ML20021A121

NRC Form 741 (Blank)

ML20021A121
Person / Time
Issue date:	01/21/2020
From:	Office of Nuclear Material Safety and Safeguards, NRC/OCIO
To:
Liu T
Shared Package
ML20021A117	List: ML20021A121 ML20021A123 ML20092K107
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Download: ML20021A121 (1)

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23a. MISCELLANEOUS DOE/NRC FORM 741 (MM-YYYY) Previous editions are obsolete MANDATORY DATA COLLECTION Public Laws83-703, 93-438, 95-91 NUCLEAR MATERIAL TRANSACTION REPORT Estimated burden per response to comply with this mandatory collection request: 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> and 15 minutes. This information is required for IAEA accounting reports that show changes in inventory of nuclear materials. 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, (3150-0003), 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.

APPROVED BY OMB: NO. 3150-0003 EXPIRES: (MM/DD/YYYY)

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

5. PROCESSING CODE

7. DOCUMENTATION (Only if document is classified SECRET)

1. SHIPPER'S RIS

2. RECEIVER'S RIS

3. TRANSACTION NO.

4. CORRECTION NO.

a. SHIPPER

b. RECEIVER PAGE OF PAGES COPY OF COPIES SERIES NO.

DISTRIBUTION OF COPIES 1

8.a. NAME AND ADDRESS OF SHIPPER

b. LICENSE NO.

c. ATTENTION:

d. TELEPHONE:

9.a. NAME AND ADDRESS OF RECEIVER

b. LICENSE NO.

c. ATTENTION:

d. TELEPHONE:

10. NO OF DATA LINES

11. NATURE OF TRANSACTION 12.a. SHIPPED FOR ACCOUNT OF

b. RIS 13.a. SHIPPED TO ACCOUNT OF

b. RIS 2

3 4

5 6

7 8

9

15. EXPORT OR IMPORT TRANSFERS: LICENSE NO.

14. TRANSFER AUTHORITY - CONTRACT, NM DRAFT, OR ORDER NUMBER 17.

LINE NUMBER

b. SHIPPER'S CORRECTION

c. RECEIPT

d. RECEIVER'S MEASUREMENT

e. RECEIVER'S CORRECTION

a. SHIPMENT MONTH (MM)

DAY (DD)

YEAR (YYYY)

24. TOTAL GROSS WEIGHT

25. TOTAL VOLUME (Waste Transfers Only)

16. MATERIAL TYPE AND DESCRIPTION

b. CONCISE NOTE ATTACHED

c. UK REPORTABLE?

YES NO BACK REFERENCE NUMBER a.

TYPE OF INV.

CHANGE c.

IDENTIFICATION (ITEM/BATCH NAME) d.

NO. OF ITEMS e.

PROJECT NUMBER f.

MATE-RIAL TYPE g.

COMP/

FACILITY CODE h.

OWNER CODE i.

KEY MEAS.

POINT j.

1 BASIS MEAS. IDENT.

k.

2 OMP 3

METHOD GROSS WEIGHT l.

NET WEIGHT m.

ELEMENT WEIGHT n.

ELEMENT LIMIT OF ERROR o.

WEIGHT %

ISOTOPE p.

ISOTOPE WEIGHT q.

ISOTOPE LIMIT OF ERROR r.

26. SHIPPER'S DATA 26s. SHIPPER'S DATA SIGNATURE OF AUTHORIZED OFFICIAL AND DATE SIGNED 27s. RECEIVER'S DATA SIGNATURE OF AUTHORIZED OFFICIAL AND DATE SIGNED

27. RECEIVER'S DATA 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.

18.

COUNTRY OF OBLIGATION 19.

MATERIAL TYPE 20.

OBLIGATED ELEMENT WEIGHT 21.

OBLIGATED ISOTOPE WEIGHT For Enriched Uranium Only

22. ACTION DATE LINE NO.

b.

6. ACTION CODE

a. SHIPPER

b. RECEIVER DOE/NRC FORM 741 (MM-YYYY)

AUTHORIZED BY 10 CFR 30, 40, 50, 70, 72, 74, 75, 150