ML20006D713

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

ML20006D713
Person / Time
Site:	Susquehanna
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Keiser H PENNSYLVANIA POWER & LIGHT CO.
References
NUDOCS 9002140284
Download: ML20006D713 (8)

Text

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tf 5 1990-r I

Docket-Nos. 50-387-50-388-

+

Pennsylvania Power & Light _ Company _

ATTN: Mr. Harold W. Keiser Senior Vice President - Nuclear 2 North Ninth Street

{

Allentown, Pennsylvania'-18101 1

!!J ;

Gentlemen:-

l 4-1 L

SUBJECT:

=. REVISED NRC = FORMS 396' AND 398 -

Enclosed is a copy of the: revised;NRC Form-398.(Enclosurei1), Personal Qualifications-Statement '-. Licensee and revised.NRC Form-396 (Enclosure 2),

,b 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 app 1_ications for licenses are to be submitted on these revised forms no

.later than February 1, 1990.

I U

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,

' ' c' 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.

y Sincerely, j

^

10rigihR1 gigned M l

Robert M. Gallo, Chief

)

Operations Branch Li E

Division of Reactor Safety 1

Enclosures:

As stated I

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'900214o284 900105 i

PDR ADOCK 0500 87 i

OFFICIAL RECORD COPY 396 & 398 FORMS - 0033.0.0 12/14/89 i

c Pennsylvania Power & Light Company 2

cc w/o enc 1:

A. R. Sabol, Manager, Nuclear Quality Assurance J. M. Kenny, Licensing Group Supervisor R. G. Bryam, Superintendent of Plant-SSES S. B. Ungerer, Manager, Joint Generation Projects Department J. D. Decker, Nuclear Services Manager, General Electric Co.

B. A. Snapp, Esquire, Assistant Corporate Counsel.

H. D.-Woodeshick, Special Office of the President J. C. Tilton, III, Allegheny Electric Cooperative, Inc.

. William Locothert, Manager, Nuclear Training (w/ enclosures)

Public Document Room (PDR)

Local Public Document Room (LPDR)

Nuclear Safety Information Center (NSIC) i NRC Resident Inspector i

Commonwealth of Pennsylvania bec w/o enc 1:-

Region I Docket Room (with concurrences)

Management Assistant, DRMA (w/o enc 1)

P. Swetland, DRP M. Thadani, NRR J. Dyer, ED0

.0L Facility File

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h; e

DRS:RI Gallo/p N

01 9

d L I QW 0FFICIAL RECORD COPY 396 & 398 FORMS - 0034,0.0 12/14/89 4

h INSTRUCTl!NS FOR ODMPLETING CC FORM 308 l

PEZ80NAL QUALIFICATION STATEMENT-LICENSEE TO CEMAIN VAllD,THIS FORM MUST NOT BE ALTERED 6 ' 4. - TYPE C F* APPLICATION 2.s NEW "X" IF YOU AHE A NEW APPLICANT. COMPLETE EACH CATEGORY OF THE FORM COMPLETELY, FOLLOWING THE INSTRUCTIONS BELOW. THIS 18 TO INCLUDE ALL EDUCATION, TRAINING AND EXPERIENCE THAT YOU HAVE i

RECEIVED UP TO THE DATE OF THIS APPLICAT4ON. NOTE: SEE / TEM 74 - THERE IS AN EXCEPTION. ALSO,THIS BLOCK IS TO BE MARKED IF PREVIOUS NEW APPLICATION WAS WITHDRAWN, PLEASE WRITE " WITHDREW" NEXT j

TO "NEW "

t 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 E XCEP' TION.

2.b RENEWAL -."X"IF 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.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 PREVIOUSLY BEEN DENIED A LICENSE AND ARE REAPPLYING.

2.f WAIVER REQUESTED "X" THLAPPLICABLE WAIVER REQUESTED AND JUSTIFY 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 GFES WAS NOT TAKEN, YOU MUST HAVE PASSED AN NRC LICENSING EXAMINATION ON THE APPLICABLE REACTOR TYPE (PWR OR BWR) AFTER FEBRUARY 1,1DB2,WHICH LED TO THE l

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 AREAtS) OF STilDY. INDICATE THE NUMBER OF YEARS SPENT IN EACH COLLEGE CURRICULUM AND THE HIGHEST DEG RECEIVED, USING THE DEGREE CODE PROVIDED. FOR VOCATIONAL / TECHNICAL EDUCATION, INCLUDE PROGRAMS SUCH ~

AS NUCLEAR POWER SCHOOL, MILITARY TRAINING, AIR CONDITIONING /REFRICERATION, DIESEL MECHANIC SCHOOL, ETC.

INDICATE THE NUMBER OF MONTHS IN EACH PROGRAM AND WHETHER A CERTIFICATE OR DEGREE WAS AWARDED, IF ADDI.

l TlONAL SPACE IS NEEDED, CONTINUE UNDER COMMENTS (ITEM 171.

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 Cl_ASSROOM TRAINING SPREAD OVER A 2. MONTH PERIOD), THEREFORE, THE DATE COLUMNS MAY INDICATE A LARGER TIME SrAN 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 "

J 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 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 T NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEED THE NUMBER OF MONTHS THAT ARE TIME PERIOD.

i 14.

FACILITY OPERATOR TRAINING PROGRAM - INDICATE a. GRADUATE OF INPO ACCREDITED OPERATOR TFIAINING PR AND b. @TIFIFO Mu MCC eOW M OR MRC f,PPoOyCO S'MULAT;ON FActLITY IS USED IN THE Ur:Enslott i nAINING PHO.

GRAM. IF "YES" IS CHECKED IN BOTH ITEMS Ida 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 NU OF SIGNIFICANT CONTROL MANIPULATIONS UNDER ITEM 12.3. NOTE: INPO ACCREDITED MEANS ACCREDITATION B NATIONAL NUCLEAR ACCREDITING BOARD AND MEANS THAT AT LEAST THE MINIMUM REQUIREMENTS OF REGULATORY GUIDE 1.8,REV.2, ARE MET, 15.

FOR RENEWALS ONLY - (1) ENTER THE APPROXIMATE NUMBER OF HOURS SINCE PREVIOUS RENEWAL OR ISSUANC LICENSE IF FIRST RENEWAL. (2) ENTEH DATE AND RESULT OF MOST RECENT NRC ADMINISTERED REQUALIFICATION 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 TRAt%UG COORDINATOR'S SIGNATURE AND THAT OF YOUR SE MANAGEMENT REPRESENTATIVE ON SITE.

j

- DETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS 398 (ORIGINAL AND TWO COPIES EACH) T PRIATE REGIONAL ADMINISTRATOR,

'- -~ ~

F' ~

DATE RECElvtD IERC DORM 30$

U E NUCLE 4.R kl.ULAlvaY COMMieseON E.PPROvt D S,Y O.MS:E KP RE. i 3 O. 31604000 ITop --=

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_l OS.47,eef 66M ESTlWATED SURDEN PER RESPONSE TO COMPLY WITH.

1 TH18 - INFORMATION COLLSCTION REOUESTr2D HRS.

FORW ARD COMMENTS REGARDING BURDEN E STIMATE

?

T PER80NAL OUAUFICATION STATEMENT-LICENSEE TO THE INFORMAh0N AND RECORDS MANAGEMENT

$ RANCH (9430), U.8_ NUCLEAR flEGULATORY COMMIS-1 BION. WASHINGTON DC 20666. AND TO THE PAPERWORK REDUCTION PROJE6T 131600000). OFFICE OF MANAGE.

TO REMAlW VALID,THit FORM MUST NOT BE ALTERED MENT AND SUDGET, W ASHINGTON. DC 20603,

1. APPLICANT'8 FULL NAME (Last, first, At,(/tlle) AND ADORESS (include ftp CodF)

4. TYPE OF APPLICATION (meck app /kable bomas)

t. HOT l

e. RE APPLIC Af TON l

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--2. COLD

1. FIRST 1mHITTENICesspeayJ

a. NEW 2 a SND 2.OPEf ATING # Case-to. RENEWAL

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3. ELIQlSILfTY -

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6. MULT4. UNIT (AMENO TO INCLVOE ADOITIONnL

4. MEDsCAL

2. CITIZENSHIP

3. BIRTH DATE UNITI s.OTHER

$ UNITED 8TATES MONTH DAY YEAR

g. DATE PASSED GENERIC FUNDA.

MM YY ME NT ALS E X AMINATION SECTION QL OTHER t$neetND l

l l

LIF APPLICA0 LEI S. TYPE OF LICENSE APPLIED FOR

6. PREVIOUS LICENSE (5) HELD e, OPERATOR

e. DOCKET NUMSER RO SRO h LICENSE NUMBER how

d. F ACILITY DOCKET NUMBER a

an h SENIOR OPERATOR I

3 I

55-1 I

I 50-l s. LIMeTE D 4RO te s. Feet Henmerf I

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7. NAME AND ADDRESS (includelle CodPIOF APPLICANT'S EMPLOYER

10. CURRENT POSITION AT F ACILITY

s. PLANT SUPERINTENDENT A AUAILIARY UNIT OPER.

ATOR/T RAINE E/TUROINE

h. ASSISTANT PLANT SUPERINTENDENT BUILDINO/ EQUIPMENT OPERATOR INON LtCENS.

SHIF T SUPERVISOR ED ONRA TOR) 8.

eL ST AFF ENGINEER

l. OTHE R (Spect&l lF ACILITY DOCKET NUMBEM S. N4ME OF APPLICANT ~5 F ACILIT Y

o. SHIFT TECHNICAL ADYlSOR/8HIFT ENGINEER

f. INSTRUCTOR

9. d.001 TION AL F ACILIT Y DOCKE T8 (Metes.va## &censest S $ENIOR CONTROL ROOM OPERATOR lt CONTROL ROOM OPE R ATOR

11. EDUCATION b HIGH SCHOOL

s. MAJOR AREA 481 OF STUDY J,'"O'/1f, 7,'771!.'

DEGREE COOES

d. VOCATIONAL / TECHNICAL ig"[g',N I"

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ORADUATE ENGINE ERING t!IELO3)

GED EOUlvALENCY ERTIFICATE 2 ASSOCIATE NO

3. BACHELOR t

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4. MASTER F

6. DOCTG A AL

12. TR AINING (SINCE L AST APPLICA TION - SEE INSTRUCTIONSI

13. E XPE RIENCE (00 NO T 00UBLE COUNT-SEC INSTRUCTIONSI

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1-NUCLEAR PCWEP PLANT FUNDAMENTALS ruomi 1.RO 2 -PLANT SYSTEMS

2. EOOW/PPWO CLASSROOM

3. EWS/PPWS OBSE RVATION

[. E RS/CRW 3-OPE RATINO PRACTICE 5 OTHER (spect&J CONTROL ROOM OPERATIONS ON SHIFT SIMULATOR OPER ATINO (ineAntes caewoomi pogggt

6. OPE R ATO R

[q'p SIMULATOR N AMES l%8 by h,gghk @ 7. SUPERVISO R q

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u COMMERClAL NUCLE AR tincludene Remrentrest Reactors 4 -SRO INSTRUCTION

10. REACTOR OPERATOR Iticensed) 5 - bNg# 'g'[,$,"u$8" 'N C0"i"O' "00"

11. SENIOR OPERATOR tiesasedl r

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6 REQUALIFICATION 13 STAFF / SHIFT ENGINEER (Leensarp 7-OTHER tssect&A

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15. PLANT STAFF

16. OTHE R Isoec14J I'

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l, 6, CERT 8FatD Ok NRC FORA ele l41,ULA TIO t !ACIUTv

-GRAguATE OF lesPO EDITED OP62ATOR.

$e19t ' 0000000 Pha'ayTHAT 84 BASED UPON A YES-NO-Cf%TtF#CA Tf0Jr? 02 NRC t.PPflOVED SIMULATION YES1 NO -

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RECENT NRC ADMINISTERED i

600VR$ 0PGRATED F ACILITY:.

REQUALIFICATION ERAMmATION PAb6 EAIL t

18. EXPERIENCE DETAILS

' s PO$ff 00N TITLE F ftOM TO

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L-18, NRC PORM 308. CERTIFICATION OF MEDICAL EXAMINATION SY P ACILITY LICENSEE,48 ATTACHED q

ANY F ALSE STATEMENT OR OMISSION IN THis DOCUMENT, INCLUDING ATTACHMENTS MAY BE SutJECT TO CIVIL AND CRIMINAL SANCTIONS.

tes. I senHy under penehy et smnury that the information in shu oseumen* eM aneehmems 6e true end soneet. I further eenity ther I have notitied my current empsever of: 41) en orewtous engesevere;

. Q) eny instense genere I houe tiesn tested tpy e Health and Human Servlees IMH$) CeQlhed Drue iestins Lenoretory or e Licenese's testing tec6Hty for escoho or a controesed essemenos, and the test n

Mott lowete estatsleshed purtuant to 10 CPR Port 28;(3) any instanse vehere I have been errested for the sese, use or possession of a controhed outistense eserteed in to CFR Part 26;

, feeults assented the e'r tenevel or revoceiton of uneurorted sesses et e nueteerliscilhy, i esso authorhe the NRC to subm6t the results of esernenstaans 10 my empsoyers f and 14) any veggens se

' pengreme, as sensemary f

SiONATUR5 APPLICANT -

. DATE 7

CHECK APPLICABLE DOX b, t earthy that the above named tntiewedwel het succeaefully comspeted the fetilny lecensees requirementa to be hcensed es en Operstor/ senior Ooerster pursuant to Totte 10, Code of 9eriores Regulatene?

Port GE;and ther the indathhtel hee a need for en Operator / Senior Oserotor tasonse to perform h6e/her ensegned putage and that the testetspeill be made sus 40ebas for esemNteten, t else eartify untler penalty of pertury that the information in thee (kpcoment eved ettschments le true and sorrett, e, REN0titAL ONLY - I certify that the enovo named indadduet meets the asomved requesification proerem (wira enceptmas nomat m item 77J en required by esetion 60141411 of 10 CFR 60. and that he/she hee discherygd h6s/her licensed respontitWistles tempstently and esfety, I seco certify unoer poneny af perjury that tne information in the document and attachments J[

~ le true enti oDtract, TRAINING COORDINATOR SENIOR MANAGEMENT REPRESENTATIVE ON SITE PRINTED OR TYPEO NAME PRINTED OR TYPEO NAME SI1 NATURE -

DATE

$10 NATURE lDATE FOR NRC USE W AtVE R ICheck or Compiere # ems. as applicable) l MEET $ REQUIREMENTS l l DOES NOT MEET REQUIREMENT $ tispAern 4Wowl unawTs u ev osmsooy Ct.TE00RY '

HEADQuARTEms REOtoh HE ADQUARTE R&

REG m tT RITTEN OPERATING EL101BILITY '

MgotcAL ssGNATURE RE. VIEWER DAfg OTHER.

s' NRC FORM Jeg (1949).

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CERTIFICATION OF MEDICAL EXAMINATION

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$ RANCH 19 4 301 US NUCLEAR RE0utATOmv comen%

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• A$HINGT081 DC 20555. AND TO THE Partageomet mapucT60m emoJErr 131acco24 oHiet of MANAot.

MENT ANO suDGE f. W ASMINGTON DC 20003 j

NAME OF APPLICANT

^

F ACILIT Y l F ACILITY DOCKET NUMOER A. MEDICAL EXAMINATION CERTIFICATION THIS IS TO CE RTIF Y THAT THE ABOVE NAMED APPLICANT FOR AN OPER ATOR! SENIOR OPE R ATOR LtCENSE HAS BEEN EXAMINED BY A PHY$1CIAN.

InINTED N AME tof anys,csans l STATE AND LICENSE NUMBER l EXAMINAflON DATE BASED ON THE RESULTS OF THE EXAMINATION. INCLUDING INFORMATIGN FURNISHED BY THE APPLICANT. THE PHYSICIAN HAS DETERMINED THAT THE APPLICANT'S PHYSICAL CONDITION AND GENER AL HE ALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPERATION AL E RRORS ENDANGERING PUBLIC HE ALTH AND SAF ET Y. I CE RTIF Y THAT IN RE ACHING THIS DETERMINATlON. THE GUIDANCE CONT AINED IN ANSl/ANS 3 41983.OR ANSI /ANS 15 41977 !N3801 WAS FOLLOWED AND THAT DOCUMENT ATION IS AVAILABLE FOR REVIEW BY NRC.

ON THE BASIS OF THE RECOMMENDATION OF Tti.fHYSICIAN. ( RbCOMMEND THAT THE APPLICANT'S OPERATOR LICENSE BE CONDITIONED AS FOLLOWS

1. NO RESTRICTIONS

2. CORRECTIVE LENSES 8E WORN WHEN PERFORMING LICENSED DUTIES

3. HE ARINO AfD BE WORN WHEN PERFORMING LICENSED DUTIES 4 RESTRICTED LICENSE OR E xCEPTION Provide details below and attach supporimg enedical evidence for NRC review.

5. RESTRICTION CHANGE FROM PREVIOUS SUBMITTAL Provide deteis below and attach supporting medical evalence for NRC review.

PROPOSED WORDING OF RESTRICTION (8/ock d anovel rit LATIONSHIP OF REST HICTION TO DISOU ALIF YING CONDITION I8neNy macere how restrmTen west correct the d,aque/rryme condtren?

REMARKS FOR RESTRICTION CHANGE (8/ock 6 abovel B. NONMEDICAL CERTIFICAllON POWE R R E ACTORS.

THl3 CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS

• AND FtTNESS FOR DUTY REOUIREMENTS OF THl3 F ACILITY FOR LICENSED OPE R ATORS.

NON POWE R RE ACTORS.

THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE $AFEGUARDS' REQUIREMENTS OF THis F ACILITY FOR LICENSED OPER ATORS. AND 1 HAVE NO KNOWLEDGE OF THE APPLICANT EXCEEDING THE CUTOFF LEVELS FOR ALCOHOL l-DR CONTROLLED SUBSTANCES AS ESTABLISHED PURSUANT TO 10 CFR 26 l<

l LNY F ALSE ST A T EMtNt on OMISSION ih rHnS DOCUMeNY INCtuDINu A r r ACMMLNTS M Av st suaJECT TO CivlL AND CR6MiNAb bANCliU% I CtH lif f UNUEH 8'4NALIT Of l;

PERJURV THAT THS INFORMATiO* 18t THIS DOCUMENT AND ATT ACHMENT515 TRut ANDCORAtCT.

PRINTED NAME AND SIGNATURE ISemor MsMeemear #eoresentative on S,res l TITLE DATE 1

l^

L l

in accordance witn 10 CF R 55.5. Commumcatens, tnts form snail De submitted to tne NRC as follows. SY MAIL ADDRESSED TO.

i l

Regional Admmntrator Regen i Regenal Admmistrator. Regen 11 Regionas Admmatrator. Region ill U.S. Nuclear Regulatory Commnuon U.S. Nuclear Regulatory Commnsen U S. Nuclear Re<pJiatory Commmen I

475 Allendate Road 101 Marietta Street. Suite 3100 799 Rooseveit Road King of Prusus. PA 19406 Atianta G A 20323 Gien Ellyn. IL 60137 Regenal Admimstrator. Region IV Regional Admemstrator, Region V l:

U S. Nurlear Requietory Conimission U.S. Nuclear Regulatory Commission

$11 Ryan Piaae Drive. Suite 1000 1450 Maria Lane. Suite 210 Arlington. TX 76011 Walnut Creen. CA 94596 PRIV ACY ACT STAT EMENI Pursuant to 5 U.S.C. 552atel(31. enacted mio baw ey wetion 3 of the Privacy Act of ROUTINE USES The mformaten may be disciosed to en appropriate Federas. State. or 1974 (Public Law 93579L ene followmq.etatement is *urnisned to moiviavais who local agency m the event the mformation mdicates a viotation or cotential violation of law succly mformaten to tne U.S Nucsear Regulatory Commnsen on NRC Form 396. and m the event the mformat on mo cates a violation or potential violation of law and m This mformation is maintained m a system of records oeugnated as NRC 16 and the course of an admmistrative or pudicsai procembnq in additson tn.s mformation may be described at 51 Faleval Register 33157 (September 18.19863 transferred to an appropriate Federat. State, and local agency to tne extent resevent and AUTHORITY: Sections 107 and 1610) of the Atomic Energy Act of 1954, as necessary for an NRC decision about you.

amemted (42 V S.C. 2137 and 2201(i)L WHETHER OISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON PRINCIPAL PURPOSEISh Information enterms on this form is und to determine INDIVIDUAL OF NOT PROVIDING INFORMATION Disclosure 4 voluntary. If t?ie whether the onysical condition and generat heetth of the applicant are such that tney requested mformation 4 not proviued, however, the application for a facihty operator's will not cause operational errors endangermg punhc hea<th and safety. This mforma of sener operator s license may be oemed tion may be uset by the NRC statt to determme if the imiividual meets the renu re-SYSTEM MANAGERIS) AND ADDRESS Chief. Operator ucensmo Brancn. Office of ments of 10 CF R 55 to taae an enemmation or to be issued an operator s hcense Nucie.r Reactor Requiet on. U.S. Nuclear Requistory Commm.on. Wasnmyton. DC 20555 m._ _ m,.

i

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4 g.;

6 EH3460RE 3 SGtRRY OF QElGES '!O 180 PORf 396 Medical Examination Certification Added block " Restriction Change Fzte l

Pzwious Sutaittal" plus Remarks J

emetien.

tkm-Hedical Certification (hnemi non-==linal certification statement to: Power Beactore-This oertifies that the applicant has been found to most the safeguards' and fitness for eksty neuirements of this this facility for licensed operators.

Nonpomer 'Ihis certifies that the appliomat has been found to meet the i

l r.,m,ds*- requimments of this.

facility for 14amammel operators and:-

- I have no knowledge of the applicent w ing the autoff levels for alcohol 3

L or controlled substances as es+=h14=w j

p pursuant to 10 CFR 26.

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ENCU3SURE 4 L

i SUtMARY OF CHAN3ES 'IO NBC Pole 396

- Item 4.d Added clarifying statesmat to indicate this is to be I

checked only if applicatism is to amend license to i

add additional unit (s),

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

Added " Nadi m l".

• M i

Item 4.s Added a new ites "Date Passed Generic Fundamentals Exandnation Section".

L

' Item 12.3 Changed wording to " Certified Startup h.

Completed" for clarification.

Item 12.5 Changed worsiing to " Extra Person (h Shift In Control Room i

3 (13-week miniana)" for clarification.

Item 12.5a Added a new item "Then On Shift Above 20E Peper (6-week minissa)".

Lem 14.a Abded the words "'Ihat Is Based Upon A Systems Approach to Tr=4a4a=" for clarification.

Item 15 Added "Date-and Beault of.Most Roosnt NBC kadnistered Bequalification Enemination".

Item 19.a Added the wording "I flarther certify that I have notified ur current employer of: (1) all previous employers; (2) any instance where I have been tested by a Health and Human Services (HBS)' Certified Drug Testing La6.ww or a Licensee's testing facility for alochol or a centrolled substance, and the test results awand=4 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 substanos described in 10 CFR Part 26; and (4).any reescos for removal or revocation of unescorted access at a nuclear facility".

Item 19.b arxl Item 19.c Moved 19.b and 19.c tesother. Applicable box must now be checked. Also added bicek for typed name of Training Coordinator and Senior Manesement Representative On Site.

POR NBC USE (bder waiver category added "thdi=1".

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