ML20006D692

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

ML20006D692
Person / Time
Site:	Nine Mile Point
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Burkhardt L NIAGARA MOHAWK POWER CORP.
References
NUDOCS 9002140257
Download: ML20006D692 (8)

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' Docket Nos. 50-220

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50-410-

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Niagara Mohawk Power Corporation O

ATTN:: Mr.. Lawrence Burkhardt,.III Executive Vice President

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Nuclear Operations

'301'Plainfield Road 1

Syracuse, New York' 13212.

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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.

't All applications' for licenses are t; be submitted on these revised forms no ciaterithan February:1,<1990.

.i

-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 oy writing: to her, U.S; Nu lear Regulatory Commission, Information and Records Management Branch, Mail Stop-NMBB 7714, Washington, D.C.

20555.

m 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.

l Sincerely, Criginol Signed By:

i x

Robert M. Gallo, Chief T

Operations Branch Division of Reactor Safety

Enclosures:

As stated

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V 0FFICIAL RECORD COPY 396 & 398 FORMS - 0003.0.0 12/14/89 1

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Niagara Mohawk Power Corporation 2

t cc w/o encl:

C. V. Mangan, Senior Vice President W. Hansen, Manager, Corporate Quality Assurance R. Smith-Unit 2 Superintendent, Operations C. Beckham, Manager, Nuclear Quality Assurance Operations R. Abbott, Unit 2 Station Superintendent J. Perry, Vice President, Quality Assurance K. Dahlberg, Unit 1 Station Superintendent R. Randall, Unit 1 Superintendent, Operations Jr Willis, General Station Superintendent C. Terry, Vice President Nuclear Engineering and Licensing J. Warden, New York Consumer Protection Branch T. Conner, Jr., Esquire G. Wilson, Senior Attorney J. Keib, Esquire A. Rivers, Training Superintendent (w/ enclosures)

R. Seifried, Assistant Training Superintendent (w/ enclosures) 4 Director, Power Division, Department of Public Service, State of New York State of New York, Department of Law Public Document Room (PDR)

Local-Public Document Room (LPDR)

Nuclear Safety'Information Center (NSIC)

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

Region I Docket Room (with concurrences)

Management Assistant, DRMA (w/o encl)

J. Wiggins, DRP D. Limroth, DRP R. Barkley, DRP M. Slosson, NRR J. Dyer, EDO OL Facility File yci ' p (f

'DRS:RI f,B 90 Gallo/pb 01/02/90 Q

0FFICIAL RECORD COPY 396 & 398 FORMS - 0004.0.0 12/14/89

INSTIUCTIONS FIR 00MPLETING NRC FORM 300 PEISONAL QUALIFICATION STATEZENT-LICENSEE i'

TO REMAIN VALID,THIS FORM MUST NOT BE ALTERED

' 4.

TYPE f F APPLICATION 2.s NEW' "X" lF 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 APPLICAT4ON, NOTE: SEE / TEM 74 - YHERE IS AN EXCEPTION. ALSO, THIS BLOCK IS TO BE MARKED IF PREVIOUS NEW APPLICATION WAS WITHDRAWN. PLEASE WRITE " WITHDREW" NEXT.

TO "NEW."

. 2.b tlw 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 16 AN EXCElilON.

2.b RENEWAL "X"(F YOU ARE RENEWING CURRENT LICENSE.

2.c UPGRADE "X"IF YOU HOLD A RO LICENSE AND ARE NOW APPLYING TO UPGRADE YOUR LICENSE TO A SRO, 2.af MULTl. UNIT

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

s RENT LICENSE TO ADD AN ADDITIONAL UNIT, 2.e REAPPLICATION "X"lF YOU HAVE PREVIOUSLY BEEN DENIED A LICENSE AND ARE REAPPLYING, 2.f WAIVER REQUESTED "X"THLAPPLICABLE 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 GFESWAS NOTTAKEN, 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 INSTFIUCTOR CERTIFICATION EXAMINATIONS OR REQUALIFICATION 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 RECEIVED, USING THE DEGREE CODE PROVIDFD. 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-TIONAL SPACE IS 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 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 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 REQUALIFICATION ITEM, PLEASE DO NOT " DOUBLE LIST" THE TIME SPENT IN REQUALIFICATION 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 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 NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEED THE NUMBER OF MONTHS THAT ARE IN THAT TIME PERIOD,

' 14 FACILITY OPERATOR TRAINING PROGRAM - INDICATE a. GRADUATE OF INPO ACCREDITED OPERATOR TRAINING PROGRAM ANDtt CERTIFIED fON NRC FOAM 474) OR NRC APPROVED SIMULATION FACILITY 13 USED IN THE OPERATOR TRAINING PRO.

GRAM. IF "YES" IS CHECKED IN BOTH ITEMS 14.s 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 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 OF LICENSE IF FIRST RENEWAL. (2) ENTER DATE AND RESULT OF MOST RECENT NRC ADMINISTERED REQUAllFICATION 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 APPLI.

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

TlON.

18.

NRC FORM 396, CERTIFICATION OF MEDICAL EXAMIN ATION 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 SUBMIT THE COMPLETED NRC FORMS 398 IORIGINAL AND TWO COPIES EACH) TO THE APPRO.

PRIATE REGIONAL ADMWISTRATOR,

, _ _ _. ~ _ -.

ISC PORM 3M UA NUCLEAA 6.E AUL& TORY C004s10SIOle APPROVED BY OMO: NO 3160 C 00 DATE RECElvf D

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"KNIEs: i.siaa (T* *' *""**"' *r **CJ u.si u.3a..

LA7 ESTIMATED SURDEN PER RES'ONSE TO COMPLY WITH THl$ INFORMATION COLLECTION REQUESTS 3D HMS FORW ARD COMMENTS REGARDING 90RDEN ESTIMATE PERSONAL QUAllFICATION STATEMENT-LICENSEE TO 7"E iNFORMATION ANO RECORDS MANAGEMEtif ORANCH (P.630). U.S. NUCLEAR REOULATORY COMMIS.

SiON. WASHINOTON. DC 20166. AND TO THE PAPERWORK REDUCTION PROJECT (316040eol, OFFICE OF MANAOE.

TO REMAIN VALID,THIS FORM MUST NOT BE ALTERED MENT AND DVDOET,W A$HINGTON, DC 20603.

1. APPLICANT'S FULL NAME (Last, first, Mdt/W ANO ADDRESS (include 2/P CDur)

4. TYPE OF APPLICATION (Check app /kabte bones) l

e. RE APPLICATION l

f. W Alvf R REQUE5TED

1. HOT f ksttN en Reeersp)

1. F IRg7 l WRITTENfcesspery/

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e. NEW 3.SECOND

b. RENEWAL

3. T HIRD 7"'Y#

e. UPORADE

3. EllC:BILITY d, MULTI. UNIT (AMENO TO tNC&E/OE ADO /FtONAL

4. MEDICAL i

2. CITIZENSHIP

- 3. BIRTH DATE UNIT) i 6.OTHER

e. UNITED $TATES MONT H OAY YEAR g DATE PASSED OENERIC PUNDA.

MM YY MENT ALS EX AMINATION SECTION

b. OTHER(SeneINl l

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Ilf A*9LICABL tl 6.YYPE OF LICENSE APPLIED FOR

6. PREVIOUS LICENSEls) HE LD e, OPERATOR

e. DOCKET NUMsER RO SRO b. LICENSE NUMBER

d. F ACILITY DOCKET NUMSER y

th SENIOR OPERATOR l

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'a. LIMITED 5Ro te e. fuet Namiterl 50

7. NAME AND ADDRESS (/nclude 2/P Codel OF APPLICANT'S EMPLOYER

10. CURRE NT POSITION AT F ACILITY

e. PLANT $UPERINTENDENT L AuxlLIARY UNIT OPER.

ATOR/ TRAINEE /TURglNE

b. AS$lST ANT PLANT SUPERINTENDENT BUILDINOtEOUIPMENT OPER ATOR INON t/CENS.

e. $HIFT SUPERVISOM E0 0PERA TOR)

d. STAFPthGlNEER l OTHER (Spec /&l lF AC.Lif v DOCKET NUMBER

e. $HIFT TECHNICAL ADVISOR / SHIFT ENGINEER O. NAME OF APPLICANT'5 F ACILITY

f. INSTRUCTOR

9. ADDITIONAL F ACILITY DOCKET 5 (Muitownstlicensest

s. SENIOR CONTROL ROOM OPERATOR

h. CONTROL ROOM OPERATOR

11. EDUCATION

& HIGH4CHOOL

s. MAJOR AREAISI OF STUDY f",",*f,*,

ga*,'

DEOREE CODES

d. VOCATION AL/ TECHNICAL N%ER g g

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2. AS$OCIATE

3. BACHELOR h NUM9kN OF 4. M AST E R y

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

13. E XPERIE NCE (DO NO T DOUBLE COUNT - SEE INSTRUCTIONS) e vc u n. a~n v e a a

. MONT H ANO v 5 A R o nowma

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• ma NAVY

• aou to (CAsss.

1-NUCLEAR POWER PLANT FUNOAMENTALS rowns I RO 2 -PLANT SYSTEMS 2. EOOW/PPWO CLASSROOM

3. EWS/PPWS OBSERVATION

- 4. E RS/CRW 3-OPERATINO PRACTICE 5 OTHER (spect&J CONTROL WOOM OPERATIONS ON SHIFT l

SIMULATOR OPER ATING (lacentes Chasroom>

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10. REACTOR OPERATOR (tecenantJ 5 - f,",$r^g7Nf ff,,5"'" '" G

11. SENIOR OPE RATOR (treenanti M

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12. SHIFT SUPERVISOR (trenantJ 6 -REQUALIFICATION

13. STAFF / SHIFT ENGINEER (Leensects 7 -OTHE R Isaee/41 14 AUX./ EQUIP. OPE R ATOR INoalkenser/J

15. PLANT STAFF

16. OTHER tspect&/

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- 14. FACILITY OPERATER TRAINING PROG 2AM -

,3 h CERTIFIED ON NRC FOR A 47e d"S/Mutaff0.J FACit/TF

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sM L son 1 YES NO/

j RAM Ts YES NO. -

Q,(If7jd,fQfg"T E SY$YSG05 A8FROACM TO TRAlsilNG R7 Tg 1 i

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16. FOR RENEWALS ONLY l e c,

k DATE AND RESULT OF MOST.

DATE

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18 NRC FORM 308, CERTIFICAT10N OF MEDICAL. EXAMINATION SY FACILITY LICENSEE,18 ATTACHED ANY F ALSE STATEMENT OR OMISSION IN THIS OOCUMENT,(NCLUDING ATTACHMENTS. MAY BE SuluECT TO CivlL AND CRIMINAL SANCTIONS.

tee. 4 aortity umser monelly of smiury that er:e informetton in this docunem and stechnwnts is true end correct. i further certify that I how notifed my current employer of.11) sH preWous engloyers;.

', {3i eny inelanco schere i lleve lleen tesled lW e Health erid Human Gmv6ces (MH81 Certified Drug f ating Letsoretary or a Licenese a testin0 facWty for alcohol or a controlled esentense.and flee test resume eusseded the metott leven osiehnehad pursuant to 10 CFR Pert 26;(38 eny Instante where I hegg been erfgeted for the sete, use or posenaten of a controhed mahetence dearthed in 10 C7R Port 26; end (48 eny reemene cor rumouse or revoceston of unescorted eccese et a nucseeriticar6ty, i eino suihorin the NRC to euhmn the results of enminstens to my empecyers for um in properang retretning e

presume. m neesmery

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8tONATURE-APPLICANT -

DATE CHECK APPLICABLE BOX i

d k i serttey then the above n.a.m.dusi has,idust ha su.ccessfully compsetas.the feettny hcensen reuuirememe to be heensed as en opera. tori.senio.r. opera ed ladiv to T een es; mid ihm ihe ind need ter n oometeris.nor o mmor ueena to omsorm h siher me ned dui.m end thei ih as co.

w made e.eush en neten. i iso eenity unde.

3 penotty of pertury that the information in this document eral ettechments is true end correct.

i 1

e, RENEWAL ONLY ~ l certify that the above named indinduel maste the approved requellfacetion program (with esceptione moredin from f/J at required by esetion 50.64 ti 8) of 10 CFR 60, and inet he/she has discharged h6s/her licensed responsitHHEtes tempetently and sefely. I eleo certify under penetty of pequry that the infonftstiDft let this doCurnent and ettschments :

-l

- is true end correct.

TRAINING COORDINATOR SENIOR MANAGEMENT REPRESENTATIVE ON SITE PRINTED OR TYPED NAME PRINTED OR TYPED NAME w

8tGNATURE.

DATE s4GNATURE DATE j

FOR NRC USE WAIVER (Check or Qwnolere items as aAplice6/e) l MEETS REQUIREMENTS l l DOES NOT MEET REQUIREMENTS (Esedern ees OnANTEDeV Dented ev

CATE10RY, Ha annua nis ms nroeos um aoova nT s ms e t oios WRITTEN OPERATING -

i E..L.IGIBI LITY SIONATURE-RkVIEVWER DATE MEDICAL 1 OTHER-NRC FORM 308114898 s

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U S. NUCLEE 60 auLaf oa v COMasiS88+N mRoveD ev oms No sito.co2a N,,RC,s,oR3 Jeg

-1.imt 00 10 CF a t4 23, S$ 2h

$$tl MATE D SVTOf N 982 8 8EPONst TO COesPLv artTN.-

eas e6 67 T Mig IN # 0R M A T ION LOLL ECTiON RaGuttT: 29 MRS CERTIFICATION OF MEDICAL EXAMINATION g % c,,c,Tay,La*a,*ao g o;, g', g A,

3,R ANCM oC im.ARANo to TM OR,Y,,co.nses.s

, oN. w A le Hor. U S NUCLE RIOULAT BY FAClUTY LICENSEE nINoToN A R OR Repuctioh oRoJeet isitow?as ossics or isANAos.

MENT AasO SUDG41.n ASHINGioN DC 20003 1

l 1

NAME OF APPLICANT F ACILIT Y l F ACILITY DOCKET NUMsER A. ME0lCAL EXAMINATION CERTIFICATION i

THIS IS TO CE RTIFY THAT THE ABOVE NAMED APPLICANT FOR AN OPERATOR! SENIOR OPE R ATOR LICENSE HAS BEEN EXAMINED HY A PHYSICIAN.

j PRINTED NAME tof anyssesen; lST ATE AND LICENSE NUMBER l EKAMINATION DATE

~

BASED ON THE RESULTS OF THE EXAMIN ATION. INCLUDING INFORMATION FURNISHED BY THE APPLICANT. THE PHYSICIAN HAS DETERMINED THAT THE LPPLICANT'$ PHYSICAL Q)NDITION AND GENE R AL HE ALTH ARE NOT SUCH THAT f f WlGHT CAUSE OPER ATION AL E RRORS ENDANGERING Pb8LIC HE ALTH AND SAFETY. l CERTIFY THAT IN RE ACHING THIS DETERMINATION THE GUIDANCE 03NT AINED IN ANSl/ANS 3.41983.OR ANSI /ANS th e 1977 (N300l WM FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW SY NRC.

ON THE BASIS OF THE RECOMMENDATION OF '.NHYSICIAN. I RECOMMEND THAT THE APPLICANT'S OPER ATOR LICENSE BE CONDITIONED AS

' I FOLLOWS.

1. NO RESTRICTIONS

2. CORRECTIVE LENSES BE WORN WHIN Pl!RFORMING LICENSED DUTIES

~

3. HEARING AlD BE WORN WHEN PERFORMING LICENSED DUTIES l

4. RESTRfCTED LICENSE OR E XCEPTION. Provide details below arid attach supporting medical evidence for NRC review.

5 RESTRtCTION CHANGE F ROM PRE vlOUS SUBMITTAL-Prow.de rioteds below and attach supportmg motheat evidence for NRC review.

PROPOSED WORDING OF RESTRICTION I8/ock dauovel LE LATIONSHIP OF RESTRICTION TO DISOUALIFYING CONDITION IBrie tr onducate how restracten woIIcorrect tho dosoueisfyme cenarten) r REMARKS FOR RESTRICTION CHANGE (8/ock 5 aboveJ

8. NONMEDICAL CEftilFICATiON IOWE R RE ACTORS.

THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAF EGUARDS' AND FITNESS FOR DUIY REQUIREMENTS OF THIS F ACILITY FOR LICENSED OPER ATORS Not+ POWER RE ACTORS.

THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS' REQUIREMENTS OF THIS F ACILITY FOR LICENSED OPERATOR $. AND 1 HAVE NO KNOWLEDGE OF THE APPLICANT EXCEEDING THE CUTOFF LEVELS FOR ALCOHOL OR CONTROLLf D $UBSTANCES AS ESTABLISHED PUR$UANT TO 10 CFR 26 l

s.NY P AL5E St A f tMtNT OM OMiSS10N IN TMI5 DOCUMENT. INCLUDING AT T ACMMtNTS MAv SE SUBJtCT TO Civik AND CR.MiNAL aANClauN3. I ttM lie r UNatM PtNAbi r Oe itRJURy THAT THf INe0RMAf TON IN THIS DOCUMENT AND ATT ACHMENT513 TRut AND CORRICT.

7 RINTED N AME AND SIGNATURE (San or 4denegement Neoresentarne on SereJ TITLE DATE in accordance witn 10 CF R 55.5, Communications. inis form inaal be submitted to the NRC as follows: 8 Y Mall, ADDRESSED TO:

Regional Admmastrator. Region i Regional Admmntrator. Regen il Regional Admmistrator Region ill U.S. Nuclear Regulatory Commissen U.S. Nucker Regulatory Commmion U.S Nuclear Requiatory Commission i

415 Allendaie Road 101 Marietta Street. Suite 3100 799 Roosevent Hoad Kmg of Prussia. P A 19406 Atlanta GA 30323 Geen Ellyn. IL 60137 Regional Administrator. Region IV Regional Administrator, Region V l

U.S. Nucmar Regulatory Cornmissen U S. Nuclear Regulatory Commission 611 Ryan Plaza Orive. Suite 1000 1450 Maria Lane. Suite 210 l

Arhngton. TX 76011 Wa6 nut Creest. CA 94596 PRlV ACY ACT ST ATEMENT l

Pursuant to 6 UAC 55240eH31. enacted mio law by wetion 3 of the Pnvacy Act of ROUTINE USES. The mtormation may uv discloud to an appropriate Feoeras. State, or 1974 (Public La* 9}579L the followmg statement n 'urnisned to mdividuals who locas agency m tne event the mformation mdicates a vinsation or potenteel violaten of law supply mformaten to the U S Nuclear Regulatory Commusen on NRC Form 396.

ar.d m the event the mformation md. cates a corat on or potential violaten of law and m i

This mtorenation n mamtamed m a system of records designated as NRC 16 and the course of an admmistf ative or audicial proceedmg in addition tn.s mtormation may be described at 61 Federal Register 331$1 (September 18 1986l transferred to an dooropriate Federal. State. and local agency to the extent televant and AUTHORITY: Sections 107 and 16tM of the Atomic Energy Act of 1954, as necessary for an NRC cecnion aoout you.

amenued l42 U.S.C. 2137 4nd 2201N).

WHETHER DISCLOSURE IS MANDATORY OR VOLUNT ARY AND EFFECT ON PRINCIPAL PURPOSEISL Informaten entered on ihn form is used to determme INDIVIDUAL OF NOT PROVIDING INFORMATION Disciosure a voluntary. If the I

whether the anysical conditen and generas hea#th of the acolocant are such inat they requested mtormation is not provided. however. ihe aposication for a facility operator's l'

will not cause acerstnnai ermes endangenng pueric neaith and safety. Thn mtorma or seaior operator's nicense may be denied ten may be used by ine NRC statt to determme if the mdividual meets the require-SYSTEM MANAGERISI AND ADDRESS Cnief Operator L<ensmq Branch. O fece of ments of 10 CF R $5 to taae an esaminaten or to be nsued an operaeor s ucense Nuclear Reactor Regulalion. U S. Nuclear Regulatory Commmion. Wasningtori. DC 20555 NReso=Mymor>at

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IDICIdiURE 3 SMtARY OF OWGES TO NRC P0tti 396

_ Medical N-4natien Certification Added block " Restriction Change Frta Prwious Sutaittal" plus Remarks meetion.

Han-Medical Certification Changed non-==iinal certification statement to: Pbuer Beactors-This certifies that the applicant has been found to meet the safeguards

• and fitname for duty requirements of this this facility for licensed operators..

i Nonpower-this certifies that the applicant has been found to meet the safeguards' requirements of this facility for li h operators and I have no knowledge of the applicant-w 4an the autoff levels for alochol.

or ocatrolled saabstances as established pursuant to 10 CFR 26.

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EHCIIIBURE 4

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l SUttiARY OF CHAtMS TO HIC 50EM 398 Item 4.d

-- Added clarifying statement to indicate this is to be checked only if applicatican is to amend license to add additional unit (s).

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

Added.. "tindinal".

Item 4.s Added a now. ites "Date Passed Generic Fundamentals i-Examination Section",

t Item 12.3 mansed wording to " Certified Startup.".w.

Ccepleted" l

for clarification.

Item 12.5 Changed wording to " Extra Person & Shift In Control Boom (13-week minimum)" for clarification.

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

l Item 14.a

- Added the words "That Is Besed Upon A Systems Approach to Tr=4aia " for clarification.

i Item 15 Added "Date and Beault of Host Roosnt NRC Administered Requalification lhe==4 nation",

r Item 19.a Added the wordi's "I Aarther certify that I have notified my current employer of: (1) all pawious employers; (3) any instance where I have been tested by a Health and Human Services (HHG) Certified Dng festing It.-.6,.i or a Licensee's testing facility for alcohol or a controlled substance, and the test results==a== dad the cutoff levels established pursuant to 10 CFR Patt26; (3) any instance where I have been arrested for the sale, use or possession of a controlled substence described in 10 CFR Part 26; and

~,

.(4) any reasons for removal or zwvocation of unescorted i

i access at a nuclear facility".

- Item 19.b and E'

Iten 19.c Moved 19.b and 19.c tesother. Applicable box saast now be checked. Also added block for typed name of Tr=4ains Coordinator and Senior Honessment Representative & Site.

14 HRC USE Under waiver catesoey added "tindinal".

o

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