AND VOCATIONAlJTECHNICAL POST HIGH SCHOOL EDUCATION. FOR MAJOR AREA (S) OF STUDY, INDICATE THE NUMBER OF YEARS SPENT IN EACH COLLEGE CURRICULUM AND THE HIGHEST DEGREE l

RECEIVED, USING THE DEGREE CODE PROVIDED. FOR VOCATIONAL / TECHNICAL EDUCATION, INCLUDE 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 DEGREE WAS AWARDED, IF ADDl.

l l

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

12.

TRAINilGI - INDICATE THE TRAINING YOU HAVE RECEIVED TO MEET THE REQUIREMENTS OF ANSI N18.1/ANS 3.1 THE i

l BREAKDOWN OF TRAINING IN THIS CATEGORY PARALLELS THE ANS STANDARDS. REFER TO THE STANDARDS IF YOU NEED J l

FURTHER CLARIFICATION, INCLUDE BOTH BEGINNING AND COMPLETION DATES AND THE TOTAL NUMBER OF WEEKS SPENT 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 NUMBER OF WEEKS SPENT IN FULL. TIME TRAINING. TIME IN TRAINING FOR THE LICENSE APPLIED FOR CANNOT BE DOUBLE COUNTED UNDER EXPERIENCE (ITEM 13),

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

13.

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

l HELD, COMPLETE ITEM 16. DO NOT DOUBLE COUNT TIME, IF YOU HAD OVERLAPPING DUTIES,THE MONTHS SHOULD REFLECT THE PROPORTIONATE AMOUNT OF TIME YOU WERE ASSIGNED TO THOSE PARTICULAR DUTIES. IN NO CASE SHOULD TH NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEED THE NUMBER OF MONTHS THAT ARE IN THA TIME PERIOD.

l 14 FACILITY OPERATOR TRAINING PROGRAM - INDICATE e. GRADUATE OF INPO ACCREDITED OPERATOR TRAINING PR CERTWIFD (ON Mac ropy 4711 OR NRC APPROVCO Clf,'ULATIO!4 F ACILITY 13 USED IN TrtE OPERATOR TRA!NING PRO.

AND b GRAM, IF "YES" IS CHECKED IN BOTH ITEMS 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 ACCHEDITED MEANS ACCREDITATION BY THE NATIONAL NUCLEAR ACCREDITING BOARD AND MEANS THAT AT LEAST THE MINIMUM REQUIREMENTS OF REGULATOR GUIDE 1.B. REV,2 ARE MET, 15.

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

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

TION.

NRC FORM 398, CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE - MUST ACCOMPANY THIS APPLICATION, 18.

19.

SIGNATURES - SIGN AND D ATE ITEM 19.a. OBTAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YOUR MANAGEMENT REPRESENTATIVE ON SITE.

DETACH THESE INSTRUCTIONS AND SUSMIT THE COMPLETED NRC FORMS 394 (ORIGINAL AND TWO COPIES EACH PRIATE REGIONAL ADMINISTRATOR.

___,_7_

~~~~4

~.

i e

f i

pores se uk esuckt.R R40VLw108tv Cotestettoes APPROVt1BY Oesti NO 3160 4000 b"II "I U

it i

II8 8' **"*"' ##

40 CPft 7. 91. M 36, t xPgRg g: 33142 OSL7,ead 06 &7 EtTIMAT8D DURDIN PER RLOPONSI TD ColdPLY wf7H g

THIS INSORMATION COLLLCTION RIQutST: ts Hott FORM ARD COMMENTS REGARDileG SURDEN ($YlWATE PERSONAL OUALIFICATION STATEMENT-LICENSEE To THa 'N'OaM AY aohNUCLE AR 'REOULATORYa coaps MA*AGEM'pl8-AND ai DRANCH (P4E. U S Cons 5

giole. masuiNOTON, DC pubb6 AND TO THE PAPERWORK

}

Rf DUCTION PROJECT (31b040001, Of flCE OF MANAGt.

TO REMAIN VALlD,THl$ $ORM MVST NOT DE ALTERED MLNT AND suoGtT.m AsHINGTON. DC 2nnos.

1. APPLICANT *$ FULL NAME (Last. Idrst, M,dcrael AND ADORESS (mcluor I/P Codef

4. T YPE OF APPLICATION (Chece appleshie bones)

t. HOT l

e. Rt APPLICAT60N

,, [d$1D 3.COLO

1. f IRST WR6TINihi I"

~

$. opt R &T aNG (Ceer b.RENinAL

3. THIRD

s. UPGRADE 3 6 LIGISILif v W. IAULT1. UNIT (AMEND TD fNC&t/Of A00tFf0NAL

4. MEDICAL

2. CITl2EldSHIP

3. BIRTH DATE 6 0THER g UNITFD ST Af t$

MONTH DAY YEAR

$ DAf t PA$$1D CINERIC FUNDA.

MM YY

=

MENT ALS 8 XAMINATION SICTION

b. OTHER faaer#4J l

l l

tit APPL #CA#i t#

6. TYPE OF LICINSE APPLf t D FOR

6. PRE VIOUS LICE NSE851 Ht LD A OPERATOR

a. DOCKET NUMalR RO GRO tt LICEN56 NUMBER "uf[

W. F ACILITY DOct(ET NUMD&R h

b $1N10ROPERATOR I

3 I

I I

I 60-

4. L IMITI D BRO le e. Fesef NwHHeti l

(

l

7. NAME AND ADDRESS (frieduorl/P Codr1 Of APPLICANT'S EMPLOYE R

10. CURRENT POSITION AT f ACILITY jyff,",jugyfy V l a PLANT sVPtRINTINDtNT

,g l

AbstSTANT PLANT SUPIRINTINDENT tL E

NT g

ggmg.

4. SHIFT SUPERV4SOR (D M4 A WJ A STAf f INGINEER

l. OTHtft (Asses &s l t ACILIT v DOCnti NUMalR

s. SHIFT f tCHNICAL ADVISOR /$HIFT (NGtNEER t.w.ME DF APPLICANT'5 f ACILtiv

f. INSTRUCTOR D t.DDITIONAL 9 ACILIT Y DOCA t TS (Myrreenst 4.oreassas 6 SENIOR CONTROL ROOM OPERATOR

h. CONTROL ROOM OPER ATOR l

11. EDUCATION N

% HIGHSCHOOL

(. MAJOR ARE ALSI DF ETUDY

1. '71!.

" t."J.'l Ot0REE 00 DES at VOCATION A L/TICHNICAL g,

Y'ig"uNNoagg

,pg,,,g,

' vet M S**'N'No MONTHS 031ADUAfg (NGINt 4 RINQ fFitt0$J

,qs

% g,,,

u D

I, c"g RT at IC AT E GED (QUIVALE NCY g,gt,

7. ASSOctAYt NO 3.DACHELOR th NUMDtHOP 4. M AST E R OF

6. DOCTOR AL

12. TR AlNING (SINCE L AST APPLICA TION - SEE INS TRUCTIONSI

13. E KPt RIE NCE (00 NO T DOUBL E COUNT - SEE INSTRUCTIONS) e MUNT N AND

• t A h 4 MONT H AND VG AR

, gg,,

, em g a NAVY

'a0*

'o

'" "" Z

'o (casa.

1 -NUCLEAR POWER PLANT FUNDAMENTALS toom>

1.RO l-2 -PLANT SYSTEMS

2. EOOW/PPWO

~

CLASSROOM 3.gwSfppws OBSE RV ATION

4. E RS/CRW

3. OPERATINO PR ACTICE

5. OT HE R tssecsty; CONTROL ROOM OPE RATIONS ON SHIFT SIMULATOR OPE R ATINO truainus ceu, m>

FOS $tL SIMULATOR NAMES 6 OPERATOR g

a.

-!?<'

7. SUPE RVISOR NE1'u c*o'u'eYsYs o l l YES l l NO g.

i

8. PLANT ST AF F b.

jq s

(

9. OT H E R (soecd41

'.7 Nuwee n t.s ee Ac t ivit v v&N *m A v ions 1'

3 PLANT 5:UULATOWr 4

4 4

ax COMME RCIAL NUCLE AR (twsmtsa, Amerre/ Test neeceerJ 4 -SRO INST RUCTION

10. REACTOR OPER ATOR ttisensurf 6 -N^ TEN,b I,$.6*' T '* C N ' "O ' " M M

11 SENIOR OPE RATOR tres,aants 8.IN,'rYENiNv'yO30U***

12. SHIFT SUPE R V1SOR ILoceasur) 6 AEQUALIFICATlON 13 5TAFF/ SHIFT ENGINEER ftdreasars

? -OiHER (sepev&#

14. aux./EOUIP. OPE R ATO R INonstreand)

16. PLANT STAF F 16 OTHER(sopre&i NRC 7ORM 38B 11049)

'~

l

~

~ X~ ~ ' '

i

14. FACILITY OPCATOR TRAINING PROGRA~:2 l l) 6 crRTaresp on NRe poRM oe suut A F#0A #ac#uf r l

Y YES NO

'QO,",","g,",,",,%D,8@'Q*N YES NO C

e m

15. FON RENEWALA ONLY g,

k DATE AND RESULT Op a0087 DA" "II 4 '

j esintR60PGRAftD f ACILITY:

RictNT senc ADMINisit Rio REQUALIF eCATIOes (RAMiss4760N p4gg pggg g

J to. EXPERIENCE DETAILS r

r i

GL POtif t00d TITLE t Roes 10

h. 8 ACILITV

s. DUTitt J

J J

)

17. MNT$ dhemsNW ses deem menneer se eseet pov om aestudeems difesse estfredener siispfe se assessory./

i F

?

I L

I i

1 i

1 d

4 l

18, NRC PORM SES, CERTIFICatTION OF MEDICAL EXAMINATION SY P ACILITY LICENSEE, SS ATTACHED ANY F ALSE ST ATEMENT OR OMIS$60N $N THis DOCUMENT, INCLUDING ATT ACHMENTS. MAY SE SUBJECT TO CivlL AND CRIMINAL SANCTIONS.

m

.e.ue, us.se, -,...e lur, ici...nso,m.on in ici.

sumem.. mi--e = true e co

. i sun.iee somt, ihs, i t.,e rou.

m, sure.oi or - t: in

.r-ous ream.e,t.

(26 eny enmasse woore I hoe tissa semes by e Hastih eens Hinnen aseviese IHHS) Cornfese Deue T teiene Latsoretary oe e Lloonese e tesisas teciesey for esconos se a somreised euemisase, eriis the test ens 44) en,neses too autoft Issoas estantiemed pursuem to 10 C# 84 Port 26. (3) sov inssence erhem I have tesen arressed ear the eso, use or poesseeen of e conteohad eatenience usurem susuhe ess seasons see venovei or revoisten et unserorted morees et e nuessee,escothy, t also authoatre the httC is subenn she reevns et seeminaiens to my emesvers eor use in properene voireuung asmesoms. as namessary

$400eATURE. APP 68 CANT DATt

~

CHECK APP &lCARLE SOX

] b. I seriae ehse the shoe named indhneuel has ossessefuhy computest the se,cWNy Mcensees eeGW'emame te to heenesd as en Oswrmottlener Opersone pursuem io l

v l'

.#e.re 05:a,an ease,the eneveausi has e nose s.er en o.pe.re.ie.rtsene.r Ousreio emense se poeterm histhee asupies outins and the the essnegath ge mene se6ambao Der enempu 1

.hv. p rtu, ihm the intermann in i ii. one.

ad mi chmem. = irue end so lL s

1-4 RINE14AL ONLY

• I sordly that the amove named lndwedust meets the appnmd feeuellficeilon pecorem tw#re easeptmee metod av from th as reautred by esetton 60.54101 of 10 CF R 60.and -

l that he/she has descherysd his/hst beeneNi voeponsibienes openpetemiv end asfely. 4 eleo seretty unose penetty of persury ihet the intofrheison in the gesumeni Sqd entschments.

is true oms soevoet TRAtWING COORDINATOR SENIOR MANAGEMENT REPRESENT ATIVE ON SITE PR48tT50 0R TYP40 8s AME PRINTED OR TVPtD hAMt P

lDATE geQesaTURE l0 ATE g

$VWATURE FOR NRC USE WAIVER tchsch or Q mptere dterns.es applacetdr) l mitts R$ QUIRE ME NTS l l Dots NOT MEtt REQUIREMENT 5 fispastn ewsw/

D""" " D "nFQtDN HE ADQU ANTE n"3" D " nE GION D'

CAttOORY HEADQUAnTERt (CITTEN OPERATING ELIGISILITY ME0lCAL 1 ssGNATunt-Riviewsn goATE OTHER -

884C Postas age 1 pass

4 U. cuCw a oum R v Coii=*o=

a-on,oa,vg.,;ogi.coou go.u e c.e.., u v

.,., -a.v i o..v o.p.. wumio r....ov.a.

pr..,,H so e.R.. a.o

,o

-is i eo m.

.e 4

CERTIFICATlON OF MEDICAL EXAMINATlON ga g o,,c,,ogj=ay, p,a,*ae;g g,, g o

emateCM ie Di Nu acQut tDay c BY FACILITY UCENSEE ai 4.]or. u, loc cL.L ANa~o,o,a.i ean.O sts.ib

. soy l

o oa alDuctioN.uDGE T, n a&MihGioN OC 70bo)(3tto4ip?si oesset op man AGE emo>t c7 uth?AhD j

l NiMk OF APPLICANT F ACILIT Y lF ACILITY DOCKET NUMBER A. MEDICAL EXAMINATION CERTIFICATION THis 15 TO CE R Tlf Y THAT THE ABOVE NAMED APPLIC. ANT FOR AN OPER ATOR' SENIOR OPE R ATOR LICENSE M AS BE EN E k AMINED BY A PHYSICIAN E R AMINAT40N DATE j

PRINTED N AME forphysscsant lST ATE AND LICENSE NUMBER l

B ASED ON THE RE SULTS OF THE E X AMINATION INCLUDING tNFORMATION F URNISHED BY THE APPLICANT. THE PHYSICIAN MAS DE TERMINED TH AT THE APPLICANT'S PHYSICAL CONDITION AND GENE R AL HE ALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPER ATION AL E RRORS ENDANGERING PUSLtc HE ALTH AND SAF ETV I CERTIF Y THAT IN RE ACHING THis DETE RMIN AflON THE GUID ANCE CONT AINED IN ANSl/ANS 3 41983.OR ANSI /ANS 16 41977 iN3801 W AS FOLLOWE D AND THAT DOCUMENT ATION is AVAILABLE FOR REVIEW BY NRC.

ON THE BAST $ OF THE RECOMMENDATION OF TillfHYSICIAN I RECOMMEND THAT THE APPLICANT'S OPER ATOR LICENSE BE CONDITIONED AS FOLLOWS.

1. NO RESTRICTIONS 2 CORRECTIVE LENSES BE WORN WHEN PE AFORMING LICENSED DUTIES

3. HE ARING A1D SE WORN WHEN PERFORMING LICENSED DUTIES

4. RESTRICTED LICE NSE OR E XCEPTION Provide conaile below and etisch supportmo medicai ev.dence for NRC review 6 RE ST RICTION CHANGE F ROM PRE VIOUS SUBMITT AL Provee netsiis beme and attach supportmg medical eveence for NRC revee

' PROPOSED WORDING OF RESTRICTION tS4re 4 atesel LE LATIONSHIP OF REST RICTION TO DISOUALIF VING CONDITION I8teerir ent/ care now restracten writ correct the asseust,4mp conenten/

LEMARKS FOR RESTRICTION CHANGE tSJoce 5 aboers

8. NONMEDICAL CLRTIFICAllON iOWER RE ACTORS.

THis CE RTIFIES THAT THE APPLICANT HAS STEN FOUND TO MEET THE SAF EGUARDS* AND FITNESS FOR DUTY REOulflEMENTS OF THis F ACILITY FOR LICENSED OPE R ATORS NON POWER RE ACTORS THl$ CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARD $' REOUiRE MENTS OF THis F ACILITY FOR LICENSED OPERATORS. AND I HAVE NO KNOWLEDGE OF THE APPLICANT EXCEEDING THE CUTOF F LEVELS FOR ALCOHOL OR CONTROLLED SUBSTANCES AS ESTABLISHED PURSUANT TO 10 CFR 26 p.v e san sta rtwint un owssiom in ims pucvwen t incivoimu at t acawtN r> ua, se susatc t t o civit amu camina6 samo riuw i cta t er = usuin etNasi v ue

,anJumv vwat fut thronuatich sh THis DocuutNT amo artacMutNYs is inut aNo complct.

PAINT ED N AME AND SIGN ATURE ($ensor Menegemeng Neprymentari e on 5,rei TITLE DATE la accoroance wita 10 CF R 55.5. Communicateng. this form than be suomitted to the NRC as toilows. SY MAIL ADDRESSED 10.

Regenal Administrator. Region i Regenal Administrator, Regen la Regionai Administrator, Region til l

U E Nucioat Regulatory Comminen U S Nuclear Repatory Comminion U S Nuclear Remnatory Commiumn 475 Aliennase Road 101 Marietis Street. Suite 3100 799 Rooseveit Road Emg of Prunia e A 19406 Atlanta GA 30323 Gien Elivn, IL 60137 Regenal Administrator. Region IV Regenal Administrator, Region V U S Nucmat Repaatory Commsuen U.S Nucmar Regulatory Comminen 611 Ryan Plaza Dnve. Suite 1000 1450 Maria Lane. Suite 210

(

Arhngton, Tx Mt1 Walnut Crnk. CA 94596 w

i PRiv ACY ACT STATEMENI Pursuant to S U S.C 552aleH31. enacted imo sea by section 3 of the Pnvecy Act of ROUTINE USES: The m6ormation may be discioned to an appropriate Feoerai. State. or 1974 IPublic Lan 93 5791.the foisowmg statement it turnished to ma'viduais *no local agency in the event the informaien indicates a v oisten or potent as violaien of *an suppiv m'ormaten to the U.S Noctor Regulatory Commenen on NRC Form 396 and m the event the information moscates a viouten or potentiai veisten of ia. ersy in This mtormaten is maimained in a system of recoros oeognated as NRC 16 and the Courte et an Samenestrative or ludicial proceed nt) In addition, th.g information mae be describec et 51 Fawral Reg. ster 33157 ISeptember 18.19861 transferred to an appropr. ate Federat State, and locai egency to the estent renvent and AUTHORITY; Sectens 107 and 1610) of the Atomec Energy Act of 1954. as necenary for en NRC decision aoout you.

amenood l42 W S C. 2137 are 2201W WHETHER OtSCLOSURE IS M ANDATORY OR VOLUNTARY AND EFF ECT ON PRINCIPAL PURPOSEIS1, Informaten emered on this form is used to oevermin, INDIVIDUAL OF NOT PROVIDING INFORMATION Disciosure is voeur tary. If the recuetted intoematen it not provided howevet, the appocaten tar a facihty operator's whetner the pnvocal conditen and generai hesith of the appucant are luch that they will fiot Cadie opPrationai errott trutangefsmg pubisC health and taletV Ihit enformg or wmOr oDerator'l 16 cense mey be ceased ten may be useo Dv the NRC statt to determme if the me,viduai mots the reauire SYSTEM MAN AGERIS) AND ADDRESS Chief Operator Licenung Seanch O'fice of ments of 10 CF R 55 to taae an enammsten or to tm inued an operator ilicenw Nucteer Reactor Requieten. U S Nucwar Re9uistory Commiumn Washington. DC 20555 i

we ewu m.

I

i t

l DK1460!E 3 l

l d

SGtERY OF QWGES M HIC FollM 396 I

i f

Medical Fxamination Certification Added block "hastrictian Change Frta Prwicus Suhaittal" plus Renarts section.

1 Han-Madio21 Certificaticrt rhantad non-endiani certificaticrt statement to: Power Renatore-lhis certifies that the applicant has been found to most the mafarmitis' and fitmens for cksty requirements of this this facility for licensed operatore.

Hanpower-lhis certifies that the applicant has been found to meet the l

=*w==ds' requirements of this l

facility for liaanand operators and l

I have nu knowledge of the applicant

)

===adiar the cutoff 1svols for alcohol or aantrolled substaname as established puruunnt to 10 CFR 26.

I i

..~.,,,.-------..-,m

l

~.4 i

INCIASURE 4 Sutt%RY OF QEtM510180 FoIM 398 Item 4.d Added clarifring statmourt to indiasta this is to be checked caly if application is to amend liannes to add additional unit (s).

I Item 4.f Added "(Categorr)" to Operating.

Added "Nadiaal".

~

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

Item 12.3 i

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

Item 12.5 Changed wording to "Ertra Person On Shift In Control Room (13-week miniana)" for clarification.

Item 12.5a Added a new item " Time on 8tdtt Above 205 Power (6-week minimum)".

Item 14.a Added the words "That Is Based Upon A Systems Awev s to Tr=4aia=" for clarification.

1 Itam 15 Added "Date and Result of Host Roosnt NHC Administered Hegualification ih==4aation",

s Item 19.a Added the wording "I Aarther certifr that I have notified er current employer of: (1) all pewicus esployers (2) any instance where I have been tested by a Health and Human Services (HBB) Certified Dnag Testing h.Wii or a Licensee's testing fenility for alcohol or a controlled substance, and the test resulta M the autoff levels-l established pursuant to 10 CFR Part 26; (3) any instance where I have been arrested for.the sale, use or possession 1

of a controlled substanos desoribed in 10 CFR Part 26 and.

u (4) any reasons for removal or revocation of unesoorted man=== at a nuclear facility".

Item 19.b and Item 19.c tioved 19.b and 19.c tesother. Applicable box aust now be checked. Also added block for typed name of Training Coordinator and Senior Manas====t Representative On Site.

50R HBC USE Under waiver estesory added "Nadiaal".

OL.

r

="

'