ML20006D715

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

ML20006D715
Person / Time
Site:	Seabrook
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Ellen Brown PUBLIC SERVICE CO. OF NEW HAMPSHIRE
References
NUDOCS 9002140290
Download: ML20006D715 (8)

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JAN 51990

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Docket No. 50.443

-Public Service Company of New Hampshire

' ATTN:

Mr.' Edward A. Brown, President-1

'and Chief Executive Officer New Hampshire Yankee Division Post Office. Box 300-Seabrook, New Hampshire 03874 Gentlemen:

SUBJECT:

REVISED NRC FORMS 396 AND 398 1

Enclosed is a-copy of tnt revised NRC Form-398 (Enclosure 1), Personal 1

- Qualifications Statement

. Licensee and revised NRC. Form-396 (Enclosure 2),

Certification cf Medical Examination By Facility Licensee.

All changes to t N NRC' Form-396 are detailed in Enclosure 3. ' Changes to NRC_.

Form-398 are det&iled in Enclosure 4.

All applications'for licenses are to'be submitted on these revised formsino later than February 1, 1990.

'The enclosed applications are for your use. Additional copies'can be obtained by contacting Beverly Martin, :U.S. Nuclear Reguhtory 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.

If'you have any-questions regarding Onese forms, please contact' Richard J.

Conte at (215)' 337-5120 or Peter W. Eselgroth at (215) 337-5211.

Sincerely, piaird sib"'O Robert M. Gallo, Chief Operations Branch Division of Reactor Safety

Enclosures:

As stated b

00" gg2%$h.k h

v 0FFICIAL RECORD COPY 396 & 398 FORMS - 0037.0.0 12/14/89 4:}

A 1:.

Public Service Company 2

of New Hampshire cc w/o enc 1:

J. C. Duffett, President and Chief Executive Officer, PSNH T. C.-Feigenbaum, Senior Vice President and Chief Operating Officer, NHY J. M. Peschel, Operational Programs Manager, NHY l

D. E. Moody, Station Manager, NHY l

T. Harpster, Director of Licensing Services R. Hallisey, Director, Dept. of Public Health, Commonwealth of Massachusetts S. Woodhouse, Legislative Assistant P. Richardson, Training Manager Public Document Room (PDR)

Local Public Document Room (LPDR)

Nuclear Safety Information Center (NSIC)

NRC Resident Inspector State of New Hampshire, SLO Commonwealth of Massachusetts, SLO Designee j

Seabrook Hearing Service List bec w/o enc 1:

Region I Docket. Room (with concurrences)

Management Assistant, DRMA (w/o encl)

E. McCabe, DRP

.i J. Johnson, DRP l

SRI - Seabrook (w/ concurrences)

V. Nerses, NRR i

OL Facility File j

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l ph, 0 DRS:RI Gallo/pb)j l' {9 01 90 0FFICIAL RECORD COPY 396 & 398 FORMS - 0038.0.0 12/14/89 I

-_______s

INSTRUCT 60NS POR 00MPLETING 98RC PORM 300 PE ROONAL OUALIFICATION ST AT EMENT-LICENSEE TO CEMAIN VALID,THit FORM MUST NOT BE ALTE2E) e 4.

YYPE OF APPLICATION 2.s NEW

• X" IF YOU ARE A NEW APPLICANT. COMPLETE EACH CATEGORY OF THE FORM COMPLETELY, FOLLOWING THE INSTRUCTIONS DELOW THit 18 TO INCLUDE ALL EDUCATION, TRAINING AND EXPERIENCE THAT YOU HAVE RECEIVED UP TO THE DATE OF THIS APPLICAT40N. NOTE: Sff / TEM f 4 - THERE IS AN $XCEPTION. AL90, THIS BLOCK is TO BE MARKED lF PREVIOUS NEW APPLICATION WAS WITHDRAWN, PLEASE WRITE " WITHDREW" NEXT TO "N EW."

2.b thru 2.e - FOR 2.ts THRU 2.e, COMPLETE E ACH CATEGORY COMPLETE LY, BUT INDICATE ONLY THE EDUCATION, TRAINING, AND EXPERIENCE YOU HAVE RECEIVED SINCE YOUR LAST APPLICATION NOTE: Sff / TEM 14 - THERE l$ AN E XCEPTION, 2.b RENEWAL = "X"IF YOU ARE RENEWING CURRENT LICENSE.

2.s UPGRADE "X"IF YOU HOLD A RO LICENSE AND ARE NOW APPLYlNG TO UPGRADE YOUR LICENSE TO A SRO.

2.d MULTI. UNIT

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

RENT LICENSE TO ADO AN ADDITIONAL UNIT.

2.e REAPPLICATION "X"IF YOU HAVE PREVIOUSLY BEEN DENIED A LICENSE AND ARE REAPPLYlNG.

2.f WAIVER REQUESTED "X"THi. APPLICABLE WAlVER REQUESTED AND JUSTlF Y IN COMMENTS SECTION (ITEM 17L 2.g DATE PASSED GENERIC FUNDAMENTALS EXAMINATION SECTION (GFESL THi$ 18 NOT APPLICABLE TO RESEARCH REACTORS. ENTER THE MONTH AND YEAR THE GENEFIC FUNDAMENTALS EXAMINA.

TION SECTION OF THE WRITTEN EXAMINATION WAS PASSED. IF THE GFES WAS NOT TAKEN, YOU MUST HAVE PASSED AN NRC LICENSING EXAMINATr3N ON THE APPLICABLE REACTOR TYPE (PWR OR BWRI AFTER FEBRUARY 1,1DB2,WHICH LED TO THE ISSUANCE OF A LICENSE, THIS DOES NOT INCLUDE INSTRUCTOR CERTIFICATION EXAMINATIONS OR REQUALIFICATION E XAMINATIONS, 11.

EDUCATION - INDICATE BOTH ACADEMIC AND VOCATIONAL / TECHNICAL POST HIGH SCHOOL EDUCATION. FOR MAJOR AREAIS) OF STUDY, INDICATE THE NUMBER OF YEARS SPENT IN EACH COLLEGE CURRICULUM ANO 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. OlESEL MECHANIC SCHOOL, ETC.

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

TlOWAL SPACE 15 NEEDED, CON 1 tNUE 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 THl8 CATEGORY PARALLELS THE ANS STANDARDS REFER TO THE STANDARDS OF 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 18 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). THEntFORE, THE DATE COLUMNS MAY INDIC/,TE A LARGER TIME SPAN THAN THE ACTUAL NUMBER OF WEEKS SPENT IN FULL TlWE TRAINING, TIME IN TRAINING FOR THE LICENSE APPLIED FOR CANNOT SE DOUBLE COUNTED UNDER EXPERIENCE tlTEM 13),

ALL REQUALIFICATION TRAINING TIME IS TO BE ACCOUNTED FOR IN THE REQUAllFICATION ITEM, Pl. EASE DO NOT "DOJBLE LIST" THE TIME SPENT IN REQUALIFICATION TRAINING UNDER ITEM 12.6, REQUAllFICATION, EVEN THOUGH IT MAY INCLUOE CLASSROOM OR SIMULATOR TIME, 13.

EXPERIENCE - A MINIMUM OF 6 MONTHS AT THE SITE FOR WHICH THE LICENSE IS SOUGHT 18 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 e. GRADUATE OF INPO ACCREDITED OPERATOR TRAINING PROGRAM AND E """ LED (ON NRC FOP.M 474) OR NRC f.PPROVC0 SIMULATICN " ACILITY IS USED W THE OrERxTOR T halNsNu PHO.

GRAM. IF "YES" IS CHECKED IN BOTH ITEMS 14.s AND 14.12. THEN ITEMS 11 (EDUCATIONI.12 (TRAININGl,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 ACCREDITEO ME ANS ACCREDITATION BY THE NATIONAL NUCLEAR ACCREDITING BOARD AND MEANS THAT AT LEAST THE MINIMUM REQUIREMENTS OF REGULATORY GUIDE 1.B, REV. 2, ARE MET,

ifi, 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.

N ATION.

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 15 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.

15.

NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY F ACILITY LICENSEE - MUST ACCOMPANY THIS APPLICATION.

l l

19.

SIGNATURES - SIGN AND DATE ITEM 19.e. OBTAIN YOUR TRAINING COORDINATOR *$ SIGNATURE AND THAT OF YOUR SENIOR l

MANAGEMENT REPRESENTATIVE ON SITE,

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

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.o CERTIFICATION OF MEDICAL EXAMINATION yg'oj,T4=,'pt.afo;g,g,f,y,g BY FACIm LICENSEE en ame.n.ip s..eavo,s muet..aRano,o,a.tomye ae.c.o am.is, u

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FOLLOWE D AND THAT DOCUMENTATION 15 AV AILASLE 8 0m Rt vitw BY NRC.

ON THE BA$tE Op tHE RECOMMENDAtl0N OF T%fHY$1CIAN 4 RECOMMEND THAT THE APPLICANT'$ OPER ATOR LICENSI 85 CONDITIONED A$

FOLLOWS.

l. NO fitSTRICTIONS

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$ ROPO$t D WQRDING Of RESTRICTION v8ssaa 4 steer kt LATIONSHIP OF RIST RICTION TO DISQUALIF YING CONDiflON t8re /r mcreare n w rearsten west conert the armhmurens conostens r

o Et MAna,5 FOR RtSTRicTION CHANGE (8/oca 6 acows

61. NONMLPtCAL CE HilflCAllON POwt R f<t ACTOR $

THIS CE RTIFit$ TH AT THE APPLICANT HAS STEN f ouND TO Mt Ei THE EAf EGUAfiDS~ AND FITNESS FOR DUTY REQUIREMENTS Of THis F ACILif Y FOR LICEN5ED OPE R ATOR$

NON POWE R Rt ACTORS THl$ CERilFit$ THAT THE APPLICANT HA5 8ttN f OUND TO MEET THE SAFEGUARDS' Rf 0UIREMENT5 0F THIS F ACILITY FOR LICEN$tDOPER ATORS AND I HAvt NO KNOWLEDGE OF THE APPLICANT E KCEEDING THE CUTOF F Livf LS FOR ALCOHOL OR CDNTROLLED SUBST ANCES AS ESTABLISHED PUR$UANT TO 10 CFR 76 pv e a6bt sin t two wt on uwav= in iwas ovevwe=f =uumNu ni < as. wamis war et sumatti f u cwie amu ceuwana6 saws.tivNs e ctu lir = uNuta et Na6 ii ut stRJUfiv Yhai TH{ lheORwatiON IN THe5 DOCuwtNT aND a fiaCHwshf 8 is THut AND CO6IRLC1

$ RINTED N AME AND SIGN AT URE dener 4ranepement stepressarer,w on S,res flTLE DAIt in accoroance wien 10 CF R H A Communicatens. this form theit be submitted to the NRC as toHows 8 Y MAIL ADDRt S$t D 70.

Regenal Admemstrator Regen i Regenet Admminitator, Region il Regional Admenntfoor. Regen all V 1. Naciear Requietory Comminen U $ Nuclear Requistory Commiumn U $ Nucrea, peouestoi, Comminen 47% Aliennais Road 101 Manetta Sirest Suite 3100 799 Rooseveit Road Emg ot Pruuia. P A 19406 At6 ante G A 30373 Glen tilyn. L ticl37 Regenal Adminiittator, Region IV Regionai Administrator, Region V U S Nucseat Regu6 story Commenen U S Nucle.' Requistory Comminen 611 Ryan Pisaa Drive Suite 1000 1450 Maria Lane. Suite 710 Aehngton. T K 76011 Wamut Greet. CA 94b96 PRiv ACY ACT $1 AILME NI Pursuant to 6 U.$.C 667steH3t eneeted into saw tiv tecuon 3 of the Pnvecy Act of ROUTINE USES The information may be discioned to an approswiate Federal, State, of 1974 (Public La* 93 5791,the sonoming statement is 'urnished to moividuais who soc.ai agency m the event the moormaten mdicates a vioicion or potentini viotaien of tee suppiv information to the U $ Nuclear Regulatory Comminion on NRC Foem 396 ants in the event the iritormation moscates a viosaica oe omential violaten of saw and in Th entormation is morntained in a system of comros cenignated as NRC 16 and the course of an admmistrative or suoiciai proceedme in addition. th.i m6ormaten may be oescribed at 61 Federsi Regmw 33167 ISeptemtiet 18 19861 tramiteriod to an appropr< ate Federat. State, ano lor.at opncy to ibe entent reievent end AUTHORITY Sectens 107 and 161M ci the Atomic Ene'ov Act of 1954 ai neceuary for en NRC onmen steut you amended (42 U $ C 7137 and 770lM).

WHLTHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFiCT ON PRINCIPAL PURPOSt(S) Informatiam entwed on teni form is used to oetemme INDivlDUAL OF NOT PROvtDING INFORMAtlON Disciowe 4 voiuntary. If the whethe the pnvocai conditen are geneemt heanth of the appiecent are such inat thev

• tue"ed mNrmaten is not provided. ho*ever. the appsicai un tot a taciisty oserstor's will not cause olefstenai efroft erttiangenf g puDisc heefth and seletv. Thst informa of senior operator iiscense may be ceNeo ten may be used by the NRC natt to oeiermme d the md;viouc meest the repre $YSTtM MANACERi$) AND ADDRtSS Chief. Opvator Licenono Branch Omce of ments of 10 CF R 56 to tese en enemmaten or to be issued an operator's hcense Nuclear Peactor Reguistion U S Naciear Requietor, Comminion. Washingioi DC 20566 e h( enegi Met < if) Aisi v

i D U 46DRE 3 StatERY OF CHAN3ES M IGC FORM 396 i

f Medical r-Ntion Certificatim Added block "Bestriction Change Fres Prwious Sunnaittal" plus Ramarts 4

secticri.

He-Medical Certificatico Changed non-mariinal certification statement to: Power Reactors-This certifies that the applicant has been found to unet the safeguards' and i

fitness for chaty requirementa of this this facility for licensed operators.

N a pouer-this certifies that the applicant has been found to meet the I

safesuards' requirementa of this facility for licensed operators and I have no knowledge of the applicant

==a==iig the curtoff levels for alcohol i

L or controlled substances as es+=h14=hant parsuant to 10 CFR 26.

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DCUCSURE 4 SttttARY OF CHAMES '!O IEC 70R1398 Itan 4.d Added clarifying statement to indiasta this is to be checked caly if application is to amend lioenee to add additional satit(s).

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

Added "te atn.1".

Item 4.s Added a new item "Date Passed Generic 1%ndamentals Examination Section".

I Item 12.3 Changed wording to " Certified Startup r.w.

Ccepleted" for clarification.

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

Item 12.5a Added a new item " Time on Shift Above 20E Power (6-week i

minisam)".

Item 14.a Added the words "'! hat Is Based Upon A Systems Aw.M.

to Training" for clarification.

Item 15 Added "Date and Result of Host Roosnt NRC Administered Requalification Enemination".

Item 19.a-Added the wording "I further certify that I have notified er current employer of: (1) all prwicus employers: (2) any instance where I have been tested by a Health und Human l

Services (HBB) Certified Dms Testing Laboratory or a Licensee's testing facility for alochol or a controlled substanos, and the test tumults==a== dad the cutoff levels established pursuant to 10 CFR Part 26; (3) any instance where I have been arzwoted for the sale, use or possession of a controlled substenos described in 10 CFR Part 26; and (4) any asemens for removal or twvocation of unescorted access at a nuclear facility".

Item 19.b and Item 19.c Moved 19.b and 13.c tesother. Applicable box aust now be checked. Also added block for typed name of Training Coordinator and Senior Man.sament Representative On Site.

ICR HIC USE Onder waiver estesory added "tematnaia,

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