ML20006D690

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

ML20006D690
Person / Time
Site:	FitzPatrick
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Fernandez W POWER AUTHORITY OF THE STATE OF NEW YORK (NEW YORK
References
NUDOCS 9002140254
Download: ML20006D690 (8)

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JAN 5 1990 Docket No. 50-333 Power Authority of the State of New York James A. FitzPatrick Nuclear Power Plant ATTN: Mr. William Fernandez Resident Manager P. O. Box 41 Lycoming, New York 13093 Gentlemen:

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SUBJECT:

REVISED NRC F0kiiS 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),

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Certification of Medical Examination By Facility Licensee, i

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

Changes to NRC Form-398 are detailed in Enclosure 4.

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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 Deverly Martin, U.S. Nuclear Regulatory Commission, by telephone.

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

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

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, Orf etui ts.med h r" Robert M. Gallo, Chief Operations Branch Division of Reactor Safety

Enclosures:

As stated cc w/encls:

J. Phillip Bayne, President J. Brons, Executive Vice President A. Klausmann, Senior Vice President - Appraisal and Compliance Services R. Patch, Quality Assurance Superintendent G. W11verding, Manager Nuclear Safety Evaluation

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G. Goldstein, Assistant General Counsel 0

0 9002140254 900105 PDR ADOCK 05000333 V

PDC

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y-Power Authority of.the State 66 of New York l

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[I R. Beedle, Vice President Nuclear Support l

S. Zulla, Vice President Nuclear Engineering R. Burns,,Vice President Nuclear Operation Dept. of Public Service, State of New York State of New York, Department of Law Public Document Room (PDR) l Local Public Document Room (LPDR)

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t Nuclear Safoty Information Center (NSIC)

NRC Resident Inspector State of New York-bec w/ enc 1:.

Region I Docket Room (with concurrences)

Management Assistant, DRMA-(w/o enc 1)

J. Wiggins, DRP t

D. Limroth, DRP R. Barkley, DRP D. LaBarge, NRR J. Dyer, EDO

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OFFICIAL RECORD COPY 396 & 398 FORMS - 0066.0.0 f

12/14/89 l

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INSTRUCTIONS FOR COMPLETING NRC PORM 388 PE AGONAL QUALIFICATION STATEMENT-LICENBEE L.

TO CEMAIN VALI),THis FORM MUST NOT BE ALTEZE) f 4

TYPE OF APPLICATION 2.s NEW "X" IF YOU ARE A NEW APPLICANT, COMPLETE EACH CATEGORY OF THE FORM COMPLETELY, FOLLOWING THE INSTRUCTIONS DELOW. THIS 18 TO INCLUDE ALL EDUCATION, TRAINING AND EXPERIENCE THAT YOU HAVE RECEIVED UP TO THE DATE OF THIS APPLICATJON. NOTE: SEE / TEM r4 - THERE 15 AN EXCEPTION ALSO, THIS BLOCK IS TO DE MARKED IF PREVIOUS NEW APPLICATION WAS WITHDRAWN, PLEASE WRITE "WlTHDREW" NEXT TO "N EW."

2.b thru 2.e - FOR 2.b THRU 2.e COMPLETE E ACH CATEGORY COMPLETELY, BUT INDICATE ONLY THE EDUCATION, TRAINING, AND EXPERIENCE YOU HAVE RECElVED SINCE YOUR LAST APPLICATION NOTE: SEE / TEM r4 - THERE IS AN EXCEPTION.

2.b RENEWAL

• X"lF YOU ARE RENEWING CURRENT LICENSE.

l 2.s UPGRADE

• X"lF YOU HOLD A RO LICENSE AND ARE NOW APPLYING TO UPGRADE YOUR LICENSE TO A SRO, 2.el MULTI. UNIT "X" IF YOU CURRENTLY HOLD A LICENSE AT YOUR FACILITY AND ARE APPLYlNG TO AMEND YOUR CUR.

RENT LICENSE TO ADD AN ADDITIONAL UNIT.

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

2.f WAlVER REOUESTED "X"THLAPPLICABLE WAlVER REQUESTED AND JUSTIFY IN COMMENf8 SECTION (ITEM 17L 2.s DATE PASSED GENERIC FUNDAMENTALS EXAMINATION $ECTION (GFES).

THl$ 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 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 INCLUDE INSTRUCTOR CERTIFICATION EXAMINATIONS OR REOUALIFICATION EXAMINATIONS.

11.

EDUCATION - INDICATE BOTH ACADEMIC AND VOCATIONAL / TECHNICAL POST HIGH SCHOOL EDUCATION. FOR MAJOR AREAtSt OF STUDY, INDICATE THE NUMBER OF YEARS SPENT IN EACH COLLEGE CURRICULUM AND THE HIGHEST DEGREE RECEIVED, USING THE DEGREE CODE PROVIDED. FOR VOCATIONAL / TECHNICAL EDUCATION, IFLUDE PROGRAMS SUCH AS NUCLEAR POWER SCHOOL, MILITARY TRAINING, AIR CONDITIONING / REFRIGERATION, OlESEL MECHANIC SCHOOL, ETC, INDICATE THE NUMBER OF MONTHS IN EACH PROGRAM AND WHETHER A CERTIFICATE OR DEGREE WAS AWARDED, IF ADDI.

TlONAL 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 NEE 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 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 " DO LIST" THE TIME SPENT IN RFOUALIFICATION TRAINING UNDER ITEM 12.6, REOUALIFICATION, EVEN THOUGH IT MAY INCLUDE OLAS$ ROOM OR SIMULATOR TIME, 13.

EXPERIENCE - A MINIMUM OF 6 MONTHS AT THE SITE FOR WHICH THE LICENSE IS SOUGHT IC REQUIRED FOR EACH HELD, COMPLETE 1 TEM 16. DO NOT DOUBLE COUNT TIME, IF YOU HAD OVERLAPPING DUTIES,THE MONTHS SHOULD REFLECT THE PROPORTIONATE AMOUNT OF TIME YOU WERE AS$1GNED TO THOSE PARTICULAR DUTIES. IN NO CASE SHOUL NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEED THE NUMBER OF MONTHS THAT ARE IN T TIME PERIOD.

14 FACILITY OPEP:ATOR TRAINING PROGRAM - INDICATE e. GRADUATE OF INPG ACCREDITED OPERATOR TRAIN AND b. CERTM m N5* FORM 474) OR NRC APPROVED SIMULATION FACILITY IS USED IN THE CFERATOR TRAIMNG P GRAM. IF "YES" ts CHECKED IN BOTH ITEMS 144 AND 14.b, THEN ITEMS 11 (EDUCATION),12 (TRAININW,13 (EXPERIENCE).

AND 16 (EXPERIENCE DETAILS) DO NOT HAVE TO BE DOCUMENTED. NEW APPLICATIONS MUST STILL INCLUDE THE OF SIGNIFICANT CONTROL MANIPULATIONS UNDER ITEM 113. NOTE: INPO ACCREDITED MEANS ACCREDIT ATION BY NATIONAL NUCLEAR ACCREDITING BOARO AND MEANS THAT AT LEAST YHE 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 ISSUA LICENSE 1F FIRST RENEWAL. (2) ENTER DATE AND RESULT OF MOST RECENT NRC ADMINISTERED REQUAllFICATION t

NATION.

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

TlON, 18 NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE - MUST ACCOMPANY THIS APPLICATION.

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18.

SIGNATURES - SIGN ANO DATE ITEM 19A OBTAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YO MANAGEMENT REPRESENTATIVE ON SITE.

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TETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS 398 IORIGINAL AND TWO COPIES E l

l PRIATE REGIONAL ADMihlSTRATOR,

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Regenal Admmistrator. Region 1 Regional Administrator, Regen 11 Regional Admimstrator Re7on lh U S. Nvcuar Reguinary Commmion U.S. Nuclear Regulatory Commmet U S Nuctw Reguiatory Commmen 476 Alternisse Road 101 Marietta Street. Suite 3100 799 Roosevent Raad

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i Pursuant to S UTC $52sim0L enacted mio ise by wetion 3 of the e ency Act of ROUTINE U$ts The miormaten may be d4cioned to an approoriate Feomai. State. or J

1974 (Pubhc Lee 93$79). the followmg statement is turn 4hed to moividuals who locai agency in the event the information irubcates a vioisten or poteroial veisten of lae suppey m'ormation to the U S Nuciese Requistory Commm on on NRC Form 396 and m she event the information swicates a vioistion or potentias vio#aten of law arnlin This informaison is memtaired m a system of records oesignated a NRC 16 and the couru of ari admimstrative or punicial proceedmg in artdition. th s mformation may be described at $1 Feomal Rmrster 33157 (Sapiemtwr 18.19864 transfe' red to an appropriate Federal, State and local agency to the entent resevant end AUTHORITY: Smetiores 107 a us 161M of the Atomic f ae gv Act of 1954. m necessa'y for en NRC aection soout you.

amenaed (42 U.S C. 2137 aad 270iw WHtTHER DISCLOSURE IS MANDATORY 09 VOLUNTARY AND EFFECT ON PRINCIPAL PURPO$(ISL informaten emered on tries form is uwd to determine INDIVIDUAL OF idof PROVIDING INFORMA flON. 04ctosure is voluntary, if the whnhor the physical coredition and gmeral health of the appucant are such that they mwested information is ret provided. %owever. the apphcation for a facility operator s edl not Cause operatenal errors a ndangming pubiet health a'id Wetv. This eforma. or senior oDef ator s Iccense may be Denied I

ffon Irlay tue used DV the NRC staff to determme of the md.widual meets the require SYSTEM MANAQtR($1 AND ADDRELS Cmet Operator Licensmo Branch once of monts of 50 CF R M to tame an enemmaren ne to tw issued an ope 9 tor s license Nucie.t Reac'or Reguistion. U.S Nuciese Requietory Commmion. Washm9 ton. OC 20S56 wee m w w

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oortifies that the aselicant has been j

found to newt the safeguards' and fitnama for duty reunirunanta of this this facility for licensed operatore.

Hansouer-this certifies that the aselicant has been found to aset the i

safeguards' repairements of this fantlity for 14a===ed operators and i

I have no knowledge of the aseliaant J

emoeeding the astoff Invols for alcohol or aantrolled entertances as es+=h14=w pursuant to 10 CFR 26.

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V B4 CLOSURE 4 O

SUtttARY OF CHAtCES TO HRC PCEE 398 Item 4.d Added clarifying statement to indiente this in to be checked only if applicatica is to anwed license to

- add additional unit (s).

Itan 4 f Added '".(Category)" to operating, g.

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

q

' - Item 12.5 Changed wrding to " Certified Startup ' w Completed" -

i ror clarification.

Item 12.5-Changed matting to " Extra honen On Shift Io. Ocntrol Roco (13-week minimus)" for clarification.

Item 12.5a Added a new ites " Time on Shift Atxwe 205 Power (6-week mininn)"

^

i Item 14.a I

Added the wortis "That Is Bened Upon A Systems Aw.ve:A

{

to Traiaia=" for clarification.

]

Item 15 Added "Ihte and Result of tbst Recent NBC Administered

% qualification Itxamination".

i i

Item 19.a Added the wording "I further certify that I have notified.

my current emplorer of: (1) all.pswious employers; (2) any instanna where I have been tested by a Health and ihman Services (HRB) Certified Drug Testing LalL;,.W-, or a Licensee's testing facility for alcohol or a centrolled l

substance, and the test results amnmadad the cutoff levels established pursuant to 10 CFR Part 26; (3) any instance l

where I'have been arrested for the sale, use or possession of a controlled substance described.in 10 CPR Part 26; and (4) any reemens for removal or revocatica of unesaorted annaam at a nuclear facility".

Item 19.b and Itam 19.c tioved 19.b and 19.c tesether. Applicable box must now be checked. Also a& led block for typed name of Tr=4aian Coordinator and Senior tienagement Representative On Site.

PCR HRC USE Under waiver ca % r added "MaM ani".

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