ML20006D658

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

ML20006D658
Person / Time
Site:	Indian Point
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Russell J POWER AUTHORITY OF THE STATE OF NEW YORK (NEW YORK
References
NUDOCS 9002140180
Download: ML20006D658 (8)

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- JAN ; 5-1990 w

Docket!No. 50-286 f

> Power Authority of'the State of New York Indian Point 3 Nuclear Power Plant ATTN:.Mr. Joseph Russell Resident Manager W

P

0. Box 215' Buchanan, New York ~-10511

. Gentlemen:

SUBJECT:

REVISED NRC FORMS 396 AND 398 s

' Enclosed.is a copy of the' revised NRC Form-398 (Enclosure 1), Personal j

~

Qualifications Statement - Licensee and revised NRC Form-396 (Enclosure 2),

l Certification off Medical Examination-By Facility Licensee.

i 1

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

Form-398 are detailed in Enclosure 4.

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

.I

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

by contacting:Beverly Martin, U.L. Nuclear Regulatory Commission, by telephone-f

.(301) 492-8138 or--by writing to her, U.S. Nuclear Regulatory Commission, e

Information and Records Management Branch, Mail Stop NMBB 7714, Washington,.

.D.C.

20555, 1

l

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

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

Sincerely, 1

1 Originni signed BYt i

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

Enclosures:

-As stated

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0FFICIAL RECORD COPY 396 & 398 FORMS - 0021.0.0 12/14/89

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Power.Authdrity of the State 2

of New York cc w/o encl.

J. Phillip Bayne, President-J. Brons, Executive Vice President - Nuclear Generation J

G. Goldstein, Assistant General Counsel A. Klausmann, Senior Vice President, Appraisal and Compliance Services F. Pindar,' Quality Assurance Superintendent

'G. Wilverding, Chairman, Safety Review Committee J. Del Percio, Manager, Regulatory Affairs R. Beedle, Vice President Nuclear Support W. Jostger, Vice President Nuclear Operations and Maintenance S. Zulla, Vice President Nuclear Engineering P. Kokolakis, Director Nuclear Licensing - PWR S. Bredges, Operator Training Supervisor (w/ enclosures)

Dept. of Public Service, State of New York State of New York, Department of Law t

Public Document Room (PDR) local Public Document-Room (LPDR)

Nuclear Safety Information Center (NSIC)

NRC Resident Inspector State of New York bec w/o encl:

Region I Docket Room (with concurrences) l Management Assistant, DRMA (w/o encl)

J. Wiggins,DRP D. Limroth, DRP i

R. Barkley, DRP J. Neighbors, NRR

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J. Dyer,.EDO l

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01/02/ I Y

l 0FFICIAL RECORD COPY 396 & 398 FORMS - 0022.0.0 i

12/14/89 A

INSTZUCTIONS FOR ODMPLETING NIC FORM 300 PERSONAL CUALIFICATION STATEMENT-LICENSEE TO REMAIN VALID,THIS FORM MUST NOT BE ALTERED

' 4e 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 RECElVED UP TO THE DATE OF THIS APPLICATJON. NOTE: SEE / TEM N - THERE IS AN EXCEPTION, ALSO, THl3 BLOCK IS TO BE MARKED lF PREVIOUS NEW APPLICATION WAS WITHDRAWN, PLEASE WRITE " WITHDREW" NEXT TO "N EW,"

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 LAET APPLICATION, NOTE: SEE / TEM N - THERE IS AN 4

EXCEPTION.

I 1

2.b RENEWAL "X"IF YOU ARE RENEWING CURRENT LICENSE, 2 c UPGRADE "X"(F YOU HOLD A RO LICENSE AND ARE NOW APPLYING TO UPGRADE YOUR LICENSE TO A SRO, 2.el MULTI. UNIT "X" IF YOU CURRENTLY HOLO A LICENSE AT YOUR F ACILITY AND ARE APPLYING TO AMEND YOUR CUR.

RENT LICENSE TO ADD AN ADDITIONAL UNIT, 2.e REAPPLICATION "X"lF YOU HAVE PREVIOUSLY BEEN DENIED A LICENSE AND ARE REAPPLYlNG.

1 2.f WAIVER REQUESTED "X"THLAPPLICABLE WAIVER REQUESTED AND JUSTlFY IN COkMENTS SECTION (ITEM 17),

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

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

I 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 j

EXAMINATIONS.

11, EDUCATION - INDICATE 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 l

RECEIVED, USING THE DEGREE CODE PROVIDED, FOR VOCATIONAL / TECHNICAL EDUCATION, INCLUDE PROGRAMS SUCH' f

I AS NUCLEAR POWER SCHOOL, MILITARY TRAINING, AIR CONDITIONING / REFRIGERATION, DIESEL MECHANIC SCHOOL, ETC.

l.

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

i j.

TlONAL SPACE ls 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 CATcGORY 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 TYPE OF TRAINING. THE NUMBER OF WEEKS IS PROVIDFD, IN ADDITION TO BEGINNING AND COMPLETION DATES, TO ACCOUNT FOR INTERMITTENT TR AINING (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 DOUSLE COUNTED UNDER EXPERIENCE (ITEM 13),

ALL REQUALIFIC

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

. CLASSROOM OR SIMULATUR TIME, 1-13.

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 YOU HAD OVERLAPPING DUTIES,THE MONTHS SHOULD REFLECT THE PROPORTIONATE AMOUNT OF TIME YOU WERE ASSIGNED TO THOSE PARTICULAR DUTIES. IN NO CASE SHOULD THE I

NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEED THE NUMBER OF MONTHS THAT ARE IN THAT TIME PERIOD.

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

AND in CERTIFIED (ON NAC FOAM 474) OR NRC APPROVED S!MULATION FACILITY IS USED IN THE OPERATOR TRAINING PRO.

GRAM. IF "YES" IS CHECKED IN BOTH ITEMS 14a AND 14b, 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 ACCREDITATION BY THE NATIONAL NUCLEAR ACCREDITING BOARD AND MEANS THAT AT LEAST THE MINIMUM REQUIREMENTS OF REGULATORY

. GUIDE 1.0, REV,2, ARE MET,

>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.

N ATION, 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 lF NECESSARY, ATTACH ADDITIONAL INFORMATION.

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

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 19.a. OBTAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YOUR SENIOR MANAGEMENT REPRESENTATIVE ON SITE.

DETACH THESE INSTRUCTIONS AND SU6MIT THE COMPLETED NRC FORMS 398 (ORIGINAL AND TWO COPIES EACH) TO THE APPRO.

PRIATE REGIONAL ADMINISTRATOR,

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DATE RECEIVED

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IstC PORM 3G u.5, tuCLEM lea ULATORY COmasseS404 g,pp=gygg gY ORIS: NO. 31%D4000 I#NII" N#

C J.31. 66.36, 86.47, emi tt.67 ESTIMATED DURDEN PER RESPONSE TO COMPLY WITH TH18 INFORMAT 60N COLLECTION REQUE$ft24 HR$.

BURDEN ESTIM ATE PERSONAL QUALIFICATION STATEMENT-LICENSEE FORW ARD C,OMMENTS hEGARDING RECORDS MANAotuEN.S.

T TO THE iN ORMATiON AND COMM

.I BRANCH (P 630L U.S. NUCLE AR REGULATORY SiON, WASHINGTON. DC 20b66, AND TO THE PAPERvv0RK i

REDUCTION PROJECT (316000901. OFFICE OF MANAGE.

TO REMAIN VALID.THIS FORM MUST 1407 BE AL TERED MENT AND sUDGET, W ASHINGTON. DC 20503.

1. APPLICANT'S FULL NAME (last, first, Middle) AND ADDRES1(melude //P(bdP/

4. TYPE OF APPLICATION (Check app /rableboJras/

1. MOT l

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d. MULTI. UNIT (A4ff ND TOINCLUDE ADOfflONAL

4. MEDICAL

2. CIT 12ENSHIP

3. BIRTH DATE UNITJ 5 OTHER 6 UNITED 87ATES MONTH' DAY YEAR g DATE PASSED GENERIC PUNDA.

MM YY MENT ALS E M AMIN ATION SECTION l

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tif AP9LICABLES

6. TYPE OF LICENSE APPLIED FOR

6. PREVIOUS LICENSEISI HELD 6 OPERATOR

a. DOCKET NUMEER RO $RO k LICENSE NUMisER j hy

d. F ACILITY DOCKET NUMBER y

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h. SENIOR OPERATOR I

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10. CURRENT POSITION AT FACILITY

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i. OTHER (SpecINJ lF ACILITY DOCKET NUMBER S. NAME OF APPLICANT'S F ACILITY e $HIFT TECHNICAL AOvlSOR/$HIFT ENGINEER

f. INSTRUCTOR l'

' S. ADDITIONAL F ACILITY DOCKET 8 (Estrnunst trenses' 6 SENIOR CONTROL ROOM OPERATOR to CONTROL ROOM OPER ATOR l

11. EDUCATION N

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& H40H SCHOOL

s. MAJOR AREA (Si OF STUDY f.",,'?f,

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DEGREE CODES

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12. TR AININO (SINCE LAST APPLICATION - SEE INSTRUCTIONS)

13. E MPERIE NCE (OO NOT DOUBLE COUNT-SEE INSTRUCTIONS)

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3. EWS/PPWS OBSERVATION

4. E RS/CRW 3 OPERATINO PRACTICE 6.OTHER tssecsNJ CONTROL ROC,M OPERATIONS ON SHIFT E!MULATOR OPE R ATING (snesuore Csusroom!

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COMMERCIAL NUCLE AR tinctumna RomientTest Reactort 4 -SRO INSTRUCTION

10. REACTOR OPERATOR (tkensent) 6 -yg*gNN,$8"'" * '

11. SENIOP OPE R ATOR (tsensed; N

a. $ 'rfy C L'jf"

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12. SHIFT SUPE RWSOR (tkenseal 6 -R EQUALIFICATION

13. STAFF / SHIFT ENGINEER ttkens os

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14. AUX /EJUIP, OPERATOR (Noniscenseas

15. PLANT STAF F 16 OTHER (spect41 NRC FORM 398 (10am s 47.

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14. FACILITY OPERATCR TRAINING PROGR AM q

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4 91aAcuATE OP. lefftD ACCREDITED OPE *ATOR TetAsessese PROGRAes THAT t)DASED UPOed A YES-NO Cf27tF/CA Ffor'J OR NRC K,PPHOYED $148ULS. TION ygg-NO e ACittTv $ USED IN THE OPERATOR TRAININO SVWVSAN APPMOACM TO TRAleesteG.

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16. FOR RENEWALS ONLY -

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b. DATE AND RESULT OF MOST D" "

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HOURS OPERATED F' ACILITV' yfu LtF PAIS I AIb '

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16. EXPERIENCE DET AILS

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18. N, C FORM 308. CERTIFICATION OF MEDIC.t.L EXAMIN ATION SY F ACILITY LICENSEE,88 ATTACHED ANY F ALSE ST ATEMENT OR OMISSION IN THIS DOCUMENT, INCLUDING ATTACHMENTS. MAY BE SUILJECT TO CIVIL AND CRIMINAL SANCTIONS.

r Tee. I eartity ususer penstiv of portury that the informatton in th6edocument and etischenente le t*ue enis correct. I further certsty that I have noitfiett suiy current empsover of. 4il aH prestove erneseyers; Cll any ineaanse where I have timen teases by e Hesten end Humes services (HHS) Certified Drug Testing Lahorstory or e Licecese's testing facihty for secohol or e controlead eutustense, and the test resume sessused the outert sewege estebushed pursuant to 10 C7R Port 26. (3) any onesence where I have been errested for the seio. use or poteseema of a contreated eatissance dessetted in 10 CFR Port 26; aret t4l eny reasons for remomet er townesten of unescorted eccess at e nucieertesciitty, e eleo authorue the NRC to sutumn the results of emenwnstens to fny ornployert ter use en preparing retraenang pengreme,sa m 840 NATURE-APPLacANT.

DATE

.r CHECE APPLICA9LE SOX

b. $ certify that the abowe named individual het successfully completed the leclisty leceneses requirements to he deconeed as en Operator /$ensor Operator pursuant to Tale 10. Code of Federal Regulatens, Port BS efel fleet the indh4thael has e need $se en Operator / Senior Operefor latenes to perform hes/her eenieted outsee and that the W be speede ouessebee for seemesistoon. I e#co certify unuser genehy of pegury that the inforenetion in this document and ettechments le true and corrett.

t REleEWAL ONLY = l certify that the aeovo named indsviduel meets the approved requesificaten proerem letrA esesprione nosest a trem f /J as requ6ted by seetton 60.54 lo H of 10 CF't 60. and that he/she has descharged Ne/her licensed responestninies corppetently and sefely, I esso certify under penetty of portury that the information in thas docuenent end attachmente

' la true ered correct.

TRAINik80 COORDINATOR SENIOR MANAGEMENT REPRESENTATIVE ON SITE -

PRINTED OR TYPED NAME.

PRINTED OR TYPED NAME 84GNATURE, DATE siONATURE lDATE FOR NRC USE WAlVER (Check or CornWefe trems as apsalicab/r/

l MEf 78 REQUIREMENTS l l DOE 8 NOT MEET REQUIREMENTS (EspAem DeJewf s

. CATEGORY

""* D "a f GION D" U "

Hi ADQU AMit RL Mr ADOV A n f E n$

afG60N WRITTEN =

l OPE RATING ELIGISILITY MEDICAL sameATURE-REVIEWER DATE OTHER-NetC FORJ 300 0049)

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I ag'tE SEE SAANCH 19 43ol. US NUCLEAR REQULATORY COteM4 a

. BY FACIt, asw sioN, wa5HeNGTON OC 2o656. AND TO THE P APEResoRet

'i REDUC a.4 PROJE CT (3tto4so24L 08 8 tC E OF MAseAGE.

MENT AJ SUDGET.W ASHtNGTDN. DC 200o3.

NAME OF APPLICANT l F ACILITY DOCKET NUMBER F ACILIT Y A. MEDICAL EXAMINATION CERTIFICATION THl$ l$ TO CERTIFY THAT THE ABOVE NAMED APPLICANT FOR AN OPE RATOR! SENIOR OPERATOR LICENSE HAS BEEN EXAMINED BY A PHYSICIAN.

PRINT ED NAME to'pa s,c, ant l$T ATE AND LICENSE NUMBER EXAMIN ATION D ATE r

BASED ON THE RESULTS OF THE EXAMINATION. INCLUQiNG INFORMATION F URNISHEO BY THE APPLICANT. THE PHYSICIAN HAS DETERMINkD THAT THE APPLtCANT'S PHYSICAL CONDITION AND CENER AL HE ALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPER ATION AL ERRORS END ANGERING PUSLIC HE ALTH AND SAF ETY, I CE RTIF Y THAT IN RE ACHING THIS DETERMINATION. THE GUID ANCE CONTAINED IN ANSI /ANS 3.41983. OR ANSI /ANS 16 4-1977 IN3801 WAS

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FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY NRC.

ON THE BASIS OF THE RECOMMENDATION OF T11.2HYSICIAN, i RECOMMEND THAT THE APPLICANT'S OPERATOR LICENSE BE CONDITIONED AS FOLLOWS.

1. NO RESTRICTIONS -

l-

2. CORRECTIVE LENSES BE WORN WHEN PERFORMINO LICENSED DUTIES

3. HEARING AfD BE WORN WHEN PE RFORMING LICENSED DUTIES

4. RESTRICTED LICENSE OR E XCEPTION. Provide details below and attsch supporting medical evidence for NRC review.

6 RESTRICTION CHANGE FROM PRE VIOUS SUBMITTAL Prov ne dmails benow and attaen supporting medical evntence for NRC review.

FRCPOSED WORDING OF RESTRICTION (8/ock 4 doovel r E LATIONSHIP OF RESTRICTION TO DISQUALIF YING COND4 TION (#rref& mct,cere how restracTen weit cortset the stesqual,4ene sonairens REMARKS FOR REST RICTION CHANGE (8/ock 5 inoovvi

8. NONMEDICAL CER T!FICATlON 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 LICENSEC OPER ATORS NON POWE R RE ACTORS.

THIS CERTIFIES THAT THE APPLICANT HAS BEEN WOUND TO MEET THE SAFEGUARDS' REQUIREMENTS OF THIS F ACILITY FOR LICENSED OPERATORS. AND I HAVE NO KNOWLEDGE OF THE APPLICANT EXCEEDING THE CUTOFF LEVELS FOR ALCOHOL OR CONTROLLED SUBSTANCES AS ESTABLISHED.'URSUANT TO 10 CF R 26.

c.NV F ALSE ST A TEMENT QH OMISSION th TwiS DOCUMtNT. aNCLUDINu AT T ACMMtNTS MAY St buSJECt TO civil AND CHIMINAL aANCTiCNS. I CtHIiP Y UNutH FtNAL (

• UP PERJURY THAT THE IN80RMATlON IN THIS OOCUMENT AND ATT ACHMENTS IS TRut AND CORRf CT.

PRINTED NAME AND SIGN ATURE (Sener Management Hepresenterne on Serei TITLE DATE in accoroance witn 10 CF R 55.5, Communications. ttus form snail be suomitted to the NRC as follows. BY MAIL ADDRESSED TO; Regional Administrator, Region i Regional Admmistrator, Region 11 Regiondi Administrator. Region til U.S. Nuclear Regulatory Commisuon U.S. Nuclear Regulatory Commissen U.S. Nuclear Requiatory Commission 476 Allemsaie Road 101 Marietta Street. Smte 3100 799 Roosevett Road Cng of Pnasua. PA 19406 Atlanta. G A 30323 G.en Ellyn. IL 60137 Ragonal Adminntrator, Region IV Regenas Admmistrator. Region V i'

U S. Auctear Regulatory Commisuon U S. Nuclear Regulatory Commissen 611 Ryan Plata Dnve. Suite 1000 1450 Maria Lane. Suite 210 Actington. T X 76011 Walnut Creen. CA 94596 PRIV ACY ACT STAIEMENI Pursuant to 6 UAC. 5524(eH3L enacted mto law by section 3 of the Pnvacy Act of ROUTINE USES: The mformation may be disciosas to an aporopriate Federat. Stre, or 1974 IPublic Law 93579L the tollowmg statement is 'urnisned to moivmuais wno locat agency m the event tne mformation imsicates a viosaien or potentia # violation of law supply mfor.=stion to tne U.S Nuclear Regulatory Commission on NRC Form 396.

and in tne event tne mformation mdicates a vioietion or potentiae viosation of law and m This m'ormat on is naintamed in a system of terords deugnated as NRC 16 and the course of an admmistrative or judicial proceedmg in addition. tn.s mformation may be Geschbed at 518werai Register 33157 ISeptember 18,1986L transferrett to an appropriate Federas. State. and local agency to the extent relevant and AUTHORITY: htions 107 and 16t(s) of the Atomic Energy Act of 1954. as necessary for an NRC decision about you, amended (47 U S C. 2137 and 220ltiH WHETHER OISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON PRINCIPAL PURPOSEtSL Informaton entered on this form is used to determme INDIVIDUAL OF NOT PROVIDING INFORMATION Disclosure is voluntary. If the wnether the pnysical conditen ano generai healtn of the apoticant are such that they requested information is rot provided, however, tne aopiicaten for a facility operator's will not cause coerational errors endangenng polic heaith and safety. This mforma or senio'"8'ator's license may be denieo tion may be used by the NRC staff to osten.une if the mdividual meets the require-SYSTEM VMAGEHISI AND ADDRESS Chief. Operator Licenung Brance OHice of enents of 10 CF R 55 to taae an enammaton or to be issued an operator's license.

Nuctear Reactor Regulation. U.S. Nuclear Fiegu.atory Commission, wainington, DC 20555 NRc comM w.mam

a IIlMCIASUIM 3 SatM OF QWGilS 10150 POEM 396 Mad 4r*1 Examination Certification Added block "Itastriction Change Free.

Prwious Subnittal" plus Banarts sectical.

Non-Medical Certificaticri Changed non-=adia=1 certification statement to: Power Haectors-This certifies that the applicant has been found to meet the safeguards' and I

fitness for chrty requirements of this i

this facility for licensed operators.

L Honpouer-this certifies that the applicant has been found to meet the mafarmds' requirements of this facility for linanaed operators and-I have no knowledge of the applicant i

Winqr the autoff levels for alanhal or CCEttrolled Subst a cts as eg+mh14shed pursuant to 10 CFR 26.

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SutttARY OF CIWGIS M HIC PCIIM 396 i.

l-L Itee 4.d Added clartfring stata==nt to hwHamte this is to be E

checked caly if application is to amend license to add additional unit (s).

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

1:

Added "MaMn=1".

i.;

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

t.

Item 12.3 Changed wording to " Certified Startup 7.

Completed" for clarificatica.

Item 12.5 I

Changed wording to " Extra Person h Shift In Centrol Boom (13-week minista)" for clarification.

Item 12.5a Added a new item " Time on Shift Above 205 Peuer (6-week minima)".

Item 14.a Added the words "That Is Bened Upon A Systems Approach to TrainAms" for clarification.

~~

l Item 15 Added "Date and Result of Host Recent HilC Administered i

P-=1Hioatica Enemination".

Item 19.a Added the wording "I flarther certify that I have notified ur current employer of: (1) all pawvious employers; (2) any instance where I have been tested by a Health and Human Services (HHB) Certified Drug Testing Wi.6,i> or a Licensee *s testing facility for al*1 or a centrolled substance, aad the test resulte awa=adad 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

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

Item 19 b and Item 19.c I.

Moved 19.b and 19.c tesother. Applicable box must now be checked. Also added block for typed name of Training Coordinator and Senior Management Representative & Site.

PGt NRC USE Under waiver catescer added "HmMnal".

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