ML20006D714

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

ML20006D714
Person / Time
Site:	Shoreham File:Long Island Lighting Company icon.png
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Stieger W LONG ISLAND LIGHTING CO.
References
NUDOCS 9002140287
Download: ML20006D714 (8)

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D-JAN 5 1990 Docket No.-

50-322 i

Long Island Lighting Company l

ATTN: Mr. William E. Stieger, Jr.

l Assistant Vice President - Nuclear P. O. Box 618 L

_Shoreham Nuclear Power Station F

Wading River, New York 11792 i

Gentlemen:

i L

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 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 Beverly Martia 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 NK3B 7714, Washington, D.C.

2055' 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, f

M-4=1 Siened Bri" Robert M. Gallo, Chief Operations Branch Division of Reactor Safety l

Enclosures:

As stated 1

9002140287 90o1o5

{DR ADOCK 05000322 PDC OFFICIAL RECORD COPY 396 & 398 FORMS - 0035.0.0 12/14/89

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' Long' Island Lighting Company 2

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cc w/o enc 1:

J. Scalice, Plant Manager R. Gutmann, Manager, Nuclear Operations Support R. Kascasak, Manager, Nuclear Engineering J. Futter, General Counsel W. Maloney, Manager, QA Department L Calone, Training Manager

Director, Power Division State of New York, Department of Law Shoreham Hearing Service List Public Document Room (PDR) local Public Document Room (LPDR)

Nuclear Safety Information Center (NSIC)

LNRC Resident Inspector State of.New York bec w/o enc 1:

Region I Docket Room (with concurrences)

Management. Assistant,DRMA(w/oenc1)

M. Knapp, DRSS W. Hodges, DRS L. Doerflein, DRP P. Kauffman, DRP M.. Young, OGC J. N4koski, DRP S. Brown. NRR J. Dyer, EDD OL Facility File l

l' DRS:RI Gallo/pbph l

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g OFFICIAL RECORD COPY 396 & 398 FORMS - 0036.0.0 12/14/89 m

i INSTRUCTIONS POR 00MPLETING NRC PORIA 300 i

PERSONAL OUALIFICAT40N STT.TEMENT-LICENSEE TJ REMAIN VALI ATH3 FORM MUST NOT DE ALTEIED e

4 I

4 TYPE OF APPLICAYlON 2.s NEW

• X" IF YOU ARE A NEW APPLICANT. COMPLETE EACH CATEGORY OF THE FORM COMPLETELY, FOLLOWING THE i

INSTRUCTIONS DELOW. THIS IS TO INCLUDE ALL EDUCATION, TRAINING AND EXPERIENCE THAT YOU HAVE i

RECElvED UP TO THE DATE OF THIS APPLICAT4ON NOTE: SEE / TEM f4 - THERE IS AN EXCEPTION. Alto.THIS BLOCK IS TO DE MARKED IF PREVIOUS NEW APPLICATION WAS WITHDRAWh. PLEASE WRITE " WITHDREW" NEXT TO "NEW/*

i 2A tlwu 2.e-FOR 2h THRU 2 e, COMPLETE EACH CATEGORY COMPLETELY, BUT INDICATE ONLY THE EDUCATION, TRAINING, AND EXPERIENCE YOU HAVE RECEIVED SINCE YOUR LAST APPLICATION. NOTE: SEE ITEM 14 - THERE IS AN E XCEPTION.

(

2A RENEWAL

• X"1F YOU ARE RENEWING CURRENT LICENSE.

2.s UPGRADE "X"lF YOU HOLD A RO LICENSE AND ARE NOW APPLYING TO UPGRADE YOUR LICENSE TO A $RO.

2.d MULTI-UNIT "X" lF YOU CURRENTLY HOLD A LICENSE AT YOUR F ACILITY AND ARE APPLYING 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 REOUESTED "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. [NTER THE MONTH AND YEAR THE GENERIC FUNDAMENTALS EXAMIN TION SECTION OF THE WRITTEN EXAMINATION WAS PASSED. IF THE GFES WAS NOT TAKEN.YOU MUST HAVE PASSED A 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.

l

- 11.

EDUCATION - INDICATE BOTH ACADEMIC AND VOCATIONAL / TECHNICAL POST HIGH SCHOOL EDUCATION. FOR MA.

AREAtS) 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 TRAINING, AIR CONDITIONING / REFRIGERATION, DIESEL MECHANIC GCH3OL ETC.

INDICATE THE NUMBER OF MONTHS IN EACH PROGRAM AND WHETHER A CERTIFICATE OR DEGREE WAS AW TlON AL SPACE.l8 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. T BREAKDOWN OF TRAINING IN THIS CATEGORY PARALLELS THE ANS STANDARDS. REFER TO THE STANDARDS IF YO FURTHER CLARIFICATION INCLUDE BOTH BEGINNING AND COMPLETION DATES AND THE TOTAL NUMBER OF W IN EACH TYPE OF TRAINING. THE NUMBER OF WEEKS IS PROVIDED, IN ADDITION 10 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 O SPENT IN FULL. TIME TRAINING. TIME IN TRAINING FOR THE LICENSE APPLIED FOR CANNOT BE DOUSLE COUNT EXPERIENCE (ITEM 13),

ALL REQUAllFICATION TRAINING TIME IS TO BE ACCOUNTED FOR IN THE REOUALIFICATION ITEM. PLEASE DO NOT "

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 EA HELD, COMPLETf ITEM 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 SH NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCECD THE NUMBER OF MONTHS THAT ARE

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TIME PERIGD, 14.

FACILITY OPERATOR TRAINING PROORAM - INDICATE e. GRADUATE OF INPO ACCREDITED OPERATOR TRAINI AND lt CERTIFIED ION NRC FORM 47d1 OR 'MC ffPROVCD CIMULATION FACILIT'/ G C, A THE OPERATOR TRAINING PRO.

GRAM. IF "YES" IS CHECKED IN BOTH ITEMS 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 NU 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 REGULATOR GUsDE 1.8, REV,2. ARE MET, 16.

FOR RENEWALS ONLY - (1) ENTER THE APPROXIHATE NUMBER OF HOURS SINCE PREVIOUS RENEWAL OR ISSUAN LICENSE 1F FIRST RENEWAL. l2) ENTER DATE AND RESULT OF MOST RECENT NRC ADMINISTERED REQUALIFICATION E NATION.

16.

EXPERIENCE DETAILS - INCLUDE POSITIOld 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 T CATION FORM. IF THE SPACE PROVIDED IS NOT SUFFICIENT, YOU MAY ATTACH EXTRA INFORMATION WITH YOUR APPLICA.

TION.

15.

NRC FORM 398, CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE - MUST ACCOMPANY THl$ APPLICATION.

19.

SIGNATURES - SIGN AND DATE ITEM 19.e. OBTAIN YOUR TRAINING COORDINATOR'S SIGNATt'RE AND THAT OF YOUR MANAGEMENT REPRESENTATIVE ON SITE.

DETACH THESE INSTRUCTIONS AND SUSMif THE COMPLETED NRC FORMS 398 (ORIGINAL AND TWO COPlES EACH) TO T PRIATE REGIONAL ADMINISTRATOR,

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$6.47, eesi tt.67 ESTIMAf tP) DURDtN Pin RESPoldte TO COnePLY WITH THl$ INFORMATION COL L O CTION RIOutSTs 98 HR8 00Rm ARD ConsbetNTS RIGARDING DuMotN tsTIMAff PERSONAL QUALIFICATION STATEMENT-LICENSEE TO THE o*oaMAfiON Amo atCORD: MANAGEMENT BRAldCH 19 630). U.S NUCLE AR R60VLAT081Y CotAhtl$r Slots matHtNOTON, DC 2266. AND TO THE PAPensuomK REDUCTION PROJECT (31604000). Offlet OF MANAGE.

TO REhtAIN VALID,THIS FORM heUST NOT BE ALTERED MENT AND sUDGrt.m ASHINGTON. DC 20ec3.

1. APPLICAtiT*$ FULL NAldt (Last. F/rst, Afskfief AND ADDI ESS (nelude //P Codel

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12. T R AINING (SINCE L AST APPLICA TION - SEE INSTRUCTIONS)

13. E KPERIf NCE (DO NOT DOUBLE COUNT-SEE INSTRUCTIONS)

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1-NUCLEAR POWER PLANT FUNDAMENTALS rwns 1.RO 2 -PLANT SYSTEMS 2 EOOW/PPWO CLASSROOM

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4. E RS/CRW 3-OPER ATING PR ACTICE 6.OTHE R tsoec441 CONTROL ROOM OPERATIONS ON SHIFT j

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a. $",[r a,gajpve los rows m I? SHIFT SUPERVISOR (twanw hs 6 REQUALIFICATION 13 STAFF / SHIFT ENOINEER tt4:eamrt 7 -0THER tspees&i

14. AUXJEQUIP. OPERATOR (Noaranents

16. PLANT STAF F 16 OiHER tspere&i esRC PORM ass 1104e)

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14, NRC PORM 308. CERTIFICAtlON OF MEDlCAL EXAMINATION 8Y W ACILITY LICENSEE, IS ATTACedtD ANY F ALS6 ST ATEMENT OR OMIS$10N IN THit DOCUMENT. INCLUDING ATT ACHMENTE. MAY BL SUhJECT TO CIVIL AND CRIMINAL SANCTIONS.

h I earthy unser poneny of sortury thee see 6ntormaison en this comument end evierhmenis is true end sorrect.1 inssher cetteev thet I heie notifiert snv eurrem enosever ef: 411 en previous anotavers, (26 eny Inneense where i hoe hose teques by a tesehh emt Human terwees (HHtl Cartefed Deus Tamine Letoreteers or e Licensee a teaune sectiny for escehel or o comrened mansionse, end one ree; remune eseesses esse auton esseen esteenshed pursuem to 10 CFR het 28. f 3J env snownre where 4 have timen erresus for the sees. use or posessen of e sonircosse sukelence gastriend in 60 CPR Port 26; ens 441 any reasons ter somWet ur seioseteen o; unserorted seesie et e enasease'teutny, t seso sucherire the NRC to mamma the results of enanunestens la my empseyers ter use e psoper6ng regre6mns l

peesseme as nosesserv

$60 NATURE-APPLICAN1 DAT&

l CHECK APPLICASLE 80X

] k I sortsey ther the emme named irvssvideer nei sucee. stun, competed the legliny Hrenesse reautrename to.pned evisen ones etisi the be hrensed as en Operator /$enior Opersion pursuem to Tale 10. Code et Fedwal Reevisim Rest OS:eles tensi the indestehael has e need for en Operatorisonsor Operatoe tesense to suertoren ruusher one somehr of periury that the intoemenen nn the escument and ettechenente a true oms correct.

] 6 RENSW AL ONLY = I certlN thei the snow named endivalvet moei thea.moroved numaailfi,ceima proyem (+srA eareprene screer et frem f1/ en reau shot he/she has descherged h6s/ tier ucensed responsitdinme gorrggional and estety, i beso certth under pensity of pertuty that the intonnetton in tan gocument end attachmente is true entf correct.

TRAINING COORDINATOR SENIOR MANAGEMENT REPRESENT ATIVE ON $1TE PRINTSO OR TYPED hAME PRINTED OR TYPED hAME

' f SIGNATURE DATE stGNATURE lDATE FOR NRC USE m vcRrC w.,ei,,,.. - w n i umi REaumom l loot NoT um Riou Rtume,u,,.m.e uh m.o.,

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.aoh m&SMiNGTDN DC 2o.bte AND to TMt eaetnesomet wth? AND SvDGE1 th ASMthGTQh DC 2o.ect Of s3i ceD2ai Ose tahanAGE.

elDUCT 6oN ennatet 03 NAME OF APPLiLANT F ACILITY lF ACILITY DOCILET nut 4BER A. MEDICAL 1XAMIN ATION CERTIFICATION THIS l$ TO CE RTIF v THAT THE Aelovt NAutD APPLICANT FOR AN OPERATORr5ENIOR OPERATOR LICENSE MAS BE EN E EAMINED 0 Y A PHY$1CIAN PRINTED NAME sof parseceens lST ATE AND LICLNEL NUMBER l t k AMINATION DATL BA&ED ON THE RISULTE OF THE E xAMINATION #NCLUDING INFORMATION F URNISHED SV THE APPLICANT THE PHY$4CIAN HA$ DETERMINED THAT THE APPLICANT'S PHY$1 CAL CONDlit0N AND GENE R AL Mt ALTH ARE NOT SUCH THAT sf MICHT CAvst OPE R ATION AL t RROR$ END ANGERING PVOLIC HE ALTH AND LAF TTY t Ct RTif Y THAT IN RE ACHING THl$ DETE RMINAfl0N THE GUIDANCE CDNT AINED IN AN$1 SAN 5 3 41983 OR ANSI /ANS 16 41977 rN3001 *A5 FOLLOWED AND THAT DOCUMENT ATION is AVAILABLE FOR RiviEW BY NRC.

Ohi THE BA$15 0F THE Rt COMMENDATION OF ThLfHYSICIAN 4 Rt COMMEND THAT THL APPLICANT'$ OPER ATOR LICIN1E 86 CONDITIONID A$

FOLLOWS

t. NO RE5t RICTIONS

2. CORRICTlvt LIN$t$ BE WORN WHEN PERFORMING LICEN$tD DUTl[$

3. HE ARING AlD BE WORN WHEN Pt FIFORMING LICthttD Dutit$

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4. AtSTRiCTED LICE NSE OR t XCEPTION Provee aetus tween and attach supportmg medical evitence for NRC review

,emar 6 RI ST RICTION CHANCE F MOM PRt vlous SUBMITT AL.Peovce details beic* arut attach supportmo medical ogmente for NRC reywe t

iROPO&tD WORDING OF RtaiRICTION tahra 4 sie.es LE LATIONSHIP DF R E ST RICT10N TO D150VALIF YING CONDITION Isreeny mascere how restrerveen wett coreact the assous/dymp eoncurens KLMAHAS FOR RESTRICTION CHANGE (8soca 8 sho*es it. NONMLDICAL CERTIFICAllON POWL R R( ACTOR 5 THis CERTIF els THAT THE APPLICANT HAS BitN FOUND TO Mt t Y THE EAF EGUARDS' AND FITNLSS FOR DUTV REOUIREMENTS OF THl$ F ACILITY FOR LICEN5ED OPERATORS NON POWE R Rt ACTORS.

THis CERfifit$ THAT THE APPLICANT MAS CEEN FOUND TO MtET THE $Af tGUARDS' REQUIRE MFN f 5 0F THis F ACILITY FOR LICEN$tDOPERATORS. AND 4 HAvt No KNOWLEDGE OF THE APPLICANT E KCitDING THE CUTOFF LivtL5 FOR ALCOHOL OR CONTROLLED SU8tT ANCE S A$ EST ABLISHED PUR$UANT TO 10 CF R 2B n, e aua s t at t ut=v oa uwiuium en tais oucuwthr =ctuoimu At tacnwthis ua, es avsaac t vo civs ano oniwanat puc tivhn. a c6eitie. Uwth rtN% :i ue f tRJupv TWAT THE INeOmua1och th TMIS DOCUMENT AND ATT ACMME NI$ ($ TRU( AND (QRM$CT PRINTED N AME AND SIGN ATURE (Senor a8enegemerit Aeorementarsee on S res TITLE DATE i

la accorcance niin to CF R 65.6. Communicaiens. thu form she De submitted to the NRC as tollows-B Y MAIL ADDRt$5ED iO:

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Regional Admmistrator, Region i Regional Admmistrator Regen ti Flegionai Aaminatrator. Region ill i

U.6, Nuclear Requidiory Commissen U.S Nciear Repatory Commission U $ Nucioar Fleculatory Conimasen 476 Allencate Rosa 101 Marietta Street. Suite 3100 799 Rooseveit Road Kmg of Prussia. PA 19406 Atlanta. G A 30323 Geen iIf yn. tL 60137 Regenal Animmestrator. Regeon IV flegional Admimstrator. Regen V U S. Noriear Repatory Commessen U $ Nuclear Reguiatory Commissen 611 Rvan Plaae Drive. Suite 1000 1450 Mare Lane. Suite 210 Arimgton. TX 76011 Walttut Creen, CA 94596 PRIVACY ACT STATLME NT Pursuant to 6 v$.C 152ateH3L enacted mio law by weison 3 of the Privacy Act of ROUTINE U$ts-The mformaten may be disciosed to an appropriate Feoerat $ tate. or 1974 (Public La* 93 579L ihe followmg statement is Nenished to ireivewais who lout agency m the event the information ervticates a vioisten or potentist violaten of tee supply informaten to the U $ Nuclear Regulatory Commasen on NRC Form 396 and m the event the informaten erecates a ventaten or corentesi violaten of law and m This m'ormation is mamtemed in a system of records oesignated as NRC 16 and the coutw of an administrative or suaecial proceedmg in addition, th.: mtormation may be oescritwo et 61 Federal Register 33t67 (Sepiemter 18.1986>

traruterred to an sopropriate Feoerat Sisie and locat agency to the entent reievant and AUTHORITY, Sectens 107 and 16tM of the Atomic Ene gy Act of 1954, as necessary for an NRC decision ateut you amenced t42 U.S C. 2137 anU 2201M).

WHtTHER DISCLOSURE 15 MANDATORY OR VOLUNT ARY AND (FFICT ON PRINCIP AL PURPOSEISL Irdormanon entered on this form is used to neiermme INDivlDUAL OF NOT PRoviDING INFORMATION Daciosure is voluntary. If the whether the physican conditen and genefat health of the appacant are such that they 'eauested mtormation is not provided. hoerver. the appacaven for a facility oserstor s will not cause operationai errors ennangerme outmc hesith and safety. This mtorma-or unior ope'ato's l' cense may be nemea tion may be used av the NRC statt to ottermme it tre maividuai meets the reovire $YSTEM MANAGERIS) AND ADDRESS Chief Orwrator Licenong Branch OHice of ments et 10 CF R 65 to tame en esammaten or to be issued an operator s I; tense Nucteer Reactor Reguistion. U $ Nuclear Regulatory Commwon. Washmgion. DC 20656 l.

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i INCIASURE 3 StitlARY CF CHA!MS '!O HRC FORT 396 l

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Medical Examination Certification Added block " Restriction Change From Prwious Sunnittal" plus Remarts section.

i Han-Medical Certification Changed non-=arlie=1 certification

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statmeent to: Peeer Reactoss-lhis i

certifies that the aseliaant has been i

found to east the==farsantis' and-fitnoes for drty requissoants of this this facility for licensed operators.

Hanpouer-this certifies that the applicant has been food to meet the enfesuards' reesirements of this faatlity for licensed operatore and I have no knowledge of the applicant i

enameding the curtoff levels for alambol or aantrolled mabstana== as es+ahlih t

pursuant to 10 CFR 26.

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SitetARY OF CHAMES 10 W 70lti 398 i

l Item 4.d Added clarifying statesmat to indiasta this is to be checked only if appliostian is to amend limenes to add additional unit (s).

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Item 4.f l

Added "(Category)" to Operating.

Added " tend h l".

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

l Item 12.3 Changed wording to " Certified Startup Program Completed" l

for clarification.

)

Itam 12.5 Changed wording to " Extra Person Ch Shift In Control Roca (13-week minimum)" for clarification.

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

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

i Item 15 Added "Date and Result of Most Roosnt NRC Administered I

Daqiumlification Examination".

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

ur current employer of t (1) all prwious employers: (2) anr instance where I have been tested by a Health and Ikaan i

Services (HBB) Certified Drug Testing h.u, or a i

Licensee's testing facility for alochol or a controlled

.1 substance, and the test results M the cutoff levels established pursuant to 10 CFR Part 26 (3) any instance where I have been artested for the sale, use or possession of a controlled substatue described in 10 CFR Part 26 and (4) any reemens for rumoval or revocation of unescorted access at a nuclear facility".

Item 19.b and Item 19.c tkned 19.b and 19.c together. Applicable box aust now be I

checked. Also added block for typed nome of Training Coordinator and Senior Menessment Representative on Site.

POR NRC USE

- thder waiver category added " Medical",

i

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