ML20006D719

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 Form by 900201

ML20006D719
Person / Time
Site:	Oyster Creek
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Fitzpatrick E GENERAL PUBLIC UTILITIES CORP.
References
NUDOCS 9002140294
Download: ML20006D719 (8)

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JAN-51990 Docket No. 50-219' GPU Nuclear Corporation ATTN: LMr. Eugene E. Fitzpatrick Vice President and Director Oyster Creek Nuclear. Generating Station P. 0, Box'388 Forked River, New Jersey 08731 l

-Gentlemen:

SUBJECT:

REVISED NRC FORMS 396 AND 398 Enclosed is a copy of-the revised NRC Form-398 (Enclosure 1), Personal

- Qualifications Stat'ement - 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 Martin,-U.S. Nuclear Regulatory Commission, by telephone

i (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 these forms, please contact' Richard J, Conte at.(215) 337-5120 or Peter W. Eselgroth at (215) 337-5211.

.i Sincerely, original U "'

Robert M. Gallo,. Chief i

Operations Branch Division of Reactor Safety c

Enclosures:

As stated 1

b 21gQ iS2h OFFICIAL RECORD COPY 396 & 398 FORMS - 0007.0.0 12/14/89 5~

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.GPU. Nuclear Corporation-

'2.

cc w/o enc 1:

M. Laggart, BWR Licensing Manager-J D. Kowalski, Manager, Plant, Training (w/ enclosures)-

l Licensing Manager, Oyster Creek Public Document Room (POR) e Local Public Document Room (LPOR)-

Nuclear Safety Information Center (NSIC)

NRC Resident. Inspector (w/SGI)

State of New Jersey l

bec w/o enc 1:

. Region I Docket Room (with concurrences)

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

Section Chief, DRP A. Dromerick, Project Manager, NRR J. Dyer,.E00 OL Facility File i

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1 0FFICIAL RECORD COPY 396 & 398 FORMS - 0008.0.0 12/14/89

p INST.IUCTIONS FOR COMPLETING NZC FIRM 300 PERSONAL CUALIFICATlON STATEMENT-LICENSEE i

+

TO REMAIN VALID,THIS FEM MUST NOT BE ALTERED 4,

'TYPICF APPLICATION 2.a NEW "X" IF 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 74 - 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 thru 2.e-FOR 2.b THRU 2.e, COMPLETE EACH CATEGORY COMPLETELY, BUT INDICATE ONLY THE EDUCATION, TRAIN'* G, AND EXPERIENCE YOU HAVE RECElVED SINCE YOUR LAST APPLICATION, NOTE: SEE / TEM 14 - THERE IS AN E XCEl' TION, j

2.0 RENEWAL "X"lF YOU ARE RENEWING CURRENT LICENSE, 2.c UPGRADE "X"IF YOU HOLD A RO LICENSE AND ARE NOW AP!" YlNG TO UPGRADE YOUR LICENSE TO A SRO, 241 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"(F YOU HAVE PREVIOUSLY BEEN DENIED A LICENSE AND ARE REAPPLYING, 2.f WAlVER REQUESTED "X"THE. APPLICABLE WAlVER REQUESTED AND JUSTIFY IN COMMENTS SECTION (ITEM 17),

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

THIS IS NOT APPLfCABLE TO RESEARCH REACTORS. ENTER THE MONTH AND YEAR THE GENERIC FUNDAMENTALS EXAMINA.

I TION SECTION 05 THE WRITTEN EXAMINATION WAS PASSED, IF THE OFES WAS NOT TAKEN,YOU MUST HAVE PASSED AN NRC

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LICENSING EXAMINATION ON THE APPLICABLE REACTOR TYPE (PWR OR BWR) AFTER FEBRUARY 1,1982,WHICH LED TO THE j

ISSUANCE OF A LICENSE THIS DOES NOT INCLUDE INSTRUCTOR CERTIFICATION EXAMINATIONS OR REQUAllFICATION EXAMINATIONS, j

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 AND THE HIGHEST DEGREE I

RECEIVED, USING THE DEGREE CODE PROVIDED, FOR VOCATIONAL / TECHNICAL EDUCATION, INCLUDE PROGRAMS SUCH i

AS NUCLEAR POWER SCHOOL, MILITARY TRAINING, AIR CONDITIONING / REFRIGERATION, DIESEL MECHANIC SCHOOL, ETC, l

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

I TIONAL SPACE 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 1

FURTHER CLARIFICATION, INCLUDE BOTH BEGINNING AND COMPLETION DATES AND THE TOTAL NUMBER OF WEEKS SPENT IN EACri 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 3

. PERIOD) THEREFORE, THE DATE COLUMNS MAY INDICATE A LARGER TIME SPAN THAN THE ACTUAL NUMBER OF WEEKd 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 " DOUBLE i

LIST" THE TIME SPENT IN REQUALIFICATION TRAINING UNDER ITEM 12.6, REQUALIFICATION, EVEN THOUGH IT MAY INCLUDE CLASSROOM OR SIMULATOR TIME, lJ 13.

EXPERIENCE - A MINIMUM OF 6 MONTHS AT THE SITE FOR WHICH THE LICENSE IS SOUGHT IS 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 4

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 a GRADUATE OF INPO ACCREDITED OPERATOR TRAINING PROGR AND b. NTirien 'ON NRC FORM 474) OR NRC AIT" OWC 0,U,%.MiON FACILITY IS UStu m e ne veERATOR 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 NUMBER OF SIGNIFICANT CONTROL MANIPULATIONS UNDER ITEM 12.3, NOTE: INPO ACCREDITED MEANS ACCREDITATION BY THE j

NATIONAL NUCLEAR ACCREDITING BOARD AND MEANS THAT AT LEAST THE MINIMUM REQUIREMENTS OF REGULATORY GUIDE 12, REV,2, ARE MET, 15.

FOR RENCWALS 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, j

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 lF NECESSARY, i

l.

ATTACH ADDITIONAL INFORMATION, 17.

COMMENTS - USE THIS SPACE TO INCLUDE ANY EXTRA INFORMATION OR CLARlFICATION FOR OTHER ITEMS ON THE APPLI.

CATION FORM, IF THE SPACE PROVIDED IS NOT SUFFICIENT, YOU MAY ATTACH EXTRA INFORMATION WITH YOUR APPLICA.

TlON, 18.

NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION BY FACILITY LICENSEE - MUST ACCOMPANY THIS APPLICATION, 19.

SIGNATURES - SIGN AND D#E ITEM 19 a. OBTAIN YOUR TRAINING C00RDINATOR'S SIGNATURE AND THAT OF YOUR SENIOR MANAGEMENT REPRESENTATIVE ON SITE.

l l

DETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS 398 (ORIGINAL AND TWO COPIES EACH) TO THE APPRO.

E PRIATE REGIONAL ADMINISTRATOR,

~. - -

+

ISCFORJ3W W.E NUCLEAR stE4WLA104Y COesel8SION APPMOVE O SY OMS: NO. 31604000 0.nf t RECElvf D W

f0 1M4 S KPIMI; $'31C2 96 47,end t6.67 ESTIMATED DURDEN PER RESPON5E TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 2D HMS.

FORWARD COMMENTS REGARDING BURDEN ESTIMATE

. PERSONAL QUALIFICATION STATEMENT-LICENSEE TO THE INFORM ATiON AND RECORDS MANAGEMENT 1

BRANCH IP 630). U.S. NUCLE AR REOULATORY COMMIS.

l' SiON. WASHINGTON, DC 20666. AND TO THE PAPERWORK i-REDUCTION PROJECT (31604000). OFFICE OF M ANAGE.

l TO REMAIN VALID.THIS FORM MUST NOT BE ALTERED MENT AND BUDOET,W ASHINGTON. DC 20603.

i l>

1. APPLICANT'S FULL NAME Ilest. Firar,Mnk(lel AND ADDRESS (hactudellP Cbdel

4. TYPE OF APPLICATION (Check app /ksb/s boxes) l

s. RE APPLICATION

• 1. j A,A[

IU 1 HOT g

2. COLD

1. FIRST IWRITTENICeesporyJ

s. NEW 2 6EC W

2. OPE R ATINO fcem

b. RENEW AL

3. THIRD M

c. UPORADE 3. E LIOlBILIT Y i

1

d. MULTI-UNIT IAMEND TO INCLVOf ADOITIONAL l

4. MEDICAL Unit)

2. CITl2ENSHIP

3. BIRTH DATE 6.OTHER

& UNITEO STATES MONTH DAY YEAR

g. DATE PASSED GENERIC FUNDA.

MM YY MENT AL3 E XAMINATION SECTION

6. OTHER (ssociNI l

l l

Ilf APPLICAslEl

6. TYPE OF LICENSE APPLIED FOR

6. PREVIOUS LICENSE (Si HE LD s OPERATOR

s. DOCKET NUMBER RO SRO b. LICENSE NUMBER hg

& F ACILITY DOCKET NUMSER Ok $E NIOR OPE RATOR I

I I

55 I

I I

50-

e. LIMITED SRO te S. Fuet Hanmer) l t

l

7. NAME AND ADDRESS (include 2 P Codel OF APPLICANT'S EMPLOYE R

10. CURRENT POSITION AT FACILITY

s. PLANT SUPERINTENDENT L AURILIARY UNIT OPER.

ATOR/T RAINE E/TUR$1NE

6. ASSIST ANT PLANT SUPERINTENDENT SUILOfNG/ EQUIPMENT 09ER ATOR CNON (ICENs.

s. SHIFT SUPERVISOR f 0 0Pf RA TOR) t STAFF ENGINEER

j. OTHER (Specifyl

8. NAME OF APPLICANT'5 F ACILITY F ACILITY DOCKET NUMSER

s. $HIFT TECHNICAL ADVISOR /5HIFT ENGINEER

f. INSTRUCTOR

9. ADDITION AL F ACILITY DOCKETS iMusti+nn Licenses /

g. SENIOR CONTROL ROOM OPERATOR

h. CONTROL ROOM OPERATOR

11. EDUCATION

& HliH SCHOOL

e. MMOR AREAL $l OF STUDY

.n'",,

%9'*.*l DEGREE CODES

d. VOCATIONALITECHNICAL NE" is"O',T[

Of'G R f f

• oke<ned) gypg, v p a,q,%g MONTH $

vgg go ORADUATE E NGINE E RING (FiftOS/

H1GH

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0 OED EOUIVALENCY 5 RTIF ICAT E

2. ASSOCIATE NO

3. BACHELOR

% NUMBEM OS-d. MA$f ER g{gOS

&. DOCTORAL

12. T R AINING (SINCE LAST APPLICA TION - SEE INS TRUCTIONSI

13. E XPERIE NCE fDO NOT OOUBLE COUNT-SEE INSTRUCTIONSI 8 MON T H A N D v t A 8.

a MONTHANDVEAA a mean e wwen (Cseu

• • 0"

'o NAVY saou To

""a'"*

1 -NUCLEAR POWER PLANT FUNDAMENTALS room) 1.RO 2 -PLANT SYSTEMS

2. EOOW/PPWO CLASSROOM 3. EWS/PPWS OBJERVATION 4. E RS/CRW 3-OPERATING PRACTICE 5 OTHER (spec,41 CONTROL ROOM OPERATIONS ON SHIFT SIMULATOR OPER ATING (inesudes Causroomi FOS $1L SIMULATOR NAMES 4 g y,.. -

6. OPE R ATO R h

7 SUPERVISOR a.

' T' "

8. PLANT STAFF b.

N nYue"o N eYeo l lYES l l NO

,,Q 0. OT H E R (soec,4J Nuwsen om ac Ac'ever v uAN+vt A vioNs saa PLANT SiUULATUn V

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5 c

l

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N COMME RCI AL NUCLE AR (includen, Resseren/ Terr Reactorf 4 -SRO INSTRUCTION

10. REACTOR OPERATOR (tkens,d/

5,'r*dEgYg'S,"ugsMa T IN coNTnot Poo"

11. SENIOR OPER ATOR (teenseds

a. /j",yp4gy/tujf'

12. SHIFT SUPERVtSOR (Leenards j

^

6 -R EQUALIFICATION t 3. STAFF / SHIFT ENGINEER (teceaseds 7 -OTHER (spect&A

14. AUX./EOUlP. OPERATOR (Nonsscenseds

15. PLANT STAFF

16. OTHE R (sonctNo hu s NRC FORM 303 (1 Sag)

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w, %

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-- - - - - - - - = -< _ - cc n, 7 --

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14. FACILITY CPERATOR TR AINING PROGRAM

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s yTRATe op lespo t CcREDITED opeR Atom s CE RTnu,iEtr oN NRC rOR wa t souv.s roon vAcour v A

1. pgG PftOGRAM THAT 18 BASED UPOes A YES NO cP2Tip cAnonr~J O2 Re,MRDvsc ssMuts. TION

' SYSTSGN A89 ROACH TO TRAINING F ACILITV is UsED IN THE OPERATOR 1RAININO YES NO pnoonsy

15. FOR RENEWALS ONLY

b. DATE AND RESULT OF MOST -

DA"

"'8VL'

~ teDURS OPERATEO F ACILriY; RECENT NRC ADMINISTERED -

- REQUALIFICAllON ERAMINATION PASS FAIL

16. EXPERIENCE DETAILS 4

P. PDSITION TITLE FRDM TO

b. F ACILITv -

e. DUTIES l

l-1 I

J d

17. C0teggerTS sasse#4 ene seem numeer a wnma veu m -

Arisen eAmeener essers se.-

,J I

lC

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18, N C FORM 308, CERTIFICATION OF MEDICAL EXAMINATION SY FACILITY LickNSEE,18 ATTACHED ANY F ALSE STATEMENT OR OMISSION IN THIS DOCUMENT. lNCLUDING ATTACHMENTS, MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.

ten. i seritty usener poneny of periury that the informouon in the document end ettechments is true end correct. I further corufy thet t neve nontied my current emodover of: (il en pronous anosovers; 421 any instanee where I have been teases by a Hoenn and Hvenen services IMHS) Carlitsed Drut Tegung Laboratory or a Licenese's testing tecHity for secohol or e confroned maeseenes and the test seosite eesseded the autoff levees enemished pursuant to 10 CFR Port 26; 83) any instance where i have been errested for the gets, use or -n of e confroned ashmente desprebed m 10 CF R Port 26-

.l

- ond 14) any reemens ter removes or revoceuon of unsecorted access et e nuemoriencHky, I eien suihorue the NRC to submit the reevns of enemmetens to my emplove s eor ues in peeperme retro 6aang peoerene, es nessenerv 8408sATURE-APPL 4 CANT DATE CHECK APPLICABLE BOX -

.l 4

4 I eartifw that the above nemet indevaksel has successfuuv comoieted the fesmtv iweneses requirements to be luenced as on Operatortsoner Operator pursuant to inen 10. Code of Federal Reevietions, Port es:and thet the indevhsues hee e need lor en Operatorisoner 02erster ncense to perform hes/her essagned duuss and that the eussesecul be pnede evelisbee for eneminetton, i eden certify unser pensny of pereury that the >sormeten in this document and ettechments is true end correct.

l 6 EtNSWAL ONLY - I certify that the above named Individues meets the approved recuenfication program (wirA escopetens nosed se item #1) se required by section SO 64 Ik

'r-l that he/she hem thscharged his/her licensed responsabilities congetently end utesy, t esso certety under penetty of perjury that the informetton in thes document and ettechments le true end correct.

TRAININO COORDINATOR SENIOR MANAGEMENT REPRESENTATIVE ON SITE l

Pres #TED OR TYPED NAME PRINTED OR TYPED NAME p-SiO8tATUR E DATE

$10 NATURE lDATE I

FOR NRC USE l

WAIVER (Check or Opinplere / terns, as appI4ce6Jel l MEETS REQUIREMENTS l l DOES NOT MEET REQUIREMENTS lisaisis behrw On ANM D e "

DeWD D CATEGORY HeADQUAM?tRS Ms GION HE ADOU ANTE ne nEGION T7RITTEN liI OPERATINO E LIGl81LITY ME01 CAL ssONATURE-REVIEWER DATE OTNER NRC PORM 300 (10491 =

NRC eQR?J JB6 U S. NUCLE AA aEQULATOaY CDMMisslON Arcovt0 sv one No J160eo2s I V8788 'J14' n : eel 10 C8R 66 23,56 27 tstiMattp Sum 0f N PER Rt9Potete TO couPLY utrTM ane 96.43 Tweg sNeoRuatioN cot tactiosi r4Ecuerf'

't hrs CERTIFICATION OF MEDICAL. EXAMINATION gag D,,c,oa"Ay,La* o,AaDlgq D=,',=

, o OR AlvCH iP 4301. US NUCLEAR RIOULATORY COesusar BY FPLCll=

yggg SiON. masMINGTON DC 20656. AND FO TM4 P ArtRus0Rn a

't RE DUCTION PROJE CT (3t$000248 Opplet OF W AN Ao t.

WENT AND OVDG81.* ASHINGTON DC 20001 NAME OF APPLICANT F ACILIT Y l F ACILITY DOCKET NUMSER A. MEDICAL EXAMINATION CERTIFICATION THis IS TO CERTIFY THAT THE ABOVE NAMED APPLICANT FOR AN OPER ATOR/ SENIOR OPERATOR LICENSE HAS BEEN EXAMINED BY A PHYSICIAN E XAMINATION DATE e RINTED N AME to/ phys,csans lSTAf E AND LICENSE NUMBER BASED ON THE RESULTSOF THE EXAMINATION. INCLUDING INFORMATION FURN:SHED BY THE APFLICANT. THE PHYSICIAN MAS Dif ERMINED THAT THE APPLICANT'S PHYSICAL d)NDITION AND GENE R AL HE ALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPE R ATION AL E RRORS ENDANGE RING PUBLIC HEALTH AND SAFETY. I CERTIFY THAT IN RE ACHING THIS DETERMINATION THE GUIDANCE CONT AINED IN ANSI /ANS 3 4-1983.OR ANSUANS 15 44977 8N3801 WAS FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR REVIEW BY NRC.

ON THE BASIS OF THE RECOMMENDATION OF THLfHYSICIAN. I RECOMMEND THAT THE APPLICANT'S OPER ATOR LICENSE BE CONDITIONED AS FOLLOWS.

1, NO RESTRICTIONS

(

2. CORRECTIVE LENSES BE WORN WHEN PERFORMING LITNSED DUTIES I

3. HE ARING AfD BE WORN WHEN PE RFORMING LICENSED DUTIES l

4. RESTRICTED LICENSE OR E xCEPTION. Provide detads below and attacn supportmg medical evidence for NRC review.

l e

5 R E STRICTION CHANGE F ROM PRE VIOUS SUBMITTAL Provide detads betow and attaen supportmg medical evicence for NRC review PROPOSED WORDING OF RESTRICTION I8 tack 4 eDowel l

l l

XE LATIONSHW OF RESTRICTION TO DISOUALIFYING CONDtilON IBroe ty omtware now restrwton wott eorrect the wsqunMymg rondirent r

l REMARKS FOR RESTRICTION CHANGE (61ock 5 aDowl 1

1 B. NONME0lCAL CERTIFICATION POWE R R E ACTO RS.

THis CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAF EGUARDS' AND FITNESS FOR DUTY REQUIREMENTS OF THIS F ACILITY FOR LICENSED OPERATORS.

NON POWER RE ACTORS.

THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS' REQUIREMENTS OF THIS F ACILITY FOR LICENSED OPER ATOR$. AND I HAVE NO KNOWLEDGE OF THE APPLICANT EXCEEDING THE CUTOF F LEVELS FOR ALCOHOL i

OR CONTROLLFD SUBSTANCES AS ESTABLISHED PURSUANT TO to CFR 26.

s.Nv e ALss at ArmutNT OR ouissioN aN rais occuwem r. escovoimu At r AcmutN ts wAv es susJaci ro cmL Amo criminal >Ascriums. : cha rie v umuta sitNAt t v or FERJURV TbiAT THE INFORMAflON IN THl$ DOCUMENT AND ATT ACHMENTS 13 TRuf AND CORRECT.

PRINTED NAME AND SIGN ATURE / Senor Management Neoresenrarew on 5,res TlTLE DATE in accoruance with 10 CF R 55.5. Communicatens. inis form snasi be suomitted to the N AC as tonows 84 Mall ADO AESSED TO.

Regional Administrator, Region i Regional Admmistrator. Region ll Regionas Admmistrator. Region iti US Naciear Regulatory Commission US Nuclear Regulatory Commission U.S. Nuclear Regulatory Commessen 475 Allendate Road 101 Marietta Street. Smte 3100 799 Rooseveit Road Kmg of Prussia. PA 19406 Atlanta. G A 30323 Gien Ellyn. IL tiO137 Regional Administrator. Region IV P #g onal Admmistrator. Region V U1 N# tear Regusatory Commission U S. Nuclear Regulatory Commission 611 Ryan Ptara Drive Suite 1000 1450 Maria Lane. Suite 210 Arimgton. Tx 76011 Walnut Creet CA 94596 PRIV ACY ACT ST ATEMENT Pursuant to 5 UIC. 552atel(3). enacted mio law by section 3 of the Privacy Act of ROUTINE USES. The eformarion may be disciosed to an acoropriate Feoerai. State. or 1974 IPublic Law 93579). ine sonowmg statement is umesned to moividuais who locas agency m the event tne mformation mdicates a vioiaten or potenties violation of law r

supply informatson to the US duclear Regulatory Commission on NRC Form 396. and m the event the information md cates a viotation or potential violar on of law arw1 m This mformation is emaintained in a system of records designated as NRC 16 and the course of an arsmmistrative or suoscial proceedmg in addition. In s mtormation may be describeo at 51 Federai Regmer 33157 (September 18 1986).

iransterred to an aporopriate Federas. State. and locai agency to the extent reievant ano AUTHORITY: Svetions 107 and 161(e) of the Atomic Energy Act of 1954 as necessary for an NRC decision aoout you.

amenced I42 VAC. 2137 and 2201(a)).

WHETHER DISCLOSURE IS MANDATORY On VOLUNTARY AND EFFECT ON Disclosu e is voiuntary. If the INDtvlDUAL OF NOT PROviDING INFORMATlON r

PRINCIPAL PURPOSE (Sh information entered on inis form is used to determine wnether tne anysical condition anci generai neaeth of the applicant are such tnat they requested mformation is not provided nowever. ine aponicar on for a facitety operator's wdl not cause operational errors erw1 angering puralic nealth and safety This mforma. or senior operator s acense may be cemed tron may oe used by the NRC statt to determme of the end widuas meets tne require SYSTEM MANAGERIS) AND ADDRESS. Chief Operator Licensmg Brancn. Office of ments of 10 CF R 55 to taae an esammaten or to be issued an operator's heense.

Nur rer Reactor Regulaten. U S. Nucitar Regulatory Commisvon, Washington, DC 20555.

NRC 80psWe 144 + in Am

i pc ;

ID U ASURE 3 SGMARY OF QWGES 'IO NRC PORM 396 Medical' Examination Certification Added block " Restriction O m ge Free Prwicus Submit,tal" plus Remarks section.

H m -Medical Certification Omged nond4_a=1 oartification statement to: Power Reactors-This i

certifies that the applicant has been found to most the aefesuards' and fitness for duty retuirements of this i

this facility for licensed operators.

i Henpouer-This certifies that the j

applicant has been found to meet the l

safeguards' ruauirnments of this facility for licensed operators and I have no knowledge of the applicant 1

exceeding the cutoff levels for al

• 1 or controlled substances as es+=h14=W pursuant to 10 CFR 26.

-l l

'l i

. k llNCICSURE 4 SttttARY OF CHUGES '!O NBC POEM 398 i

Item 4.d Added clarifying statement to frwiiemte this is to be checked mly if application is to meand license to add additional tait (s).

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

Added "t4arlieml".

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

Item 12.3-i Changed wording to " Certified Startup FK,n Completed" for clarificatim.

Item 12.5 Changed wording to " Extra Perom On Shift In Cetrol Room L

(13-week minima)" for clarification.

Item 12.5a Added a now item " Time On Shift Above 205 Power (6-week minima)".

Item 14.a Added the words "That Is Based Upon A Systems Approach to Tr=4aia=" for clarification.

Item 15 Added "Date and Result of Most Recent NBC Administered P=ca= W icatica Examination",

p Item 19.a Added the wording "I further certify that I have notified er current employer of: (1) all.ptwicus employers; (2) any instance where I have been tested by a Health and Human Services.(HBS) Certified Drug Testing Laboratory or a Licensee's testing facility for alochol or a ce trolled substance, and the test results M 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 substance described in 10 CFR Part 26; and,

(4) any reasons for. removal or twooestion of unescorted access at a nuclear facilita.t".

Item 19.b and Item 19.c Moved 19.b a.nd 19.c tesether. Applicable box mast now be checked. Also added block for typed name of Training Coordinator and Senior Manessment Representative On Site.

l 70R SC OSE Under waiver category added " Medical".

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