ML20006D722

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 Encl Forms by 900201

ML20006D722
Person / Time
Site:	Peach Bottom, Limerick, 05000000
Issue date:	01/05/1990
From:	Gallo R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Corbin McNeil PECO ENERGY CO., (FORMERLY PHILADELPHIA ELECTRIC
References
NUDOCS 9002140298
Download: ML20006D722 (8)

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e 1-JAN 51990 Docket Nos.

50-277 L

50-278 50-352 50-353 Philadelphia Electric. Company ATTN: Mr. C. A. McNeil1 3 Executive Vice President-Nuclear.

Correspondence Control Desk E

P. 0. Box 7520

-Philadelphia, Pennsylvania 19101 s

Gentlemen:

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 11ater: than February 1,1990.

4 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, D.C.

20555.

Ifcyou have any questions regarding these forms, please contact Richard J.

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

Sincerely, origimi signed ByI Robert M. Gallo, Chief i

Operations Branch-Division of Reactor Safety

(

/

Enclosures:

As stated 3

0 0 g2Qgg(($$$O37 PD V.

' 0FFICIAL RECORD COPY 396 & 398 FORMS - 0009.0.0 1

12/14/89 i

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Philadelphia Electric Company 2

cc w/o enc 1:

D. R. Helwig, Vice President, Nuclear Services E. C. Kistner, Chairman, Nuclear Review Board

- Dickinson M. Smith, Vice President, Peach Bottom Atomi_c Power Station Jack Urban, General Manager, Fuels Department, Delmarva Power & Light Co.

John-F. Franz, Plant Manager, Peach Bottom Atomic Power Station T. E. Cribbe, Regulatory Engineer, Peach Bottom Atomic Power Station J. P. Wilson, Acting Project Manager, Peach Bottom Atomic Power Station Troy B. Conner, Jr., Esquire W. H.-Hirst, Director, Joint Generation Projects Department, Atlantic Electric Bryan W. Gorman, Manager, External Af_ fairs E. J. Cullen, Esquire, Assistant General Counsel (Without Report)

Raymond L. Hovis, Esquire Thomas Magette, Power Plant Siting, Nuclear Evaluations G. A. Hunger, Director, Licensing Section Doris Poulsen, Secretary of Harford County Council R. J. Lees, Chairman, Nuclear Review Board G. M. Leitch, Vice President, Limerick (w/ enclosures)

S. J. Kowalski, Vice President, Nuclear Engineering D. R. Helivig, General Manager, Nuclear Services M. :). McCormick, Jr., Manager, Limerick W. T. Ullrich, Manager, Limerick Unit' 2 A. S. MacAnish, Manager, Limerick Quality Division G. A. Hunger, Jr., Director, Licensing H. D. Honan,-Brach Head, Nuclear Engineering Licensing V. J. Ce letnicwicz, Training Manager (w/ enc 1)

'NRC Residen+. Inspector, Limerick Public Document Room (PDR)

Local Public Document Room (LPDR)

Nuclear Safety Information Center (NSIC)

NRC Resident Inspector Commonwealth of Pennsylvania-bec w/ enc 1:

Region I Docket Room (with concurrences)

Management Assistant, DRMA (w/o enc 1)

DRP Section Chief R. Martin, NRR J. Dyer, ED0 OL Facility File DRS:RI Gallo/pb ph P

01/02/S04 h

I 0FFICIAL RECORD COPY 396 & 398 FORMS - 0010.0.0 12/14/89 l

A

INSTi'UCTIONS FOR COMPLETING NRC FORM 300 PEISONAL CUALIFICATION STATEMENT-LICENSEE TO REMAIN VALID,THl3 FORM MUST NOT BE ALTERED

.,, _ TYPE CF APPLICATION

-adi

. 2.s NEW "X" IF YOU ARE A NEW APPLICANT. COMPLETE EACH CATEGORY OF THE FORM COMPLETELY, FOLLOWING THE j

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

RECEIVED UP TO THE DATE OF THIS APPLICATJON. NOTE: SEE / TEM N - THERE IS AN EXCEPTION. ALSO,THIS i

BLOCK IS TO BI MARKED lF PREVIOUS NEW APPLICATION WAS WITHDr4 AWN, PLEASE WRITE " WITHDREW" NEXT I

7 TO "NEW,"

2 b thru 2.e u 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 ITEM 74 - THERE IS AN 3

EXCEPTION.

2.b RENEWAL "X"[F YOU ARE RENEWING CURRENT LICENSE, 2.c DPGRADE "X"IF YOU HOLD A RO LICENSE AND ARE NOW APPLYING TO UPGRADE YOUR LICENSE TO A SRO, 1

2.d MULTl UNIT "X" IF YOU CURRENTLY HOLD A LIC!iNSE AT YOUR FACILITY AND ARE APPLYING TO AMEND YOUR CUR.

i RENT LICENSE TO ADD AN ADDITIONAL UNIT, i

1 2.e REAPPLICATION "X"IF YOU HAVE PREVIOUSLY BEEN DENIED A LICENSE AND ARE REAPPLYlNG, 2.f WAIVER REQUESTED "X"THLAPPLICABLE WAlVER 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 GFESWAS NOT TAKEN, YOU MUST HAVE PASSED AN NRC LICENSING EXAMINATION ON THE APPLICABLE REACTOR TYPE (PWR OR BWR) AFTER FEBRUARY 1,1982,WHICH LEO TO THE ISSUANCE OF A LICENSE, THIS DOES NOT INCLUDE INSTRUCTOR CERTIFICATION EXAMINATIONS OR REQUALIFICATION i

EXAMINATION 3.

i s.

II, EDUCATION - INDICATE BOTH ACADEMIC AND VOCATIONAL / TECHNICAL POST HIGH SCHOOL EDUCATION, FOR MAJOR AREA (S) OF STUDY, INDICATE THE NUMBER OF YEARS SPENT IN EACH COLLEGE CURRICULUM AND THE HIGHEST DEGREE RECElVED, USING THE DEGREE CODE PROVIDED. FOR VOCATIONAL / TECHNICAL EDUCATION. INCLUDE PROGRAMS SUCH AS NUCLEAR POWER SCHOOL, MILITARY TRAINING, AIR CONDITIONING / REFRIGERATION, DIESEL MECHANIC SCHOOL, ETC, INDICATE THE NUMBER OF MONTHS IN EACH PROGRAM AND WHETHER A CERTIFICATE OR DEGREEWAS AWARDED, IF ADDI.

TlONAL 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 BREAlQOWN OF TRAINING IN THIS CATEGORY PARALLELS THE ANS STANDARDS REFER TO THE STANDARDS IF YOU NE FR*dHER CLARIFICATION. INCLUDE BOTH BEGINNING AND COMPLETION DATES AND THE TCTAL NUMBER OF WEEKS IN EACH TYPE OF TRAINING. THE NUMDER OF WEEKS IS PROVIDED,IN ADDITION TO BEGINNING AND COMPLETION DATES, TO ACCOUNT FOR-lNTERMITTENT TRAINING (FOR EXAMPLE,4 WEEKS OF CLASSROOM TRAINING SPREAD OVER A 2 MONTH '

PERIODh 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 DOUBLE COUNTED UND EXPERIENCE (ITEM 13),

ALL REQUALIFICATION TRAINING TIME IS TO BE ACCOUNTED FOR IN THE REQUALIFICATION ITEM, PLEASE DO NOT " DOUBLE 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 REOUIRED. FOR EACH P HELD, COMPLETE ITEM 18. 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 SHOUL i

NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEED THE NUMBER OF MONTHS THAT ARE IN TIME PERIOD, 14, FACILITY OPERATOR TRAINING PROGRAM - INDICATE a. GRADUATE OF INPO ACCREDITED OPER ATOR TRAINING PROGRAM; AND b CEATm!FO (ON blRC FORM 474) OR NRC AMROVCD GMULATION FACILITY is USED IN THE opt:HAiOH THAlNING PRO.

GRAM. IF "YES" IS CHECKED IN BOTH ITEMS 14a 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 NUMBE 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, ib, FOR RENEWALS ONLY - (1) ENTER THE APPROXIMATE NUMBER OF HOURS SINCE PREVIOUS RENEWAL OR ISSUANCE O LICENSE lF FIRST RENEWAL. (2) ENTER DATE AND RESULT OF MOS1 RECENT NRC ADMINISTERED REQUALIFICATION EXAM

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

1 TION.

18.

NRC FORM 398, CERTIFICATION OF MEDICAL EXAMIN ATION BY FACILITY LICENSEE - MUST ACCOMPANY THIS APPLICATION.

- 19, SIGNATURES - SIGN AND DATE ITEM 19.a. OBTAIN YOUR TRAINING COORDINATOR'S SIGNATURE AND THAT OF YOUR SENIO

' MANAGEMENT REPRESENTATIVE ON SITE.

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

~ PRIATE REGIONAL ADMINISTRATOR.

ImcPog 3B U.S. NUCLE A/. l.E AULATwY COhmsIOSION APPROYE3 SY OMS: NO. 316tNIO90 D All 6.ECElYED 0

'66.3066 4 E KPIIE S: 13102 (Te te w W MCI

$647, end te.67 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST 2D HRS.

FORW ARD COMMENTS REGARDING BURDEN ESTIMATE PERSONAL QUALIFICATION STATEMENT-LICENSEE TO THE INFORMATION AND RECORDS MANAGEMENT DRANCH (P.6X)l. U.S. NUCLE AR REOULAToetY COMMIS.

SION W ASHINGTON. DC 20b66. AND TO THE PAPERWORK REDUCTION PROJECT 13160 0o00). OFFICE OF MANAGE-

.TO REMAIN VALID,THit FORM MUST NOT BE ALTERED MENT AND SUDGET. W A$HINGTON. DC 20603.

1. APPLICANT'S FULL NAME (last, //rst, Widief AND ADORESS (inclucrelie CtWel

4. TYPE OF APPLICATION (Check aPO icable bones) l

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2. CITIZE NSHIP

3. 88RTH DATE VNITI s.OTHER

- E e UNf7ED $TATES MONTH DAY YEAR e DATE PASSED OENERIC FUNDA.

MM YY MENT ALS E X AMIN ATION SECTION

6. OTHER (SueclNo l

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5. TYPE OF LICENSE APPLIED FOR

6. PREVIOUS LICENSE (5) HELD

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

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8. NJ.ME OF APPLICANT'5 F ACILITY F ACILITY DOCKET NUMGER

e. SHIFT TECHNICAL ADVISOR / SHIFT ENGINEf ft f.

INSTRUCTOR

9. ADDITION AL F ACILITY DOCKE TS (Mutrsvnst &rensesJ g SE NIOR CONT ROL ROOM OPERATOR

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A CONTROL ROOM OPER ATOR

11. EDUCATION 3 HIGH SCHOOL

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3. BACHELOR k NUMBEM Op 4. M AST E R YEAR $0F

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12. TR AINING (SINCE LAST APPLICA TION - SEE INSTRUCTIONSI

13. E XPERIE NCE (DO NO T DOUBLE COUN T-SEE INSTRUCTIONS)

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1-NUCLEAR POWER PLANT FUNDAMENTALS room /

1.RO 2 -PLANT SYSTEMS 2. EOOW/PPWO CLASSROOM 3 EWS/PPWS OBSERVATION 4 ERS/CRW 3-OPE R ATINO PR ACTICE 5.OTHER (spec /4; i

CONTROL ROOM OPERATIONS ON SHIFT SIMULATOR OPER ATING (inesuae:CsessroomJ pogggt

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SHd T IN CON T NO L MOOM g

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12. SHIFT SUPERVISOR (Licens,ds 8

6 REQUALIFICATION 13 STAFF / SHIFT ENGINEER Itscenseaf 7 -0THE R Isaves&#

14 AUX./ EQUIP. OPE RATO R (Nonteensevs i

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C/ GRADUATE 5E INPO AOCREDITEO OP8EATOR ;

k CERTdF SED ON NRC 7ORM 474 (1#4fut A TdO4 FACT &f TV 1

ThAINING PROGRAM THAT M BASED UPON A' YES NO; CansisCATsOw s On NRC APPROvEo sluuLAf toss YES-NO.

! systems APPROACH TO TRAIN 4NG

,I,T 18 USED IN THE OPERATOR TRAINING.

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16. FOR RENEWALS ONLY.

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h. DATE AND RESULT OF MOST Dan ets M t

., NOURS OPER ATED F ACILITY:

. RECENT NRC ADMINISTERED REQUALIFICATION EXAMINATION pggg pg.

16. EXPERIENCE DETAILS e6 PostT10N TITLE f: ROM TO

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17. C00AAE8fT8 dreadsy sne snwn ammeer se enen Peu we

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L 18, NRC FORM 306, CERTIFICATION OF MEDICAL EXAMINATION SY F ACILITY LICENSEE,IS ATTACHED ANY F AL8E STATEMENT OR OMIS$10N IN THIS DOCUMENT, INCLUDING ATTACHMENTS. MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS.

19e. < l certify unser penshy of pertury that the Information M this document and attachments is true ami correct. I further certlfy that i have nottfeel my cyrrent omsuoyer of: II) sal growtous erMpiovers;

' (2) any Instanee genere I heet lesen tested by e Health araj Human Serw6ees (HHS) Cert! feed Drug Testene Laterstory or e Leconsee

- resuets-the eutott iswen estenhened pursaem to 10 CP R Port 26;(3) any 6nstance where I have been errested for the saw,'s testing factMy for secohol or e controned maastence, and the tes use or posessuon of a controned subelence destreed in 10 CFR Port 26;

. and (4) any reasons for renowne or rewoesten of unescorted access et e nueseeritecilny, 5 emo authorue the NRC to submn the results of e=enunstions to my emsmovers ser use in sweperine retre.n ng peserems, se necessery SM3 NATURE-APPLICANT -

DATE

.k CHECM APPLICABLE BOX y

b. 4 eertify that the etweee nemmiIndividual has sacressfully completed the factiny lacentose requirements to tie beensed as an Operator / Senior Operator pursuant to Title 10. Code of Federal Roguastsons, I

Port 96;and that the Indoweduel hos a need est en Operator / sensor Operetor secones to perform his/her gesegreed dutees and that the "

" be made eveMehte for enemmeten. 5 eleo corr'ty under '

'i penetty of perjury that the intormation in thes cgseurnent ere$ attachments le true end correct.

e, RENEW AL ONLY - I certify that the above named individual meets the approved recuallheation program (with exceptdons noted de from f1J et required by metson 5054 la al of 10 CF R 60 end 1.

that he/she has oneherged hes/her tecensed reasonsiblinees cornpetently and tofety. I seso cert 4fy under penalty of portury that the information (# th6s document and attachments,

le true and correct; TRAINING COORDINATOR SENIOR MANAGEMENT REPRESENTATIVE ON SITE I

PRINTED Oft TYPED NAME PRINTED OR TYPED NAME I

1 1 ',

BIQNATURE.

DATE SIGNATURE DATE FOR NRC USE WAIVER (Check or Qwriptera # ems, as appiksb/e/

l MEET 8 REQUIREMENTS l l DOES NOT MEET REQUIREMENTS (isAusin 6ed U'

""#'"'D'"

HE ADQU An r E n"8 EGORY HE ADQu AR T E Rs nE GiuN nEG40N ttlRITTEN -

!i OPERATING 1'

ELIGlBILITY MEDICAL.

SIGNATURE.REvityvER DATE OTHER NRC PORM 30011M91 -

4

i V 5. NUCLE AR kE auL Ain;Y COMM168 TON tremov E Dj{

NO 3tmao23 AR.C e,ond JOS se e

'O C8m 64 23,96 23 esflMATED SUnotN ptR stap0Nst 70 coalpty gestM ans te.g3 t wit #N# 0mMafloN COL L action maout e f - it upt CERTIFICATION OF MEDICAL EXAMINATION g,ag o,,,c,y,f,y,g,,a ',a',a pag og,y,=

aa r ed e g e emANCH (#41o1. u s NuCLeam atout.Af omy comanais SY FACIAb be E" EN E SiON. W A5HtNOTON DC 20 bat AND to twt *ArteveOma at DUCTION emOJE CT 13t toc 07al. 088 set 08 MANAGE.

MENT AND SUDGli W48HtNGTON 3C 70603 NaME OF APPL. CANT F ACILIT Y l F ACILif Y DOCAET NUM8ER A. MEDICAL E XAMIN ATION C tRTIFICATION THis IS TO CER fIF Y THAT THE A8OVE NAMED APPLICANT FOR AN OPERATOR / SENIOR OPER ATOR LICENSE HAS BEEN EXAMINED BY A PHYSICIAN PAINTED NAME me anyarcsons l51 ATE AND LICENSE NUMBE R l E X AMINA flON DATE BASED ON THE RESULTS OF THE E XAMINATION INCLU0iNG INFORMATION FURNISHED BY THE APPLICANI. THE PHYSICIAN HAS DETERMINED THAT THE APPLICANT *S PHYSICAL CONDITION AND GENER AL HE ALTH ARE NOT SUCH THAT IT MIGHT CAUSE OPE RATION AL E RRORS ENDANGERING PU8LIC HE ALTH AND SAF ETY I CERTIF Y THAT IN RE ACHING THIS DETERMINATION THE GUIDANCE CONT AINED IN ANSl/ANS 3 4198J.OR ANSI /ANS 16 41977 (N380l W AS FOLLOWED AND THAT DOCUMENTATION IS AVAILABLE FOR HEVIEW 8Y NRC.

ON THE BASIS OF THE RECOMMENDATION OF T7UHYSICIAN 1 RECOfAMEND THAT THE APPLICANT'S OPERATOR LICENSE BE CONDITIONED AS FOLLOWS

1. NO RESTRfCTIONS

2. CORRECT 6VE LENSES BE WORN WHEN PERFORMING LICENSED DUTIES i

3, HE ARING AID BE WORN WHEN PERFORMING LICENSED DUTIES

4. REST RICTED LICENSE OR E XCEPTION-Provide detads helow and attach supportmq medeces evioence for NRC revww 5 RESTRICTION CHANGE F ROM PREVIOUS SUBMITT AL Provide notads below and attach supportmg matical evinence for NRC review FROPOSED WO8' DING OF REST RICTION (8/ ort 4 ebowel l~

1 tie LATIONSHIP OF RESTRICTION TO DISOUALIF YlNG CONDITION Isrw#y mdscare how restracten welicorren the assauese4me conarrtens i

l REMARKS FOR RESTRICTION CHANGE (Slock $ 40o.9)

B. NONMEDICAL CERilFICATlON POWER RE ACTORS THIS CERTIFIES THAT THE APPLICANT HAS BEEN FOUND TO MEET THE SAFEGUARDS' AND FITNESS FOR DUTY REQUIREMENTS OF THis F ACILITY FOR LICENSED OPERATORS NON. POWER RE ACTORS THIS CERTIFIES THAT THE APPLICANT HAS 8EEN FOUNO TO MEET THE SAFEGUARDS' REQUIREMENTS OF THis F ACILITY FOR LICENSED OPERATORS. AND 1 HAVE NO KNOWLEDGE OF THE APPLICANT EXCEEDING THE CUTOFF LEVELS FOR ALCOHOL OR CONTROLLED SUBSTANCES AS ESTABLISHED PURSUANT TO 10 CFR 26 f NV P AL5h St a t tMENt OH OMPL380N IN IMIS DOCUMeN T iNCLUUiNu A T T ACHMEN i$ M A wat SudbJtCI TW Civ e( ANO CMIMIN AL &ANGllUN& 8 LLM itP ' UNutiM I'kN Aq,{ v UP flMJUMV THAT TMt afdeOmMAflON IN THIS DOCUMENT AND ATT ACHMENYliS f aut AND COmmtCT.

PRINTED NAME AND SIGNATURE (Semor Menevement #eoresentative on Stres TITLE DATE in accoroance witn to CF R 65.6. Communications. inis form snan ce suomuted to the NRC as rollows: BY Mall ADDRESSED TO; Regional Administrator, Region i Regenal Administrator. Regen il Reg.onal Admmisstator, Regeon HI U.S. Noctear Requestory Commisuon U.S Nuclear R*1uietory Commimon U S Nuclear RequiaiorY Commessen 475 Allendaiemood 101 Marietta Street. Suite 3100 799 Rooseveit Road King of Pruwa PA 19406 Atlarra GA 30323 Glen Ellvn. IL tiO137 Reqmnas Adrustrator. Roton IV Reganas Admmistrator, Reton V U.S Nuclear Requiatory Commemon U S Nuclear Regulatory Commimon 611 Ryan Plaza Onve. Suite 1000 1450 Maria Lane. Suite 210 Arhngton. TX 76011 Walnut Creee. CA 94596 PRIV ACY ACI ST ATEMENI Pursuant to 6 V S.C 5524(eHM. enacted mio law by section 3 of the Pnvecy Act of ROUTINE USES. The m#ormation may be desclosed to an aporuoregio Federes. State. or 1974 tPubhc Lam 936791.the following statement is turnished to imhviduais who local agency m Inn event the informaten emiscates a volaten or potentian veiation of law supply mformation to the U.S Nuclear Regulatory Commimon on NRC Form 396 and in the event the mformaton moscates a vioisten or tmtential violaten of law ami m This information is maintamed m a system o8 records rses.gnated as NRC 16 and the course of an aesministratme or lud.cias procent nq in aid. ten. th.s mformaten may be described at St Faseral Register 33157 (September 18.1986l transferral to en appropriate Federai. State. ami locai elency to the estent retevant and AUTHORIT Y Sections 107 and 161N of the Atomic Enesqv Act of 1954. as necessary for an NRCdecismn souut you amend =14421J 5 C 2137 and 220ltd)

WHETHER DISCLOSURE IS MANDATORY On v0LUNT ARY AND EFF F.CT ON PRINCIPAL PURPOSE (SL inbrmaton enteres on this form is usat to oetermme INDIVIDUAL OF NOT PROVIDING INFORMATION Discrosure.s vasu tary, if tne n

waether the pnys cal coriditen oud generas health of the appheant are such tMat they reauesud mtormaten is not providen however. the apphcation ror a f acihty operator's wat not cause ocarratenai errors ennangermq puche neaith and safety This mforma or unior operator s kcense may be uenied tion may be usei by tee NRC staff to determme if the irw1twedua6 meets the retuere SYSTEM MANAGERIS) AND ADDRESS Chief Operator Licensmg Branch Ottice of monts of 10 CF st 65 to tame an easmmatma or to he issues an operator s hcense Nucieer Reactor Requieten. U S Nuclear Regulatory Cornmewon wasniniPon, DC 20556 Naesw v m n a

4 D n m ing 3 Sitt9ff 0F QUEES 10 IGC PORI 396 Medical Examination Certificatico Added block " Restriction Change From Prwious Submittal" plus Remarks section.

Non-Madieml Certification Chansed non-medical certification statement to: Pbuer Beectors-This certifies that the applicant has been-found to meet,the safeguards

• and fitness for duty requirementa of this this facility for licensed operators.

h ihis certifies that the i

applicant has been found to meet the safeguards

• requirements of this facility for licensed operators and i

I have no knowledge of the applicant u

w ing the cutoff levels for alcohol or ocatrolled substances as es+=h14=had parsuant to 10 CFR 26.

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L ENCIASURE 4 i

SUtt%RY OF CHAIGE '!D HIC F0EH 398 Item 4.d Added clarifying statammt to 4ael4=te this is to be-checked only if application is to amend license to add additional unit (s).

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

Added "Marunni".

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Item 4.g Added a new item " Data Passed Generic Fundamentals Examination Section".

' Item 12.3~

Changed wording to_" Certified Startup P,vm.

Completed" i

for clarification.

Itan 12.5 Changed wording to " Extra Peroca On Shift In Centrol floom (13-week =4n4==)" for clarification.

Item 12.5a Added a new item " Time on Shift Above 205 Peuer (6-week minima)".

Item 14.a Added the words "'! hat Is Based Upon A Systems Aw.ves to Training" for clarifiention.

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Item 15 Added '"Date and Besult of heet Hoosnt NEIC Administered -

L N=14+1catica Examination".

Item 19.a Added the wording "I flarther certify that I have notified my current employer of: (1) all.pswicus employers; (2) any instance where I have been tested by a Health and Human Services (HHS) Certified Drug Testing Laboratory or a Licensee's testing facility for alochol or a controlled substance, and the test results M the cutoff levels.

established pursuant to 10 CFR Part 26; (3) any instance i

where I have been arzusted for the sale, use or possession of a controlled substance described in 10 CFR Part 26; and.

(4) any reaecns for removal or revocation of unescorted access at a nuclear facility".

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

IM NRC USE Under waiver category added "HarHnal".

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