ML20021A120

NRC Form 740M (Blank)

ML20021A120
Person / Time
Issue date:	04/15/2020
From:	NRC/OCIO
To:
Liu T
Shared Package
ML2088A999	List: ML20021A120
References
OMB 3150-0057
Download: ML20021A120 (1)

Text

DOE/NRC FORM 740M (MM-YYYY)

CONCISE NOTE DOE/NRC FORM 740M (MM-YYYY)

Public Laws83-703, 93-438, 95-91 AUTHORIZED BY 10 CFR 30, 40, 50, 70, 72, 74, 75, 150 MANDATORY DATA COLLECTION APPROVED BY OMB: NO. 3150-0057 EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory collection request: 45 minutes. This information is required to satisfy the provisions of the US/

IAEA Safeguards Agreement. Send comments regarding burden estimate to the Information Services Branch (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.gov, and the OMB reviewer at: OMB Office of Information and Regulatory Affairs, (3150-0057), Attn: Desk Officer for the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 20503; e-mail: oira_submission@omb.eop.gov.

The NRC may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the document requesting or requiring the collection displays a currently valid OMB control number.

U. S. DEPARTMENT OF ENERGY AND U. S. NUCLEAR REGULATORY COMMISSION

1. Name Street Address City State Zip Code

2. Attachment To:

A. DOE/NRC 741 B. DOE/NRC 742 C. DOE/NRC 742C

3. RIS

4. Reporting Period (MM/DD/YYYY)

From Date To Date

5. Transaction Data A.

Shipper's RIS B.

Receiver's RIS C.

Transaction Num.

D.

Correction Num.

E. PC F. AC

6. Reporting Date 7A. Line No.

7B. Entry Reference 7C. Text of Concise Note To the best of my knowledge and belief, the information given above and in any attached schedules is true, complete, and correct.

8. Signature (See instructions [NUREG/BR-0006] for provisions regarding confidentiality).

9. Title

10. Date WARNING: FALSE STATEMENTS IN THIS CERTIFICATE MAY BE SUBJECT TO CIVIL AND/OR CRIMINAL PENALTIES. NRC REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRC BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECTS.

18 U.S.C. SECTION 1001 MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTER WITHIN ITS JURISDICTION.