ML20205C601
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Form Approveo 8y Station Superintancent Effective Cate Sca; Msg. mo.
STATION 800CE0uet CR FORM CHANGE A.
ICENTIFICATt0N h w.0RM NUWSER: Ec9 75 FA-H.3 I
REv.
wAN:t 80.
(Circle One) 40 0V CR FORM TITLf:__ *5he E A*' cut N* rive'a bw-N.'4b [e w f rcle One)
INITIATED BY:
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5$1 s-C ANGE N,s o w i g eo 7u.--y nk C.
REA50N Fee CHANGE hpo 0.
NON-1NTENT CHANGE AUTHORIZAT!cN (N/A for Intent changes)
TITLE SIGNATURE DATE Shif t Supervisor (
duty) kM I VI)
E.
REVIEVED
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Department Head
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F.
SPECIFIC UN8EV1 BED SAFETY QUEST!CN EVALVA TCN GE001aE0 g
Modifies inttrt af proceduta and changes oceration of systems as described in design documents.
YES ( )
NO (if yes, perforse written USQ determination and Safety Evaluation, and contact Manager, Safety Analysis Branch to determine need for Integrated safetj Evaluation.)
YES ( )
80 ENV!RCNMENTAL REVIEV REQUIRED (Adverse environmental impact)
YE5 ( )
40Q 0.
SPECIFIC SAFETY EVALUAffCN eEQUteED Af fects response of safety systems, perfomance of systets which may have been credited in the safety analysis or non-credited systees which may indirectly affect safety systee response.
YES ( )
80 (If yes, perform written Safety Evaluation and Contact Manager. Safety Analyais Branch to detemire need for Integrat.ed safety Evaivation.)
H.
INTEGRATED SAFETY EVALUATION REQu! RED YE5 ( )
No
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PORC/50RC RECCtt<EN05 APPROVAL (or confireation of interim change within 14 days)
(Ocewaent all YES responses to aeove ovestions in PCRC/50RC meeting minutes)
PCfl0/50RC Meeting Numeer 3-8/-2d7 J.
APPe0VAl, AND ImpttutNTATIOM O
The change is hereby,isgigmented,4tHI is ef f ective this date, encent for inte in changes whic
$ esente M g effective per the Authorization of 0 above, 12-17-87 u
Stat 1Wsuperintencent/ unit Swperintencent Date 9810260539 001007 SF 302 PDR ADOCK 05000213 88*-
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