ML20006D705

Forwards Revised NRC Forms 396 & 398,personal Qualifications Statement & Certification of Medical Exam by Licensee, Respectively

ML20006D705
Person / Time
Site:	Salem, Hope Creek, 05000000
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Miltenberger S Public Service Enterprise Group
References
NUDOCS 9002140272
Download: ML20006D705 (8)

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,lAN.5 1990 g

i' Docket Nos. 50-272 50-311 50-354

.Public Service Electric and Gas Company ATTN: Mr. Steven E. M11tenberger Vice President and Chief Nuclear Officer P. O. Box'236 Hancocks Bridge, New Jersey 08038 v

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.

All applications for.lictnses 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 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.

I 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.

-r Sincerely,

'Origiani Signed B7I Robert M. Gallo, Chief Operations Branch L

Division of Reactor Safety i.

/

Enclosures:

As stated 0

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'V 0FFICIAL RLORD COPY 396 & 398 FORMS - 0025.0.0 12/14/89 l

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~I Public' Service Electric and

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. Gas Company cc w/o encl:

Jack Urban, General Manager, Fuels Department, Delmarva Power & Light Co.

L. K. Miller, General Manager - Salem Operations B. A. Preston, Manager, Licensing and Regulation M. J. Wetterhahn, Esquire General Manager - Nuclear Safety Review R. Fryling, Jr., Esquire Scott B. Ungerer, Manager, Joint Generation Projects Department, 1

Atlantic Electric Company i

Licensing Project-Manager, NRR D. Wersan, Assistant Consumer Advocate,-Office of Consumer Advocate R. F. Engel, Deputy Attorney General, Dept. of Law and Public Safety

- S. LaBruna. Vice President, Nuclear J. Hagen, General Manager, Hope Creek J. Lipot, State of New Jersey i

Lower Alloways Creek Township

- Resident Inspector, Hope Creek J. Lloyd, Training Manager, Salem (w/ enclosures)

W. Gott, Training Manager, Hope Creek (w/ enclosures)

Public. Document Room (PDR).

Local-Public Document Room (LPDR)-

Nuclear Safety Information Center (NSIC)

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

Region I Docket Room (with concurrences)-

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

DRP Section Chief J._ Dyer, ED0 OL Facility File 4

DRS:RI Ga1Q/pb.)

01 2790 q6 I

0FFICIAL RECORD COPY 396 & 398 FORMS - 0026.0.0 12/14/89 A

INSTZUCTIONS FOR COMPLETING N C GRM 388 i~

PE190NAL CUAllFICATION STATEMENT-LICENBEE TO REMAIN VALID,THIS FORM MUST NOT BE ALTERED

'4 4

TYP.E CF APPLICATION 2.e 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 i

RECEIVED UP TO THE DATE OF THIS APPLICATJON NOTE: SEE / TEM 14 - THERE IS AN EXCEPTION. ALSO, THIS BLOCK IS TO BE MARKED lF 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 RECElVED SINCE YOUR LAST APPLICATION NOTE: SEE / TEM 74 - THERE IS AN EXCEPTION, 2.b REN5WAL

• X" 4F YOU ARE RENEWING CURRENT LICENSE.

2.e UPGRADE

• X"IF YOU HOLD A RO LICENSE AND ARE NOW APPLYING TO UPGRADE YOUR LICENSE TO A SRO, i

2.al MULTI. UNIT "X" lF YOU CURRENTLY HOLD A LICENSE AT YOUR FACILITY AND ARE APPLYlNG 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, 1

2.f WAIVER REQUCD " "X"THLAPPLICABLE WAIVER REOUESTED AND JUSTIFY IN COMMENTS SECTION (ITEM 17),

2.s DATE PASSED GENERIC FUNDAMENTALS EXAMINATION SECTION (GFES).

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 -

LfCENSING 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,

- 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

' RECElVED, 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 ADDI.

TlON AL (, PACE 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 POSITIO HELD, COMPLETE ITEM 16. DO NOT DOUBLE COUNT TIMEi 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, FACILITY OPERATOR TRAINING PROGRAM - INDICATE s. GRADUATE OF INPO ACCREDITED OPERATOR TRAINING PROGRAM 14

" "' t Z"'T"'1ED (ON NRC FORM 4741 OR NRC APPROVED SIMULATION rwu n y ed Usnu m a t1C Urt:HAlOH THAlNING PRO.

GR AM. 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 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.

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 SENIO MANAGEMENT REPRESENTATIVE ON SITE.

DETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS 398 (ORIGINAL AND TWO COPIES EACH) TO THE APP PRIATE RFilONAL ADMINISTRATOR.

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U.S. fouCLE AA a.E SULATORY COhhelGSION APPROVE D SY (sess: 840.31604000 DATE RECEWED EKflAES: 13102 II' 8' 88"W8 8F EC#

66.30 66A.

L.47. edit 6.67 ESTIMATED SURDEN PER RESPONSE TO COMPLY WITH THft IN FORM ATION COLLECTION REQUESTI 2 A HRS.

FORWARD COMMEldTS REGARDING BURDEN E STIM AT E

- PERSONAL QUALIFICATION STATEMENT-LICENSEE TO THE wORMAfiON AND RECORDS MANAoEMENT

$ RANCH IP.630). U.S. eduCLE AR REGULATORY COMMib SiON, W ASHINGTON, DC 20b66. AND TO THE PAPERWORK REDUC 160N PNOJECT 83160 40001, OFFICE OF MANAGE-TO REMAIN VAllD,THl3 FORM MUST NOT BE ALTERED ME NT AND BUDGET.W ASHINGTON. DC 20603.

1. APPLICANT'8 FULL NAME (Last, first, Mddie) AND ADDRESS (include 2/P Code)

4. TYPE OF APPLICATION (Check applicable bonas) l

e. RE APPLICATION l

8.

• AWER REcutsTED

1. HOT t kost4 on Roewel 2.COLO

1. F IRST l#vRITTENICaespory)

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3. E LloleILITY

0. MULTI UNfT (AMLNO TO INCtt!Of ADDITIONAC 4. MEDtCAL

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3. BIRTH DATE LINITl 6.OTHER l.

6 UNITED $T ATES MONTH DAY YEAR

g. DATE PASSED GENERIC FUNDA-MM YY lJ g

MENT AL5 E K AMINATION SECTION

b. Of HtR f3aert&B j

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It! APPLICADt El

6. TYPE OF LICENSE APPLIED FOR

6. PREVIOUS LICENSE (5) HE LD

$ OPERATOR

s. DOCKET NUMBER RO $RO it LICENSE NUMBER

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d. F ACILITY DCCKET NUMSER

t. SENIOR OPERATOR l

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7. NAME AND ADDRESS (/nctuae ItP Codel OF APPLICANT'S EMPLOYER

10. CURRENT POSITION AT F ACILITY

e. PLANT 8UPERINTENDENT L AUxlLIARY UNii OPER.

ATOR/ TRAINEE /TUR$1NE A ASSISTANT PLANT SUPERINTENDENT DUILDING/ EQUIPMENT OPER ATOR INON CICENS.

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d. 8TAFF ENotNEER

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8. NAME OF APPLICANT'S F ACILITY F ACILITY DOCKET NUMBER

e. SHIFT TECHNICAL ADVISOR / SHIFT ENGINEER

f. INSTRUCTOR

9. ADDITIONAL F ACILITY DOCK Ei$ IMulti-tensi tatemest

g. SENIOR CONTROL ROOM OPERATOR

h. CONTROL ROOM OPERATOR

11. EDUCATION A Hi1H SCHOOL

s. MAJOR ARE AIS) OF STUDY

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12. T R AINING (SINCE LAS T APPLICA TION - SEE IntS TRUCTIONSI

13. E XPE RIENCE (DO NO T DOUBLE COUNT-SEE INSTRUCTIONS) j,

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snow to e an a NAVY

• aou to 1 -NUCLEAR POWER PLANT FUNDAMENTALS roomA 1.RO 2 -PLANT SYSTEMS

2. EOOW/PPWO CLASSROOM

3. EWS/PPWS OBSE RVATION 4 - E RS/CRW

3. OPE R ATING PR ACTICE 5 OTHER (spec,&A CONTROL ROOM OPERATIONS ON SHIFT SIMULATOR OPER ATING tinesudes Cussroom>

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4 -SRO INSTRUCTION

10. REACTOR OPERATOR Itkenards a x?ma Pe asON ON emf T IN CONT ROL MOOM 6 tawrux urNrMuui j j. SENIOR OPERATOR (tkenssd1

a. $'rEr"4//Mogpve aos POwan 12 SHIFT SUPERVISOR (tkenseds 8

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13. STAFF / SHIFT ENGINEER ttscensede 7 -OTHE R ISpect&J 14. AUXJEQUIP. OPE R ATO R INon/kenseds

15. PLANT STAFF 16 OTHER (spers&A feRC FORM 30s 110401

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14. FACILITY OPERATtR TRAININ2 PROGRAM 1000eIO PRO 9 RAM THAT IS BAS 4D UPON A '

YES.

NO-es CERTIFIED Oen kRC FORA 414 t'SonuLA TIO4!ACILIT V TE Or fNaO ACCRETITSD OPE?ATO81 p, SYSTeam APPROACH TO TRAEfetNO -

CEnsisCA rsOW"J O3 NRC t.PPROYED SIZUtAf TON YES NO 8 ActLITY LS USED IN THE OPERATOR TRABNING pnoongy P

15. FOR RENEWALS ONLY

6. DATE AND RESULT OF MO8T DATt ht6 a t

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'i 13 NRC FORM 308, CERTIFICATION OF MEDICAL EXAMINATION SY FACILITY LICENSEE,18 ATTACHED -

ANY FAL8E STATEMENT OR OMISSION IN THl3 DOCUMENT, INCLUDING ATTACHMENTS MAY BE SU8 JECT TO CIVIL AND CRIMINAL SANCTLONS.

Ite. I certifs amter penstiv os pertury thei tee information in shie document end etternmenis le true end correct. I further seritty that I hows notified my survent employer of: (1) oli previous enphyers;

. - (2) any instenes where I hows tesen tute by e Health and Human Serv 6ees (HMS) Certified Drue Testing Laborotory or a Licenese's testine tecHity for escohol or e controssed eutaiense, and the test

- resume essessed the eutatt tense setenhened pursuant to 10 CFR Port 26;(3) any instance where I hows been ervesias for the esse, use et posessmen of a controhed outneance descreed in 10 CFR Port 26; -

end des any reasons eor roment oe revocetton of unescorted scene et e nueseeriesciuiv, i eien suihorue the NRC to submn the reeuite Os eneminettone to my empeovers for use in propertne retrainme pomerame, se nosamery

't stG8e TURE-APPLtCANT.

lDA1E I'

CHECK APPLICABLE DOX i'

- ~ ' -

b. I certify that the above 1 Amed leidewkhael hee successtully compleimi the teclisty liteneses requirements to he hcensed as en Operatorisensor Operator pursuant to Tale 10. Code of F ederal Reguletene. ~

Port es:and test the indhndues has a need sur en Operator /sener Operator heense to pectorm hesiner easipise dutwe end that the seems min ne snese suomenn for enemmeima. 4 eeso scritty under poneRy of parlery that the intermetion in than document and entschments to true end correct.

l0~ ] e, 5:5NEWAL ONLY = l certify then the abom noned indswedual meste the sporoved ressuellticaten proerem (with esceptene nonNI 49 frem $U es roouirers bV esCtion SJ.54111) of 1 that he/she hee esecharged hes/ner liconeed responsabantes competentiv and enterv. I esso certsty under penesty of persury that its informatson in this oocument and etteenments l ~l le true end cofrect.

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TRAINING COORDINATOR SENIOR MANAGEMENT REPRESENTATIVE ON SITE PRINTED OR TYPED N AME PHIN f EO OM TYPED NAME siONATURE.

DATE SiONATURE lDATE 7

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FOR NRC USE WAIVE R (Check or complete stems, as applicable) l MEET 8 REQUIREMENTS l l DOES NOT MEET REQUIREMENTS Idepseta bedowf 0

on Auteo e v newito n y HEADQUAnfens P EMON HE ADQventTE ns n E O SON WRITTEN '

j7 OPER ATING '

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E LIGlBILITY' -

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SiONATUH&.REviEVtER DATE

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- NRC FORM 300 t1049) i

one aos U s. NUCLE AA LE0VLATOaY COMMISSION amok t D e

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.N # 0m u A f ION LOL LtcTiON nsoves? - 75 Hms CERTIFICATION OF MEDICAL EXAMINATION

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BY gaClE=

UCENSgg SiON. WASHiNOTON. DC 20666. AND TO THE eAPamesomit t 84 m E DUCTION e810JE CT 13ttoc07al 08elCE OF WAN404 utNY AND SUDGET.n ASHINGTON OC 20003 NAMk OF APPUGANT F ACILIT y l F ACILITY DOCKET NUMOER A. MEDICAL E XAMIN ATION CERTIFICATION THIS IS TO CE RTIF Y THAT THE ABOVE NAMED AFPLICAPiT FOR AN OPERATOR' SENIOR OPERATOR LICENSE MAS BEEN E XAMINED BY A PHYSICIAN E X AMIN ATION D ATE TRIN T ED N AME tor na iscsant l STATE ANO LICENSE NUMBER r

BASED ON THE RESULTS OF THE EXAMINATION INCLUDING INFORMATION F URNISHED 8v THE APPLICANT. THE PHYSICIAN HAS DETERMINED THAT THE APPLICANT'S PHYSICAL G)NDITION AND GENER AL HE ALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPE R ATION AL 4 RRORS END ANGERING PUBLIC HE ALTH AND SAF ETY I CE NTIF Y THAT IN RE ACHtNG THl$ DETE RMINATION. THE GUIDANCE G)NT AINED IN ANSl/ANS 3 41983. OR ANSl/ANS 15 41977 (N380l W AS FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY NRC.

ON THE BASIS OF THE RECOMMENDATION OF THLfHYSICIAN I RECOMMENO THAT THE APPLICANT'S OPERATOR LICENSE BE CONDITIONED AS FOLLOWS.

t. NO RESTRICTIONS

2. CORRECTIVE LENSES TE WORN WHEN PERFORMING LICENSED DUTIES 1 HEARING AfD BE WORN WHEN PERFORulNG LICENSED DUTIES

4. RESTRICTED LICENSE OR liXCEPTION Provide details betow and attach supportmg reisdical evidence for NRC reven 5 RESTRICTION CHANGE FROM PRFVIOUS SUBMITT AL-. Provide tietails besow and attach supportmg mooical evidence for NRC review PROPOSED WORDING OF RESTRICTION (Stock 4 aoovel KE LATIONSHIP OF REST RICTION TO DISQUALIFYtNG CONDITION (Srwrty muheare how restreren we# conoci che oesquahfringendir onJ REMARKS FOR RESTRICTION CHANGE (8tock 5 acorel B. NONMEDICAL CERTIFICATION POWE R RE ACTORS.

THIS CERTIFIES THAT THE APPLICANT HAS SEEN FOUND TO MEET THE SA8EGUARDS' AND FITNESS FOR DUTY REQUIREMENTS OF THIS F ACILITY FOR LICENSED OPERATORS.

J NON-POWER REACTORS.

THl$ CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS' REQUIREMENTS OF THIS F ACILITY FOR LICENSED OPERATORS AND 1 HAVE NO KNOWLEDGE OF THE APPLICANT EXCEEDING THE CUTOFF LEVELS FOR ALCOHOL OR CONTROLLED SUBSTANCES AS ESTA8USHED PURSUANT TO 10 CFR 26.

ANv

• ALss sv A raueN r on uMiS5 EON iN r ms DOCUMtN r. iNCLVOING A r r ACHMENT5 MAY et SU. JECT TO CIVik ANO CRIMINAL 6ANC11UNS. I CtH rik e UNus;H rkNALI T OF stRJURY THAT THE IN80RWATION iN THi5 DOCUMENT AND AYT ACHMENTS 13 TRuf AND CORatCT.

PRINTED NAME AND SIGNATURE (Semor Management Repreumratae on S,re) TITLE DATE in accoroence witn 10 CF R 56.5. Communications. enes form snail be svormited to tne NRC as follows: 0Y (AAlL ADDRE SSED T0:

Regiones Administrator. Region i Regional Admimstrator. Region il Regionas Aamin,strator. Region til U.S. Nuclear Regulatory Commisuon U.S Nuclear Retsdatory Commission U S. Nuclear Requietory Commessen 475 Allenda'e Road 101 Marietta Street. Suite 3100 799 Reoieweit Reaa Kmg of Prugua. PA 19406 Atlanta GA 30323 Gien Etivn. IL 60137 l'

Regional Admemstrator. Region IV Regional Acmemstrator. Region V V S. Nuclear Requiatory Cormmssen U.S. Nuclear Regulatory Commission 611 Ryan Plaaa Drive. Suite 1000 1450 Maria Lane. Suite 219 Arhngton TX 76011 Wamut Greest CA 94596 PRIV ACY ACT ST ATEMENI Pursuant to 6 UAC. 552alelt3L enacted inm law by section 3 of the Privacy Act of ROUTINE USES. The mformation may be disclosed to an aooropriate Federet. State, or 1974 IPubhc Law 91579L the sollowmg statement is turmshed to mdividuais who local agency in the event the mformation mdicates a viosaten or potential violation of law suppsy informaten to the U S Nuclear Requestory Commission on NRC Form 396 and m the event the mformaten moscates a violation or ooientias viciation of law and m This it formaten is mamtained m a system of records designated as NRC 16 and the course of an adrmnistrative or iudicial proceeding in addrtion. tens information may be oeicribed at $1 Felerai Register 33157 (Septemtwr 18.1986L Iransferred to an appropriate Federai. State. and local agency to tne extent relevant eno AUTHORITY: Sectens 107 and 161(d of the Atomic Energy Act of 1954. as necesaarv for an NRC decivon soout you l

amenced (42 0.5 C. 2137 and 220)( H.

WHETHER DISCLOSURE IS MANDATORY OR VOLUNT ARY AND EFFECT ON PRINCIPAL PURPOSEISI: Information entered on this form is used to dete*mme INDIVIDUAL OF NOT PROVIDING INFORMATION D<sciosure is voiuntary. If tne wnetner the pn ocal conditen and generat health of the aposicant are such triat they requested mformetson is not providers however. the appocaten for a facility operator's I

v will not cause ocurrational errors endangermg punne Seaith and safety This mi3rma. or senior operator s hcense may be uenied i

tion may be used by the NRC staff to determme 10 the mdividual meets the require-SYSTEM MANAGERIS) AND ADDRESS Chief. Operator Licensmq Brancn. Office of ments of 10 CF R 55 to tase an eeammation or to be issued an operator's hcense Nucle 4r Reactor Requistion. U.S Nuciear Regulatory Commisuon. Washingiam DC 20555

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IDU460RE 3 S(HERY OF CHAIMS 'lO 150 PORI 396 t

14=ri4rmi Examination Certification Added block "Bestriction Change From-Prwious khittal" plus Ramarts meetion.

Non-Hodical Certificaticri Changed nonMM*1 certification stataeant to: Peuer anactors-This certifies that the. applicant has been found to most the safeguards

• and fitnoes for dirty reguirements of this this facility for licensed operators.

Nonpouer-This certifies that the applicant has been found to meet the safeguards' resuizuments of this fac414ty for 14 ann==ri operatore and I have no knowledge of the applicant

--==riing the cutoff levels for alcohol or aantrolled subs + man== as es+mh14= hart pursuant to 10 CFR 28.

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i EHCI4SURE 4 SUtttARY OF CHAMES TO NBC POEM 398 Item 4.d Added clarifying statement to inclin=to this is to be 4

checked only if application is to amend liaanse to add additional unit (s).

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

Added "M.m n i".

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

Item 12.3 Changed mrding to " Certified Startup Program Completed" 3

for clarification.

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

Item 12.Sa Added a new item " Time On Shift Above 205 Power (6-week minimum)".

Item 14.a Added the words "That Is Bened Upon A Systems Awwer.li to Training" for clarification.

Item 15 Added "Date and Result of Most Recent NBC Administered Bequalification Examination".

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

er current employer of: (1) all previous employers; (2) any instance where I have been tested by a Health and Human Services-(HHS) Certified Drug Testing IA-eeg or a Licensee's testing facility for alcohol or a controlled substance, and the test results avaandad 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 centrolled substanos described in 10 CFR Part 26; and.

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(4) any reasons for removal or zuvecation of unescorted access at'a nuclear facility".

Item 19.b and Item 19.c Moved 19.b and 19.c together. Applicable box must now be j

checked. Also added block for typed name of Tre.ining

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Coortiinator and Senior Marian =mant Representative On Site.

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L PGt NRC USE Under waiver ostegory added "MaMnal".

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