ML20006D659

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 Forms by 900201

ML20006D659
Person / Time
Site:	Maine Yankee
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Frizzle C Maine Yankee
References
NUDOCS 9002140182
Download: ML20006D659 (8)

Text

g. -

p4

' Y l'__

~'

d j

5 990 1

g,

,)AN I'.

.6 y

[

- Docket-No. 50-309 Maine Yankee Atomic Power Company

' ATTN: Mr. Charles D. Frizzle 1

President i

83 Edison Drive Augusta, Maine -04336-Gentlemen:

SUBJECT:

- REVISED-NRC FORMS 396 AND 398 t

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 L

- 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, t

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, Hail 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, originci sis"'O l

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

Enclosures:

As stated

/

9002140182 900105

_h PDR ADOCK 05000309 0V P

PDC

'\\

l 0FFICIAL RECORD COPY 396 & 398 FORMS - 0023.0.0 12/]4/89 i

i

e s

Maine Yankee Atomic Power Company 2

cc w/o enc 1:-

J. Randazza, Assistant Chairman of the Board J. H. Garrity, Vice President, Engineering and Licensing E. T. Boulette, Vice President, Operations / Plant Manager P.' L. Anderson, Project Manager J. D. Firth, Vice President, Public and Governmental Affairs G. D. Whittier, Manager, Nuclear Engineering and Licensing J. A. Ritsher, Attorney (Ropes and Gray)

P. Ahrens, Esquire, Maine Deputy Attorney General V. Vanags, Maine State Planning Office J. Kirsch, Supervisor, Operator Training (w/ enclosures)

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

Nuclear Safety Information Center (NSIC)

NRC Resident Inspector State of Maine, SLO Designee bec w/o enc 1:

Region I Docket Room (with concurrences)

Management Assistant, DRMA (w/o enc 1)

J. Johnson, DRP' E. McCabe, DRP H. Eichenholz, SRI - Yankee E. Leeds, LPM, NRR J. Dyer, E00 OL Facility File DRS:RI j

Gallo/phA' (f

01Od/90 L (1 OFFICIAL RECORD COPY 396 & 398 FORMS - 0024.0.0 12/14/89 1j m

t INSTIUCTIONS FOR ODMPLETING NEC FORM 3e8 PERSONAL CUALIFICATION STATE 7ENT-LICENSEE TO REMAIN VALID,THIS FORM MUST NOT BE ALTERED 1

4.'

TYPE CF APPLICATION 2.s NEW "X" fF 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 THl$ APPLICAT40N, NOTE: SEE / TEM F4 - THERE IS AN EXCEPTION. AL8O, THIS BLOCK IS TO BE MARKED IF PREVIOUS NEW APPLICATION WAS WITHDRAWN, PLEASE WRITE " WITHDREW" NEXT TO "NEW,"

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 LAST APPLICATION, NOTE: SEE / TEM 14 - THERE IS AN EXCEPTION, 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.d MULTl. 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" fF YOU HAVE PREVIOUSLY BEEN DENIED A LICENSE AND ARE REAPPLYING, 2 f WAIVER REOVESTED "X"THE.4PPLICABLE WAIVER REQUESTED AND JUSTIFY IN COMMENTS SECTION (ITEM 17),

[

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

THIS IS NOT APPI,1 CABLE TO RESEARCH REACTORS. ENTER THE MONTH AND YEAR THE GENERIC FUNDAMENTALG EXAMINA.

I; TION SECTION OF THE WRITTEN EXAMINATION WAS PASSED. IF THE GFESWAS NOT'AKEN, YOU MUST HAVE PASSED AN NRC l

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.

i 11.

EDUCATION - INDICATE BOTH ACADEMIC AND VOCATIONAL / TECHNICAL POST HIGH SCHOOL EDUCATION, FOR MAJOR AREAIS) OF STUDY, INDICATE THE NUMBER OF YEARS SPENT IN EACH COLLEGE CURRICULUM AND THE HIGHEST DEGREE RECElVED, USING THE DEGREE CODE PROVIDED, FOR VOCATIONAL / TECHNICAL EDUCATION, INCLUOE PROGRAMS SUCH 5

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 ADDI-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 CLARIFICATIC's, INCLUDE BOTH BEGINNING AND COMPLETION DATES AND THE 10TAL NUMBER OF WEEKS SPENT IN EACH TYPE OF TRAIN:NG. 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 UNDE EXPERIENCE (ITEM 13).

ALL REQUALIFICATION TRAINING TIME IS TO BE ACCOUNTED FOR IN THE REQUALIFICATION ITEM, PLEASE DO NOT " DOUBLE LIST" THE TIME SPENT IN REOUALIFICATION 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 REOUIRED, 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 OUTIES. IN NO CASE SHOULD T NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCED THE NUMBER OF MONTHS THAT ARE IN T TIME PERIOD, 14" FACILITY OPERATOR TRAINING PROGRAM - lNDICATE a. GRADUATE OF INPO ACCREDITED OPERATOR TRAINING P CERT 1Fim mM MAC FORM 4741 OR NRC APPCCWO C'MULATION FACILITY iS USED IN THE urEnnTOR TRAINING PR ANDb 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 NUM8ER 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.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 REOUALIFICATION 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 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 SE MANAGEMENT REPRESENTATIVE ON SITE, DETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS 398 (ORIGINAL AND TWO COPlES EACH) T PRIATE REGIONAL ADMINISTRATOR,

e

((, xcj 8thC PORM 33

. U.L seUCLEAA LEAULAT.AY COteHOSION AppygyE D gy")Me. NO.31604000 gy, ifD4DD -

EKhRES-14)C2 10 CP A GE Jt, b6.36, E4,47, ans t6 M ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THis INFORMATION COLLECTION REQUESTS 2D HR$.

FORWARD COMMENTS REGARDING BURDEN E STIM ATE

PERSONAL QUALIFICATION STATEMENT-LICENSEE TO THE INFORM ATION AND RECORD $ MANAGEMENT ORANCH (P IL301 U.S. NUCLE AR REQULATORY COMM IS-SiON. WASHINGION. DC 20666. AND TO THE PAPERWORK REDUCTION PROJECT 031600D901, OFFICE OF MANAGE.

- TO REMAIN VALID,TH18 FORM MUST NOT BE ALTERED MENT ANO BUDGET, W A8HINGTON. DC 20603.

1. APPLICANT'S FULL NAME (last, First, Middle) AND ADDRESS (includeI/P Codel

4. TYPE OF APPLICATION (Check app /icab/r bonasf I

l

e. REAPPLICATION l

L WAlvER RED,UESTED l* HOT f hostlN en Re wree)

=

2 COLD g. F IRST IMRITTEN(Ceespory)

~

2.OPEp AllNG ices M

tn RENEWAL

3. T HIRO

e. UPORADE

3. E LIGISILITY

d. MULTI-UNIT IAMEND To lNett/0( A00tTl0NAL

4. ME 0lCAL

2. CITIZENSHIP

3. BIRTH DATE UNiil 6.OTHER 6 UNITED $TATES MONTH DAY YEAR

g. DATE PASSED GENERIC PUNDA.

MM YY ME NT ALS E X AMIN ATION SECTION

%. OTHER (SonetNe l

l l

Ilf APPLICARLEJ

5. TYPE OF LICENSE APPLIED FOR

6. PF.EVIOUS LICE NSEIS) HE LD

& OPERATOR

e. DOCKET NUMBER RO SRO k LICENSE NUMBER (g y",

d. F ACILITY DOCKET NUMSER

,g 86 SENIOR OPERATOR I

I I

j 55-I I

I 50-I

'. LIMITED 1RO le g.. #uef Hamiderl l

l g

a

7. NAME AND ADDRESS (/nchide 2/P CDdel OF APPLICANT'S EMPLOYER

10. CURRENT POSITION AT FACILITY j

4.

PLANT SUPERINTENDENT

1. AUXILIARY UNIT OPER.

ATOR/ TRAINEE / TURBINE k ASSISTANT PLANT SUPERINTENDENT SUILDINO/EOUIPMENT OPER ATOR tarON ttCENS.

e. $HIFT SUPERVISOR (0 0P(RA TORJ el. STAFF ENGINEER j OTHER (Spect&l O. NJ.ME OF APPLICANT'8 F ACILITY l F ACILITY OOCKET NUMSER j

e. SHIFT TECHNICAL ADVISOR /5HIFT ENGINEER i

i f.

INSTRUCTOR lt

9. ADDITIONAL F ACILITY DOCKET 3 (Mutts <enst treases/

g SENtOR CONTROL ROOM OPERATOR l

h. CONTROL ROOM OPERATOR

11. EDUCATION A HIGH SCHOOL

e. MAJOR AREAISI OF STUDY f T."1.",

=J/.'

DEGREE CODES

d. VOCATIONAL / TECHNICAL NUyER R F HiGHfNEGREf"obesenevs

'*0*^'N'NG

8 NO GRA JATE E NGINE ERINO IFift03) 0 NONE GED EQUIVALENCY j

OTHER I. CERTIF ICATE

2. ASSOCIATE k0 3 8ACHELOR j

b NUM8 P

Q RAL c LLEGE

12. TR AININO (SINCE LAST APPLICA TION - SEE INSTRUCTIONSI

13. EXPERIENCE (DO NOTDOUBLE COUNT-SEE INSTRUCTIONS) l euo~vsamoveam

. uou rs awo v a an i

~

• * =

NAVY

• aou vo

• aou io o'""*

fe,,,,.

1 -NUCLEAR POWER PLANT FUNDAMENTALS roomA 1.RO j

2 -PLANT SYSTEMS

2. EOOW/PPWO CLASSRCOM -

3. EWS/PPWS

. ODSE RVATION

4. E RS/CRW 3-OPER ATING PRACTICE 5 OTHER (spec,41 CONTROL ROOM OPERATIONS ON SHIFT SIMULATOR OPER ATING (inchares esass,ve=1 FOSSIL SIMULATOR NAMES q) 4

6. OPE RATO R 3

34 kk 7 SUPERVISOR a.

i b.

M.se. 3 f.

k[

8 PLANT STAFF

[Nfh[y. ;.h [-

N$u c*ouY[eYeo l l YES lNO 9.OTHER tsom41 f"W

. M& imp

~vues a os as ac tmT v uawiew.a w~s tam stuutam g

gp 7< a 7.. ?j l

mas COMMERCIAL NUCLF.AR (inesud/ng RewcA' Test Rescrort 4.SRO INSTRUCTION

10. REACTOR OPERATOR (t/ceaseos S ~ sxt A esnsom on sme T IN CONTROL MOOM

11. SENIOR OPE R ATOR (tseenseds f13%EEK MIN!MUV!

a. Jg*g7,N 8,"41'j,ove aos Powaa 12 SHIFT SUPERVISOItsceassai 3

6 -R EQUALIFICATION

13. STAFF / SHIFT ENGINEER (tacensedt 7 -OTHE R (spect4#

14. AUX./ EQUIP. OPERATUR (Non/senants

15. PLANT STAF F 10 OTHER (spec #r J r

, NRC FOR?J 39811049) '

j

a:. ;

. @ ; W... s,..

- ~ ' " ~ ' '

'T,

,i. i %.::,,n :,.^ 1

-'X."

}

y,,-~

g.my -:-- c - ;- -

pi

'n:

.j

14. FACILITY OPERATCR TRAINING PROGAAM -

Ce GRADUATE OP lespO ACINtEDf7ED OPEPATOR -

Eh CERTIFIED ON N.4: FORM eye r 3#MULA fiO.U ACit/T F 5

C'"'#'Cd T ON"> p2 NRC APPROvEo s>MULATeON ygg.

NO.

7 ACILITY 18'Usto IN THE OPtstATOR TRAININQ M

19tA00fl000 PROGRAM T MAT IS BASED UPON A -

YES NO"

) SYSTSan APPROACN TO TRA#seleso PRooRAM F

16. FOR RENEWALS ONLY A--

b. DATE AND RESULT OF MOST -

DATE nus n T NOURS OPER ATED F ACILif Ya RECENT NRC ADMINitTER&D REQUALIF6 CATION EXAMINATION PASS F AIL.

16. EXPERIENCE DETAILS EL POtfT40NTITLE FROM 70

b. F ACILITY e, Dutits i

i l

17. 00MetTS fasseW Wee deem numeer le wedre ev ess

. Ateest eA#tdonet envers se necessaryJ r

l 1;

j i

!.i

.s l

l

[l s;

l:

18, NRC PORM 300, CERTIFICATION OF MEDICAL EXAMINATION SY FACILITY LICENSEE,IS ATTACHED ANY F ALSE STATEMENT OR OMISSION IN THIS DOCUMENT. INCLUDING ATTACHMENTS. MAY BE SUBJECT TO CIVIL Ants CRllelNAL SANCTIONS.

i

1 19e. I certify unter ponesty of perpary that the information in true clocument and setechmente is true ano correct. I further cert 6fy that i have notiferd my eurrent employer of; ill all prewtous eng;3yers;

'{

(2) eny instefWe soflere i hout been teased by e Heefth eruf Hurnen Servlees (HH5) Certified Drug Tenient Lenoretary or e Licereme a testeng lecihty for alcohol or e controlled euhatense, and the test resuRs emisseen the autoff se=en essenliehris pursuant to 10 CFR Port 26,(3) eny instance where I have been arrested for the asie. use or.

e of a controned substance deserthed in 10 CFR Port 26; I

and (4) any reemene for mmoust er revocatton of unserorted accese et e nucleeriencility, I also authorue the NRC tossbrna the reeutte el enanunetene to my employers tor use en preoering retraining l

penemme. es cessmery 1

SiONATURE-APPLICANT DATE

.j CHECat APPLICABLE SOX d

i b, I cert 48v that the shoes namelindMduel hee successfully ecms;leted the tecility treneses reQustements to be licensed as en Operefortsener Operator pur.uent to Title 10, code of Federal Regulations, Port 06: and taist the leaftwhhsed has a need for en Operatortsener operefor Heense to perform his/her essegned clutes end that the eenslano.well be modo evenable ter enameneten. I e6es eertify under

. penesty of perputy that tre Ins rmation in thee docueneet end etischments le true end correct, e

e RENEW AL ONLY. I certify that the abate named indenduel meets the spovowed reauellfleetion program twira esceptione nosed in from th as reau6ted by section 60.64 (H) of 10 CeR 60, and that he/she has discharged his/ tier Heensed roepnneibiHtsee tornpetently and estety. i steo certify under pensity of oorlury that the informellon in the GoCument and ettechmenti le true and correct.

TRAINING COORDINATOR SENIOR MANAGEMENT RFPRESENTATIVE ON 81TE PRINTED OR TT PED NAME PRINTED OR TYPED NAME i

f SiONATURE DATE slONATURE lDATE FOR NRC USE WAIVER (Check or Complete # ems. ar applicable) l MEET 8 REQUIREMENTS l l ODE 8 NOT MEET REOutREMENTS (issAssn eem on-t o s.

os ~,e o s.

c,,,,, y.

M Anou A su n ns nrosoN ng anov Anv e ns nacioN WRITTEN OPERATING EUGlBILITY MEDICAL slGNNIURE-REVIEWER DATE OTHER '

.3 NRC PORM 388110401 A

NRC 803 NG U &. NUCLE AA 640VLATOAY COMMIS$liN aMROvtD Ov OMG NO 4ttoo0M I "A I 8

J ' 48 4 to 486 10 Cefil4 M $6 27 tiflMAfl0 SuflotN PER filePONSE TO COesPLv wrTH eas t4 57 T Mit IN v O8t M AT ION LOLL ECT SON R 80utst: 7s Msis CERTIFICATION OF MEDICAL EXAMINATION

'gTO,,c, gay,La',G, Agiggog,.,y,g 3 RANCH (P 63ot U S NUCLEAR REQULATORT COesess5 a

ss E"

ggE BY FMCIIt-W E h

$10N. WA&MINGTON DC 2o%6. AND 70 TME P APERwCMac Rf DUCTION P810JE CT 1319o 40241 Of8ect Of MANAGE.

MtNT AND SVDGE i.

• ASHINGTON. DC 200o3 NAMt OF APPLICANT F ACILITY l F ACILITY DOCKET nut 08ER l

l-A. MEDICAL EXAMIN ATION CERTIFICATION THIS IS TO CERTlF Y THAT THE ABOVE NAMED APPLICANT FOR AN OPERATOR' SENIOR OPERATOR LtCENSE HAS BE EN E KAMINED BY A PHYSICIAN.

$ RINTED N AME tof onysecMas l STATE AND LsCENSE NUMBER l EXAMINATION DATE l

B ASED ON THE RESULTS OF THE EXAMIN ATION. INCLUDING INFORMATION FURNISHED BY THE APPLICANT. THE PHYSICI AN HAS DETERMINED THAT THE l.

APPLICANT'S PHYSICAL CONDITION AND GENERAL HEALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPE R ATION AL E RRORS END ANGERING PUBLIC HEALTH l,

AND SAF ETY. I CE RTIFY THAT IN RE ACHING THIS DETE RMINATION. THE GUIDANCE CONT AINED IN ANSilANS 3 4-1983. OR ANSI /ANS 15.41977 (N3801 W AS I

FOLLOWED AND THAT DOCUMENTATION 15 AVAILABLE FOR REVIEW BY NRC l

ON THE BA$lS OF THE RECOMMENDATION OF ttQHYSICIAN. I RECOMMEND THAT THE APPLICANT'S OPER ATOR LICENSE BE CONDITIONED AS FOLLOWS:

i l

1. NO RESTRlCTIONS

2. CORRECTIVE LENSES SE WORN WHEN PERFORMING LICENSED DUTIES 1

3, HE ARING AlD BE WORN WHEN PERFORMING LICENSED DUTIES l.

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

5. RESTRICTION CHANGE FROM PRE VIOUS SUBMITTAL Provide details below and attach supportmg medeca6 evmence for NRC review.

PROPOSED WORDING OF RESTRICTION (Stock 4 ecowl l

l l

K E LATIONSHIP OF R ESTRICTION TO DISOUALIF YING CONDITION (Snetty mdcare how resrncron welicorrect the assoue=#vmy competen) l

.l REMARKS FOR RESTRICTION CHANGE (Stock 5 atewJ l

l l

I I

l l

B. NONMEDICAL CERTIFICATION POWE R RE ACTORS:

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

j' NON POWER RE ACTORS.

THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS' REQUIREMENTS OF THis F ACILITY l

l FOR LICENSED OPERATORS. AND 1 HAVE NO KNOWLEDGE OF THE APPLICANT EXCEEDING THE CUTOFF LEVELS FOR ALCOHOL OR CONTROLLED SUBSTANCES AS ESTABLISHED PURSUANT TO 10 CFR 26.

ANY v AL$4 $T ATEMENT OH OMIS5 TON ih THIS DOCUMfNT INCLUDING Af f ACMMENt3 MAv et 5U8 JECT TO CiveL AND CRIMINAL SANCliONS. e UkR te*

• UNutH etNALiv OF PERJUHy THAY THE INv0RMAflON IN TMl100CUMENT AND ATT ACMM(NTS IS TRUE AND CORRECT.

PRINTED NAME AND SIGN ATURE (Semor Menevement Representerne on StreJ TITLE DATE in accoroance with 10 CF R 55.5. Commumcatens, this form snesi De suomitted to the NRC as follows: BY MAIL ADDRESSED TO:

Regional Admimstrator Region i Regenal Admimstrator. Regen 11 Regional Admmistrator, Region ill U.S. Nuclear Regulatory Commessaan U.S. Nuclear Regnatory Commmeon U.S. Nuclear Regulatory Commissen l

475 Allendate Road 101 Marietta Street. Suite 3100 799 Roosevent Road Kmq of Prussia. P A 19406 Atlanta. G A 30323 Glen Ellyn. IL 60137 Regenal Admmntrator. Repon IV Regenas Admimstrator. Region V U.S. Nucisar Regulatory Commission U S Nuclear Regulatory Commmen 611 Ryan Piama Onve. Suite 1000 1450 Maria Lane. Suite 210 Artmeton. TX 76011 Wamut Creet CA 94596 PRIVACY ACT STATEMEN T Pursuant to 5 U.S.C. 552atel(3), enacted mto law by section 3 of the Privacy Act of ROUTINE USES The eformation may be disclosed to an appropriate Federas. State, or 1974 (Pubhc La* 93579), the followmg statement is uraished to moividuais who local agency m the event the information indicates a violation or outeritial velaten of law r

supply mformaten to the U.S Nuclear Regulatory Comemssen on NRC Form 396. and m the event tne mformaten moicates a violaten or ornential veiaten of law and m This mformaten is mamta ned m a system of records designated as NRC 16 and the coune of an admimstrative or judicial proceedmg in additen. th.s mformanon may be desurited at 61 Federal Regis'ei 33157 (Septemcer 18,1986L tran ferred to an appropriate Federad. State, and local agency to the extent reievant and AUTHOftlTY: Sections 107 and 161(d of the Acomic Energy Act of 1954. as necessary for an NRC decision anout you.

amended t42 ViC 2137 and 220 lid).

WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON l

PRINCIPAL PURPOSE (S) Informaten entered on thn form is uwd to determme INDIVIDUAL OF NOT PROVfDING INFORMATION Disciosure is voluntary. If the whether the physical conditen and generas hesith of the apoticant are such triat they requested mtormation is not provided. however. the application for a facility operator's will not cause operatenet errors endangermg public hesith and safety This mforma-or senior operator s license may be denied teon may be usel Dy the NRC staff to determane if the mdividual meets the require SYSTEM MANAGERIS) AND ADDRESS. Chief. Operator Licensmg Branch Otttee of i

ments of 10 CF A 55 to taae en esammaten or to be issued an operator's licenw Nucrear Peactor Reguaaten. U.S. Nuclear Regulatory Comminon. Wasnington. DC 20555.

1 i

Nac e&v m ' m stm

/

- ~ _ _

ENCID50RE 3

- 1 l

S(It1ARY OF CRMGES 'IU NRC POEIM 396 Medical Examination Certification Added block " Restriction Change Fmn Prwious Sutanittal" plus Remarks section.

Hen-Medical Certification Ganged non W iami certificatian -

statement to: 1%uer Beectors-This certifies that the applicant has been found-to most the safeguards' and fitness for chrty requiruments of this.

this facility for licensed operators, Nonpower-this certifies that the j

applicant has been found to meet the safesuards' requirements of this 1

facility for lih operators and I have no knowledge of the applicant w iar the outoff levels for alochol or ocatrolled substances as es+=h14= hart pursuant to 10 CFR 26.

i u

l

l;*.

c, L

L EHCLOSURE 4 SUtttARY OF CHAH31!5 'to NBC POGM 398 Item 4.d t

Added clarifying sta+m==t to indicate this is to be checked only if application in to -m wi license to add additienal unit (s).

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

Added "NarHr al".

Item 4.g Added a new item "Date Passed Generic Fundamentals Examination Secticn".

L Item 12.3 Changed wortiing to " Certified Startup n.

Ccapleted" for clarificatien.

Item 12.5 Changed wortiing to " Extra Person On Shift In Control Room (13 Smak minima)" for clarifiention.

Item 12.5a Added a new item " Time On Shift Above 20E Power (6-week minim a)".

Item 14.a Added the wortis "ht Is Based Upon A Systems Approach t

to Trainia=" for clarification.

Itec 15 Added "Dete and Beault of Most Roosnt NBC Administered Bequalificatica Examination".

Item 19.a Added the wortling "I flarther certify that I have notified my current employer of: (1) all prwious esployers (2) any instance where I have been tested hf a Health and Human Services (HHS) Certified Drug Testing hei,ri or a Licensee's testing facility for alochol or a centrolled substance, and the test results am 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 substance described in 10 CFR Part 26; and (4) any reemens for removal or revocation of unescorted annaaa at a nuclear facility".

Item 19.b and Item 19.c Moved 19.b and 19.c together. Applicable box aust now be checked. Also added block for typed name of Training Coortiinator and Senior Management Representative On Site.

POR NBC USE Under waiver category added "MarHen1".

1 1

.g m.

..,,