ML20006D711

From kanterella
Jump to navigation Jump to search
Forwards Revised NRC Forms 396 & 398,personal Qualifications Statement & Certification of Medical Exam by Licensee, Respectively
ML20006D711
Person / Time
Site: Crane Constellation icon.png
Issue date: 01/05/1990
From: Gallo R
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To: Roche M
GENERAL PUBLIC UTILITIES CORP.
References
NUDOCS 9002140279
Download: ML20006D711 (8)


Text

{{#Wiki_filter::

l '

t O.< p ,; y a i .c JAN 51930 b i . Docket-No. 50-320 GPU Nuclear Corporation ATTN: Mr. M.-B. Roche . Director-of TMI-2. P.:O. Box 480 'Middletown, Pennsylvania 17057: (f+. Gentlemen: l

SUBJECT:

' REVISED NRC~ FORMS 396'AND 398 4

Enclosed is a copy-of the. revised NRC Form-398-(Enclosure-1), Personal i ' 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. 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 by contacting Beverly Martin, U.S, Nuclear Regulatory. Commission, by telephone (301)E492-8138.or by writing to her, U.S. Nuclear Regulatory Commission, , Information and Records-Management Branch, Mail 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, 't g sisnea W pgg Robert M. Gallo,. Chief Operations Branch Division of Reactor Safety

Enclosures:

As stated \\ 7 b c'. / 0FFICIAL RECORD COPY 396 & 398 FORMS - 0029.0.0 12/14/89 19002140279 900105 PDR '.ADOCK 05000320 y PDC

'~ t i .) ] l <,. ..[ GPU Nuclear Corporation: 2~ o k- 'cc w/o enc 1: l T. ' F. Demmitt, Deputy Director, TMI-2 R. E. Rogan,i Licensing'and' Nuclear Safety Director J.'J. Byrne, Manager, TMI-2 Licensing W. J.;Marschall, Manager, Plant Operations i E S. Levin, Defueling Director J. B. Lieberman, Esquire Ernest L. Blake, Jr., Esquire G. A. Kuehn, TMI-2 Site.0perations Director W. Thompson, Manager, Operator Training. TMI-Alert (TMIA) Susquehanna Valley Alliance (SVA) t -Public Document Room (PDR)- h-Local Public Document-Room (LPDR) Nuclear Safety Information Center (NSIC) NRC Resident Inspector -Commonwealth of Pennsylvania -bec w/o enc 1: 4 Region I Docket Room (with concurrences) 't Management Assistant, DRMA (w/o enc 1) DRP Section Chief' S. Lewis, OGC. Michael Masnik, PM, TMI-2. 1 J., Dyer-E00 OL Facility File k i DRS:RI Gallo/pb y; 01/0279 / (f c j0 -{ 10 0FFICIAL RECORD COPY 396 & 398 FORMS - 0030.0.0 12/14/89 A

.~ - INSTIUCTIONS FOR COMPLETIN3 NRC PORM 338 PERSDNAL QUALIFICATION STATEMENT-LICENSEE TO REMAIN VAllD,THIS FORM MUST NOT BE ALTERED - e '4 TYPE 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 RECEIVED UP TO THE DATE OF THIS APPLICATJON. NOTE: SEE / TEM 14 - THERE IS AN EXCEPTION ALSO, THIS BLOCK IS TO BE MARKED IF PREVIOUS NEW APPLICATION WAS WITHDRAWN, PLEASE WRITE " WITHDREW" NEXT TO "NEW." 2.b tlwu 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 ITEM 14 - THERE IS AN EXCEPTION. 2.b RENEWAL "X"lF YOU ARE RENEWING CURRENT LICENSE. 2.c UPGRADE "X"lF YOU HOLD A RO LICENSE AND ARE NOW APPLYING TO UPGRADE YOUR LICENSE TO A SRO. I 2.d 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.e REAPPLICATION "X"IF YOU HAVE PREulOUSLY BEEN DENIED A LICENSE AND ARE REAPPLYING, 2.f WAIVER REQUESTED "X"THEAPPLICABLE WAIVER REQUESTED AND JUSTIFY IN COMMENTS SECTION (ITEM 17), 2.g DATE PASSED GENERIC FUNDAMENTALS EXAMINATION SECTION (GFESI. 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 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. 11. EDUCATION - INDICATE BOTH ACADEMIC AND VOCATIONAL / TECHNICAL POST HIGH SCHOOL EDUCATION FOR MAJOR AREA lS) 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, INCLUDE PROGRAMS SUCH AS NUCLEAR POWER SCHOOL, MILITARY TRAlWING, 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. TIONAL SPACE IS NEEDED, CONTINUE UNDER COMMENTS (ITEM 17), 12. TRAINING - INDICATE THE TRAINING YOU HAVE RECElVED TO MEET THE REQUIREMENTS OF ANSI N18.1/ANS 3.1. THE i 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, .l TO ACCOUNT FOR INTERMITTENT TRAINING (FOR EXAMPLE,4 WEEKS OF CLASSROOM 1 RAINING 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 DOU8LE COUNTED UNDER EXPERIENCE (ITEM 13), ALL REQUALIFICATION TRAINING TIME IS TO BE ACCOUNTED FOR IN THE REQUALIFICATION ITEM. PLEASE DO NOT " DOUB 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 POSI 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 TH l NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEFD THE NUMBER OF MONTHS THAT ARE IN THAT - TIME PERIOO, FACILITY OPERATOR TRAINING PROGRAM - INDICATE e. GRADUATE OF INPO ACCREDITED OPERATOR TRAINING PROGRAM; 14 AND b. CERTIFIED (ON NRC FORM 474) OR NRC APPROVED SIMULATION FACILITY iS Uaw m THE OPERATOR TRAINING PRO GRAM, IF "YES" IS CHECKED IN BOTH lTEMS 144 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 l 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 1.8, REV. 2. ARE MET. 15. FOR RENLWALS ONLY - (1) ENTER THE APPROXIMATE NUMBER OF HOURS SINCE PREVIOUS RENEWAL OR ISSUANCE O . LICENSE 19 FIRST RENEWAL (2) ENTER DATE AND RESULT OF MOST RECENT NRC ADMINISTERED REQUALIFICAT ' NATION. 16. EXPERIENCE DETAILS - INCLUDE POSITION TITLE, TIME PERIOD-FROM/TO, FACILITY, AND A BRIEF DESCRIPTION OF DUTIES PERFORMEO 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.

I TION. l NRC FORM 396,CERTIFICATiDN OF MEDICAL EXAMINATION BY FACILITY LICENSEE - MUST ACCOMPANY THIS APPLICATION. 18. 19. SIGNATURES - SIGN AND DATE ITEM 19A. OBTAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YOUR . MANAGEMENT REPRESENTATIVE ON SITE. DETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS 398 (ORIGINAL AND TWO COPIES EACH) TO PRIATE REGIONAL ADMINISTRATOR, ~ ' ' ~ ~ ' ~ '~ X X X~ L L J E.T T

- - -. ~. 1 1 A ltBECElvED NRC FORM 3M U.E NUCLEAR E.E AULA1DRV COsasles ON APPIOVED BY Oest: NO. 316D4000 fC I *'IAII' I"IIEI 56 K t6 A 06A7,anit t4 A7 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH TH18 INFORMATION COLLECTION REOUEST: 2.0 HR$. FORWARD COMMENTS REGARDING BURDEN E $ TIM ATE PERSONAL QUALIFICATION STATEMENT-LICENSEE TO THE INFORMATION AND RECORDS MANAGEMEMY ORANCH (P 6301. U S leUCLE AR REOULATORY COMMI8-l SiON. WASHINGTON, DC 20666. AND TO THE PAPERWORK REDUCTION PROJECT 13160 4000). OFFICE OF MANAGE.- TO REMAIN VAltO,THIS FORM MUST NOT BE ALTERED MENT AND SUDOET,W A$HINGTON. DC 20603

1. APPLICANT'S FULL NAME (Last, First, A6dcfdel AND ADORESS (include 2/P Opdel
4. TYPE OF APPLICATION (Check applicable 60masJ

'I l

e. RE APPLICATION

",',N R,n $,T E D m

1. HOT g
2. COLD
1. FIRST WRITTEN /Cemywy/

~ 2.OPERAllNQ4Cere. b,MENEWAL 3.THIRO

4. UPORADE j
3. E LIOltiLIT Y

& MULTI. UNIT IAMENO TOINCLVOf ADDITIONAL 4. MEDICAL

2. CITIZE NSHIP
3. 91RTH DATE UNITi 5 OTHER 6 UNITED STATES MONTH DAY YEAR
g. DATE PASSED GENERIC FUNDA.

MM YY MENT ALS E X AMIN ATION SECTION

6. OTHth f30eciND l

l l LIF Ah*LICADlff

6. TYPE OF LICENSE APPLIED FOR
6. PREVIOUS LICENSE (S) HELD
o. OPER ATOR
s. DOCKET NUMBER RO SRO k LICENSE NUMBER h[
d. F ACILITY DOCKET NUMSER b SENIOR OPERATOR I

I I 55 I I I 50-

s. LIMITED SRO fe e. Fued HanobrJ l

l l

7. NAME AND ADDRESS (Inctursel/PCocJef OF APPLICANT'8 EMPLOYER
10. CURRENT POSITION AT FACILITY
a. PLANT SUPERINTENDENT L AURILIAHY UNIT OPER.

ATOR/TRAINE E fTURSONE k AS$1STANT PLANT SUPERINTENDENT BUILDING /EQUIPME NT OPER ATOR (NON L(Cf N3

e. SHIFT SUPERVISOR f 0 0Pf RA TOR) at STAFF ENQiNEER
l. OTHER f3pec/4J
6. NJ.ME OF APPLICANT'5 F ACILIT V F ACILIT Y DOCKET NUMBER
s. SHIFT TECHNICAL ADVISOR /3HIFT ENGINEER f.

INSTRUCTOR

9. ADOITIONAL F ACILITY DOCKET 8 (Metr # untr trenses' s SENIOR CONTROL ROOM OPERATOR k CONTROL ROOM OPER ATOR
11. EDUCATION N

ER F a HIIH SCHOOL i s. MAJOR AREA 13) OF STUDY. f."*/ff, U;'j!l DEOREE CODES & VOCATIONALff ECHNICAL g g, E'f[HND Gaff"etenevi H ''0"^'*'*o MONTHS veS NO ORADUATE ENGINEERING fFif t031 [ $RTIFIC ATE N GEO EOUlvALENCY NO

2. ASSOCIATE k NUMBEH OF 3 8ACHELOR 4. M AST E P E

gOF 6 DOCTORAL

12. TRLININO (SINCE LAST APPLICA TION-SEE INSTRUCTIONS)
13. E XPE RIE NCE (00 NO T DOUBLE COUNT-SEE INSTRUCT 10NSI ewoNinaNove g

. wowin aNo v a an ,,,o..,, (Ceu- '"O* 'O

      • "a NAVY
  • aou to
    • "'*"a 1-NUCLEAR POWER PLANT FUNDAMENTALS toomi 1.RO 2 -PLANT SYSTEMS 2 EOOW/PPWO CLAS$ ROOM
3. EWS/PPWS ODSERVATION 4 ERS/CRW 3-OPE R ATINO PR ACTICE 5.OTHER t$oneirys CONTROL ROOM OPERATIONS ON SHIFT SIMULATOR OPE R ATINO Isaceuwa Cuismono FOSSIL SIMULATOR NAMES M @.j ' p(

6 OPERATOR [hQQ 7 SUPERVISOR s, b. j hi T 8 PLANT STAFF - N fu [du'Y'sYeo l lYES l l NO g -,n 9 OTHER ($sec,41 t

f._-g 4 (s
% l(Q y M

Nuuns a o. es ac tiver v was eut a tions G.o y d rt m s t uu ta n; n 3x; %; c,f,t ? /

'?; " <

y COMMERCIAL NUCLE AR (sacswrine neswcwTest ae.crorJ 4 -SRO INSTRUCTION 10 REACTOR OPER ATOR (Licensed 1 5.- h"$^r'r'N[M' $8"# f '" ' 11 SENIOR OPE R ATOR (Leensads

a. Wgfg"4"//gayva 20m Powsm -

12 SHIFT SUPERVISOR (Licenseds 6 REQUAllFICATION 13 STAFF / SHIFT ENGINEER (teenansi 7 -0THE R ISant&#

14. AUX./ EQUIP. OPE R ATOR INoniscensedi
15. PLANT STAFF 10 OTHER (Speci&1
JeRC PORJ 30s (10 sol

-.7,1 - ~.. _. .m .y.

nom +. m -., a mn. m.<r..m w * -u^m 4 %-.a; ~ ~ ^ .'i G.a ~'~X '^<iG r s 0 G

14. FACluTY OPERATCR TRAINING PROORAM -

e_. i? L OERT tF tED ON NRC FOR1414 tEIMUL A TIOh !ACILIT Y k GRADUATS OP $NPO ACCREOtTED OPSTATOR ,. T448081000 PROGRAM THAT te SA880 UPON A. Yt$ NO-Cf A TfffCATf0Ar'J O3 NRC APPROYED $iMULATION YES NO . SYSTSAS APPROACH TO TRA18eING F ACILf7y as useO IN THE OPtRATOR TRAINING pnoonay

16. FOR RENEWALS ONLY O'

k DATE AND RESULT OF MOST D*'f 8'f 8 4 ' - NOURS OPER ATED F ACILITYt ' RECENT NRC ADMINISTERED PASS Fall REQUALIF ICATION ix AMIN ATION

16. EXPERIENCE DETAILS s POsrTION TITLE PROM TO

. k F ActLff Y -

e. DUTits I

a ] l

17. 000ASENTs apesesr see seen awneer M senarn you eve emes.Weesp. Anore espramat enseis as.

A r -I l's 4 l J l ,l 14, NRC PORM 306, CERTIFICATION OF MEDICAL EXAMINATION SY FACILITY LICENSEE,18 ATTACHED ANY F ALSE STATEMENT OR OMIS$10N IN THIS DOCUMENT, INCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS. TGs. I certify usuler penelty of portury that the information en thes occument end attachmenes to crue end corveet. I further ceftlfy that I have notified my current empiover of: (1l eil presteue surployere; I

12) any Instense genere 1 have base tested by e Health end Human Servlees (HH6) Certified Drue Testene Letsorevery or e Licensee e teetmo facility for asoohol or e sentrolled euestones, and the tear resuste sessessa the autoff temete estabhened ovessent to 10 CF R Port 26; Q) eny instance vrhere I have been errested for the esse. use or possession of e controlled subetence essertners in 10 Cf R Port 26. '

estd (4) any fossene ter femeiel or revocaterm of unescorted access et a nutteerheility, a esto sisthorue the NRC to subrnit the resulte Of emanunsuono to my empfeyers for ues en propering retreening PIEWWn8, se nogeWory SiOUTURE-APPLICANT DATE CHECK APPLICASLE BOX. . k - I certify that the above nemed inefswidual has successfully completed the factiny heeneses requaremente to be licensed es an Ooeratortsemor Operator pursuent to Tule 10. Corse ei Federsi Requietenne. Part ES:else teigt the indatestuel hee a need for en Operstorf$enior Operator iscenes to perform heather seesped outsee and taet the ' -dt be merle sueNeble for enamanetton. O e6eo sortlty unser. WY of pertury thet the inturmetton in this q$scument and ettschmente it true end Correct. & R$NtWAL ONLY.- I certify ther the above named endividuei meets the approwd requesification osoerem (with eseepedpas nosed he tree f1) es reovered bv esetton 50.54161) of 10 CFM 60. and [ ' that hetthe has deernefted heether licensed retoonelbdmese cofripetently and asfely. I also certify urider penettV of pef $ury that the information in thee giocument and ettethment$ - le true enef sorrect. TRAININO COORDINATOR SENIOR MANAGEMENT REPRESENTATIVE ON SITE PRINTED OR TYPt0 NAME PRINTED OR TYPED NAME SIGNATURE DATE S40 NATURE DATE j t l l. FOR NRC USE l WAIVER (Check or carnplere /rerns.as applicable / l MEET 8 REQUIREMENTS l l DOE 5 NOT MEtt REQUIREMENTS Issetern eesow '0 'memon 'U ' e s cie ^ CAftGORY' l nt Anou AR Y a ms us Apov Anyg ns WRITTEN OPERATING - p EllOl81LITY ] MEDICAL. stGNA TUR E-R E viewer oATE ]7 OTHER'- NRC PORM 30s i1049). !s

e 4

U1 NUCu Ar.oUuw v Co=umoN -ovi,og,v,y,y,og.-. go.u 10CeAS423.8627 83?iMATED sunDim Pen meePOeing TO cOesPtT ettTM ens tS.SF Y MiB INeonMAvioN COL LECTION meoute?- Je uma CERTIFICATION OF MEDICAL EXAMINATION gamo,,c,g".47,La',a,Aaoggo:L ',y,= O anANCH ir a not v s nucle An atoubAtOnv COisMis e aCguegg BY gaCla kB .mp. e. giON

  • A $naNOTON DC 20664 AND TO YME PAPenseonst yM b

st ouctioN enOsseY a3teoco2ai oprice oF MANaot. MtNT AND SUDQtt. A ASHINGTON DC 20e03 NAME OF APPLIC. ANT l F ACILITY DOctLET nut 48E R F ACILIT Y A. MEDICAL EXAMINATlON CERTIFICATION This is TO CERTIF Y THAT THE ABOVE NAMED APPLICANT FOR AN OPER ATOR/ SENIOR OPE RATOR LICENSE HAS BEEN E XAMINED BY A PHYSICIAN PAINTED N AME (of anysrcuni l$T ATE AND LICENSE NUMBER l E RAMIN ATION JATE BASED ON THE RESULTS OF THE EXAMINATION. INCLUDING INFORMATION FURNISHED BY THE APPLICANT THE PHYSICIAN HAS DETERMINED THAT THE APPLICANT'S PHYSICAL CONDITlON AND GENE R AL HE ALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPE R ATiON AL E RRORS E NDANGERING PUBLIC HE ALTH AND SAFETY. I CE RTIF Y THAT IN RE ACHING THIS DETERMINATION THE GUIDANCE G)NT AINED IN ANSUANS 3 41983. OR ANSUANS 16 41977 (N380) WAS FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY NRC. i ON THE basts Cis THE RECOMMENDATION OF THLfHYSICIAN. I RECOMMEND THAT THE APPLICANT'S OPE R ATOR LICENif BE CONDITIONED AS l FOLLOWS.

1. NO RESTRICTIONS
2. CORRECTIVE LENSES 8E WORN WHEN PERFORMING LICENSED DUTIES
3. HEARING A10 BE WORN WHEN PE RFORMING LICENSED DUTIES
4. RESTRICTED LICENSE OR E XCEPTION-Provide detadt below and attach supportmq medical evidence for NRC revwe

)

6. RESTRICTION CHANGE F ROM PREVIOUS SU8MITTAL Pmvine details below and attach supportmq medical evenence for NRC review PROPOSED WORDING OF RESTRICTION (BlocA d ateves l

RE LATIONSHIP OF R ESTRICTION TO DISOUALIF YtNG CONDITION raretty mdecere how restricTen ww correct fne esque/tryang conderen7 REMARKS FOR RESTRICTION CHANGE (8/oca 5 docios it NONMLDtCAL CERTIFICAllON POWE R RE ACTORS THl$ CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAF EGUARDS' AND FITNESS FOR DUTY REQUIREMENTS OF THIS F ACILITY FOR LICENSED OPER ATORS NON POWER RE ACTOR $. THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS REOUIREMENTS 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 PURSUANT TO to CFR 26 Nv e ALsa st ArauaNt on uMissium ih inis oucuMENt sNCLUDiNu A f r ACHMtNT3 MAv et sueJtC T Tu civg AND LHiMiNAb bANUt tO% e ckHlie v UNutM PtNAb f r UF (tHJuMy THAT fME INFORMATION #N TMIS DOCUMENT AND ATT ACMMENT5 IS TRuf AND CORRtCT. PAIN TED N AME AND SIGN ATURE (sener Management #eoresenrative on 5,res TITLE DATE in accordance with 10 CF R 55 5. Commumcations. tnis form snali be submitted to the NRC as tollows: BY MAIL ADDRESSED 10; Regional Admimstrator, Region i Regenal Admmistrator, Regen H Regional Admmistraroe, Region lH U S. Nuctsar Regulatory Commission U.S. Nuclear Regulatory Commissen U S Nuclear Regulatory Commission 475 Allend44e Road 101 Marwete Street. Suite 3100 799 Roosevest Ross h.mg of Prussia. PA 19406 Atianta. G A 30323 Gien Ellyn. IL 60137 . Regional Admimstrator. Ampon eV Regeul Admemstrator, Region V U.S. Nucmar Replatory Commission U.S. Nuctear Regulatory Commission 6t1 Ryan Ptara Drive. Suite 1000 1450 Maria Lane. Suite 210 Arimgton, f x 76011 Wamut Cmm. CA 94596 PRIV ACY ACT ST AT EMEN T Pursuant to 6 U.S.C 5524teH31. enacted mto law by section 3 of the Privacy Act of ROUTINE USES. The mformation may be disciowd to an sporopeiste Feoeras. State, or 1974 IPublic Law 93 5791,the following statement is 8urnishes to moividuals who tocal agency in the event the mrormaien irw1. cates a vioisten or potentias viciaten of law supply mformaten to the U S Nuctear Regulatory Commission on NRC Form 396 and m the event the mformation moscaen a violaten or potentia vupation of iew and m This mformaten is mamtammt m a system of records dnignatas as NRC 16 and the course rif an esmmistrative or audicial proceedmg in sidition. th.s information may be descr: bed at 51 Federal Regmer 33157 (September 18.19861 transferred to an approoriate Federal State. and local apacy to trie entent remvent and AUTHORITY: Sections 107 and 16th) of the Atomic Energy Act of 1954, as nuessary for an NRC decismn anout you amendet t42 V S C. 2137 ar d 22010H. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY ANO EFFECT ON PRINCIPAL PURPOSEISO Information entered on ihn form is uwd to determme INDtVIDUAL OF NOT PROVIDING INFORMATiON Disclosure is voruntary. If the whether the physecat condition and general Pealth ofthe applicant are suen (nat they reluested mformation is,mt provided. however. the appiecaton for a facility operator's will not cause operational errors endangermq puolic health and safety. This mforma-or senior oce'ator s license may be den +1 bon may be uset by the NRC statt to determme if the erwJividual meets the require SYSTEM MANAGERIS) AND ADDRESS Chief. Operator Licens ng Branch Of fice of ments of to CF R 55 to taae an esammaten or to be nsued an operator's licenu Nucw r Reactor Reptation. U S. Nucrear Requestory Commissmn, Washmqton, DC 20555 Nmeenau1esonam

1 1 l Dumuls 3 StHERY OF QWGES 10 HIC PORI 396 ' Medical Examination Certification Added block " Restriction Qianse From Prwicus Suhaittal" plus Remarts section. Non-$wii=1 Certification Changed nonwi=1 oortification ~ statement to: Power Beectors-This certifies that the asylicant has been found to aset the safeguards' and fitramos for cksty requirements of this this facility for licensed operators. Nonpower-lhis certifies that the i l-applicant has been found to meet the

== farm'ds' reguirements of this facility for liaan==ri operators and. I have no knowledge of the applicant awa==r44ng the cutoff levels for =1

  • 1 l

or ocatrolled substances as es+=h14=w pursuant to 10 CFR 26. 1-l I L F e l' m m---

1 4 ENCICSURE 4 SutttARY OF CHAN3ES M NBC 1GN 398 Item 4.d Added clarifying statement to indicate this is to be checked enly if application is to amend license to add additional unit (s). Item 4.f Added "(Category)" to Operating. Added "Nadinal". Item 4.s-Added a new item "Date Passed Generic Fundamentals Examination Section". Itam 12.3 -- Changed wording to " Certified Star 1:up " w. Completed" for clarification. Item 12.5 Chansed wording to " Extra Pereen On Shift In Control Room (13-week minimum)" for clarification. Item 12.5a Added a new item " Time On Shift Above 205 Pouer (6-week mi n 4== ) ". Item 14.a Added the words "1 hat Is Based Upon A Systems Approach to Trsining" for clari.fication. Item 15 Added "Date and Result of Most Recent NBC Administered Requalification Examination". Item 19.a Added the wording "I further certify that I have notified. er current esployer of t (1) all prwious ensplayers; (2) any instance where I have been tested by's Health and Human !~ Services (HBS) Certified Drug Testing W..e., or a Licensee's testing facility for alcohol or a eentrolled i L subacance, and the test results-aw=adad the cutoff levels established pursuant to 10 CFR Part 26; (3) any instance r l where I have been arrested for the sale, use or possession L of a controlled substance described in 10 CFR Part 26 and. i (4) any reasons for removal or zwvocation of unescorted =~=== at a nuclear facility". l. Item 19.b and Item 19.c Moved 19.b and 19.c tg O.w. Applicable box aust now be chodred. Aleo added blodt for typed name of Training L Coordinator and Senior Menessment Representative On Site. -POR NRC USE thder waiver category added "tendinal". l L = .. _ _, _ _. _ _. _ _}}