ML20214R345
| ML20214R345 | |
| Person / Time | |
|---|---|
| Site: | 07001271 |
| Issue date: | 01/13/1986 |
| From: | Bonner G SANDWICH HIGH SCHOOL, SANDWICH, IL |
| To: | |
| Shared Package | |
| ML20214R243 | List: |
| References | |
| 80533, NUDOCS 8612050437 | |
| Download: ML20214R345 (4) | |
Text
4 esRC FORM 313 U.S. NUCL E AR kE EULATORY COMMIS$10N 1144)
=.
APP,:OVED BY OMO 10 CFR 30,32,33,34, 3154012G n ond 40 APPLICATION FOR MATERIAL LICENSE E P - E-3 m i
INSTRUCTIONS: SEE THE APPROPRIATE LICENSE APPLICATION GUIDE FOR DETABLED INSTRUCTIONS FOR COMPLETING APPLICATION. SEND TWO COPIES OF THE ENTIRE COMPLETED APPLICATION TO THE NRC OFFICE SPECIFIED BELOW.
FEDERAL AGENCIES FILE APPLICATIONS WITH:
IF YOU ARE LOCATED IN:
U S. NUCLE AR 9EGULATOR Y COMMISSION ILLINOfS, INDI ANA, IOWA, MICHIGAN, MINN ESOTA, MISSOUR1, OMIO, OR OlVISION OF FUEL CYCLE AND MATERIAL SAFETY,NMSS WISCONSIN, SEND APPLICATIONS TO:
WASHINGTON DC 20555 U.S. NUCLE AR REGULATORY COMMis$lON, REGION III ALL CTHER PERSONS FILE APPLICATIONS AS FOLLOWS,IF YOU ARE MATE RI ALS LICENSING SECTION LOCATEDIN:
799 ROOSEVELT ROAD GLEN ELLYN,lL 60137 CONNECTICUT, DELAWARE. DISTRICT OF COLUMBIA, MAINE, MARYLAND, MASSACHUSETTS. NEW JERSEY, NEW YORK, PENNSYLVANIA, RHODE ISLAND, AR K ANSAS. COLOR ADO, lDAHO, K ANSAS. LOUISL AN A, MONT ANA, NE8R ASK A, OR VERMONT,SEfeO APPLICATIONS TO:
NEW MEXICO, NORTH DAKOTA, OKLA HOMA, SOUTH DAKOTA, TE KAS, UTAM, OR WYOMING, SEND APPLICATIONS TO:
U.S. NUCLEAR REGULATORY COMAnlSSION, REGION I NUCLE AR MATERIAL SECTION 8 U S. NUCLE AR REGULATORY COMMISSION REGION IV S31 PARK AVENUE MATERIAL RADIATION PROTECTION SECTION KING OF PRUSSI A, PA 19406 611 RYAN PLAZA DRIVE, SulTE 1000 ALABAMA, FLORIDA, GEORGIA, KENTUCKY, MISSISSIPPI, NORTH CAROLINA, PUE;.TO RICO. SOUTH CAROLINA, TENNESSEE, VIRGINlA, VIRGIN ISLANDS, OR ALASKA, ARI2ONA, CALIFORNI A, M AWAll, N EVADA, OR EGON, WASHINGTON, WEST VIRGINI A, SEND APPLICATIONS TO:
AND U.S. TERRITORIES AND POSSESSIONS IN THE PACIFIC, SEND APPLICATIONS TO:
U.S. NUCLE AR REGULATORY COMMISSION, REGION 11 MATERI AL RADI ATION PROTECTION SECTION U.S NUCLE AR REGULATORY con 3,t:SSION, REGION V 101 MARIETTA STRE ET, SUITE 2900 MATERIAL RADIATION PROTECTION SECTION ATLANTA, GA 30323 1450 MARIA LANE. SUITE 210 WALNUT CREEK.C.A 94596 PEISONS LOCATED IN AGREEMENT STATES SEND APPLICATIONS TO THE U.S. NUCLEAR R EGULATORY COMMIS$10N ONLY IF THEY WISH TO POSSESS AND USE LICENSED MATERIAL IN STATES SUBJECT TO U.S. NUCLE AR RE GULATORY COMMIS$10N JURISOICTION.
1.THIS IS AN APPLICATION FOR (Check epproprsereitem)
- 2. NAME AND MAILING ADDRESS OF APPLICANT (Includela Covel bcbic d Sc M' bh[
- P f C)
A. NEW L* CENSE
- 8. AMENDMENT TO LICENSE NUM8ER U [ b /-. e G e 5 SNb~/223 J s'C d ((
5 C. RENEWAL OF LICENSE NUMBER Cm cn m
mc y
y L.atk d Wi A SLI T
Y 0
7 f/f [ lsans
'~
w ma L,4.3; C / R (o 3W g
- 4. NAME OF PERSON TO BE CONTACTED ABOUT THis APPLICATION c
TELEPHOhE NUMBER hn m,- e
~
N - Nf !
SUBMIT ITEMS $ THROUGH II ON 84 a 11" PAPER. THE TYPE AND SCOPE OF INFORMATION TO BE PROVIDED IS DESCRIBED IN THE LICENSE APPLICATION GUIDE.
- 5. RADIOACTIVE MATERIAL
- a. Element and mass number, t. chemical and/or physical form, and c. manim m amou t
- 6. PURPOSEls) FOR WHICH LICENSED MATE RiA. WILL Bi USED.
u n
which Mit be possessed et any one time.
7.
NDIVIDUAL S E
$ BLE FOR R ADIATION SAFETY PROGRAW AND THEIR
- 9. FACILITIES AND EQ 8612050437 861020
- 10. RADI ATION SAFETY PROGRAM.
REG 3 LIC70 SNM-1223 PDR ia LICENSEE FEES <see,o CFR sioends.ct,on rioare
- 11. WASTE MANAGEMEN s.
AMOUNT ENCLOSED $ /7[
FEE CATEGORY fb
- 13. CERTIFICATION. (4fust be completedby app'icentf THE APPLICANT UNDERSTANDS THAT ALL STATEMENTS AND REPRESENTATIONS MADE IN THIS APPLICATION ARE BINDING UPON THE APPLICANT.
THE APPLICANT AND ANY OFFICIAL EXECUTING THs$ CERTIFICATION ON BEH ALF OF THE APPLICANT, N AMED IN ITEM 2, CERTIFY THAT THl3 APPLICATION IS FREPARED IN CONFORMITY WITH TITLE 10. CODE OF FEDERAL REGULATIONS, PARTS 30,32,33,34,35. AND 40 AND THAT ALL INFORMATION CONTAINED HEREIN, is TRUE AND CORRECT TO THE BEST OF THEIR KNOWLEDGE AND SELIEF.
WARNING.18 U S C. SECTION 1001 ACT OF JUNE 25,1948,62 STAT. 749 UAKES IT A CRIMINAL OFFENSE TO MAKE A LFULLY FAL TATE REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTER WITHIN ITS JURISDICTION SIGNA
-CE RTIF YING OF FICER TYPED / PRINTED N AME TITLE g
DATE w ef/ %
Grant Bonner Superintendent 1/13/86 14 VOLUNT ARY ECONOV'C DAT A
- a. AN N U k L m '
C E f *Y S o NUMBER OF EMPLOYEES f Toter for d WOULD YOU BE WILL.NG TO FURNtSH COST INFORMATION /3oner end/orsentf hours)
< $250K Stu-3 SM
$500K-750K
$ 7M -10M
- c. NUM8ER OF BEDS
] YES
$750K-t u
> $10M NO M k FOR NRC USE ONLY TYRE OF FEE F E LOG /'
FE E CATEGOR Y COMvEN' APPROVED BY b
ff h
-L 0V (A,,
a ONTROL NO. 8 () 5 3 3 A OUNT RECEIVE O.,
CpCK NUMBER,
v'
.~
lY Yf MO2W& L-rt uh
- b
,R,VACYAC,S,A,EMEyy 7 R,p Eg, y q ;
y
c' l
PRIVACY ACT STATEMENT Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by section 3 of the Privacy Act of 1974 (Public Law 93-579),the follow-ing statement is furnished to individuals who supply information to the Nuclear Regulatory Commission on NRC Form 313. This information is maintained in a system of records designated as NRC-3 and described at 40 Federal Register 45334 (October 1,1975).
- 1. AUTHORITY: Sections 81 and 161(b) of the Atomic Energy Act of 1954,as amended (42 U.S.C. 2111 and 2201(b)).
- 2. PRINCIPAL PURPOSE (S): The information is evaluated by the NRC staff pursuant to the criteria set forth in 10 Ci-R Parts 30, 32,33,34,35 and 40 to determine whether the application meets the requirements of the Atomic Energy Act of 1954, as amended, and the Commission's regulations, for the issuance of a radioactive material license or amendment thereof.
- 3. ROUTINE USES: The information may be (a) provided to State health departments for their information and use; and (b) provided to Federal, State, and local health officials and other persons in the event of incident or exposure, for their information, investigation, and protection of the public health and safety. The information may also be dis-closed to appropriate Federal, State, and local agencies in the event that the information indicates a violation or potential violation of law and in the course of an administrative or judicial proceeding, in addition, this information may be trans.
ferred to an appropriate Federal, State, or local agency to the extent relevant and necessary for an NRC decision or to an appropriate Federal agency to the extent relevant and necessary for that agency's decision about you.
- 4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVID-ING INFORMATION: Disclosure of the requested information is voluntary. If the requested information is not furn-ished, however, the application for radioactive material license, or amendment thereof, will not be processed. A request that information be held from public inspection must be in accordance with the provisions of 10 CFR 2.790. Withhold-ing from public inspection shall not affect the right, if any, of persons properly and directly concerned need to inspect the document.
- 5. SYSTEM MANAGER (S) AND ADDRESS: U.S. Nuclear Regulatory Commission Director, Division of Fuel Cycle and Material Safety
,3 Office of Nudear Material Safety and Safeguards Washington, D.C. 20555 NRC FORM 313
.~
=
F 5.
Pu - 238, sealed Pu-Be 150 milligrams 6.
Storage 7.
No Program l
4 8.' No Training.
Not in use.
9.-
Cannister placed in chemical stockroom.
i
- 10. No program t
- 11. No waste.
12.
9.D
$175.00 1
1 e
I h
4 e
f D No80533 I
i
~. -,. - -.,-
.,_-,-_-,.,._,_,,,.,,.,,,.,,._,,,,.,,,,n.
r Sandwich Community Send Invoice to:
entcha m Ord'r m 20130 Unit Schools District No. 430 The above order number 720 South Wells Street must appear on all pack-SANDWICII, ILLINOIS 60548 ages, invoices & shipping papers.
DATE January 10, 1986 I
l smP To Sandwich High School 515 E. Lions Rd To U.S. Nuclear Regulatory Commission Sandwich, Il 60548 799 Roosevelt Rd Glen Ellyn, Illinois 60137 smP VIA CONFIRMATION ONLY YES E N0XXXX XXXX DEI.IERY DAR QUANTITY DESCRIPTION PRICE AMOUNT Fees
- Material License 175.00 (Must be sent by January 24th) q#
C gf 96 CONTROI.so 8 0 5 3 3 N
gGM o N/
cb ---
M C~
///h Requistioner School Approval
' Centr'al Office Approval 3 2 ' @ Q INI/
RLS1VIy l 2;lZ 1 l
l I
l coldenrod-
^*
Receipt Copy Whitc-Vendor Copy Canary-School Office Copy Forward to Central Office Blue-Central Office Copy Pink-Requisitioner's Copy When Materials Have Been Received.
>