ML20214S547

Forwards Revised NRC Form 398, Personal Qualifications Statement - Licensee. Rev Made to Reflect Changes to 10CFR55 Effective 870526.All Applications for Licenses to Be Submitted on Revised Form as of 870526

ML20214S547
Person / Time
Site:	Nine Mile Point
Issue date:	06/04/1987
From:	Collins S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Mangan C NIAGARA MOHAWK POWER CORP.
References
NUDOCS 8706090314
Download: ML20214S547 (17)

Text

I O-e.

'.e JUN 4 1987 3

Docket No. 50-220 50-410 Niagara Mohawk Power Corporation ATTN:

Mr. C. V. Mangan Senior Vice President 301 Plainfield Road Syracuse, New York 13212 Gentlemen:

Enclosed is a copy of the revised NRC Form-398 (Enclosure 1), Personal Qualif-ications Statement - Licensee. This revision was made to reflect the changes to 10 CFR Part 55 effective May 26, 1987.

This revised form requires new applicants to complete each category completely including all education, training and experience received up to the date of the application.

Renewal, upgrade, multi-unit and reapplication applicants are required to complete each category except they need only to indicate the educa-tion, training and experience received since their last application.

If any applicant indicates that he or she is a graduate of an INPO accredited operator training program AND that an approved simulation facility, i.e.,

(certified on NRC Form 474 or NRC approved), is used in the operator training program, then education, training and experience DOES NOT have to be completed.

New applications must include the number of significant control manipulations under Item 12.3.

Other changes are detailed in Enclosure 2. is a set of instruc-tions for the completion of all items on the NRC Form 398.

All applications for licenses are to be submitted on this revised form begin-ning May 26, 1987.

The enclosed applications are for your use. Additional copies can be obtained by writing to Vivian Miller, U.

S.

Nuclear Regulatory Commission, Document Management Branch, Mail Stop W-548, Washington, D.C. 20555.

1 1

B706090314 870604

'k PDR ADOCK 05000220 EF PDR

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0FFICIAL RECORD COPY OL MULTI LTR - 0021.0.0 05/29/87 L

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Niagara Mohawk Power Corporation 2

If you have any questions regarding this form, please contact Robert M. Keller at 215-337-5211.

Sincerely,

~

n.-'ainal stanea m,/

Samuel J. Collins, Deputy Director Division of Reactor Projects

Enclosures:

As stated cc w/ enclosures:

R. Zollitsch, Training Manager Public Document Room (PDR)

Local Public Document Room (LPDR)

Nuclear Safety Information Center (NSIC)

NRC Resident Inspector cc w/o enclosures:

T. E. Lempges, Vice President, Nuclear Generation J. A. Perry, Vice President, Quality Assurance T. Perkins, General Superintendent, Nuclear Generation W. Hansen, Manager of Quality Assurance T. Roman, Station Superintendent, Nine Mile 1 J. Aldrich, Supervisor, Operations W. Drews, Technical Superintendent D. Quamme, NMP-2 Project Director C. Beckham, NMPC QA Manager R. B. Abbott, Station Superintendent Director, Power Division State of New York (w/ enclosures)

Troy B. Conner Jr., Esquire John W. Keib, Esquire bec w/ enclosure,s:

OL Plant File Examiners RIflLP RI[:D' P

La(t/mjd/geb Kel e 1

s

$/?v'/87 6//v'/87 4/b/87 0FFICIAL RECORD COPY OL MULTI LTR - 0021.1.0 05/28/87

INSTRUCTIONS FOR COMPLETING NRC FORM 338, PERSONAL QUALIFICATIONS STATEMENT-LICENSEE NEW APPLICANTS COMPLETE EACH CATEGORY OF THE FORM COMPLETELY. FOLLOWING THE INST ALL EDUCATION, TRAINING AND EXPERIENCE Thai YOU HAVE RECEIVED UP TO THE DATE OF THIS APPUCATION. NOTE: See ite RENEWAL. UPGR ADE0. MULTI UNIT. ANO REAPPUCATION APPUCANTS. COMPLETE EACH CATEGOR INO4CATE ONLY THE EDUCATION. TRAINING. AND EXPERtENCE YOU HAVE RECEIVED SINCE YOUR LA SPECIFIC INSTRUCTIONS FOR ITEMS 1119:

INDICATE BOTH ACADEMIC ANO VOCATIONAL / TECHNICAL PCST HIGH SCHOOL EDUCATION. FO INOICATE THE NUMBER 05 YEARS SPENT #N EACH COLLEGE CURRICULUM ANO THE HIGHEST DE 11-E DUC ATION:

PROVIDEO FOR VOCATIONAL / TECHNICAL EDUCATION. INCLUDE PROGRAMS SUCH AS NUCLEAR POW CONOiTIONING/REFRIGER ATION. OiESEL MECHANIC SCHOOL. ETC. INOICATE THE NUM8ER OF MO A CERTIFICATE OR OEGREE W AS AWARDED IF ADDITIONAL SPACE IS NEEDEO. CONTINUE UNOFR ITEM 17 NotCATE THE TRAINING YOU HAVE RECEIVED TO MEET THE REQUtREMENTS OF ANSI N181/ ANS 12 TRAINING. IN THIS ITEM :

8REAKCOWN OF TRAINING IN THl3 CATEGORY PARALLELS THE ANS STANDAROS PLEASE REFER TO CLARIFICATION. INCLUCE BOTH BEGaNNING AND COMPLETION DATES AND THE TOTAL NUM8ER OF W ING. NUMBER OF WEEKS (S PROVIDEO. IN ADDITION TO 8EGINNING ANO COMPLETION OATES. TO A (FOR EXAMPLE. FOUR WEEKS OF CLASSROOM TRAlNING SPREAD OVER A TWO MONTH PERICOL THERE 08CATE A LARGER TIME SPAN THAN THE Jt CTUAL NUMBER OF WEEKS SPENT IN FULL. TIME TR AININ APPUED FOR CANNOT BE OOUBLE COUNTED UNDER EXPERIENCE. ITEM 13.

ALL RECUAUF8 CATION TRAINING TIME IS TO 8E ACCOUNTED FOR IN THE REQUAUFICATION ITEM. PLEA ING ALL THE TIME SPENT IN REQUALIFICATION TR AINING UNDER ITEM 12 6. REQU AUFICATiON. EVEN T OR SIMULATOR TIME.

13-EXPERIENCE: FOR EACH POSJTION HELO. COMPLETE ITEM 16. DO NOT DOUBLE COUNT TIME. IF YOU H MONTHS SHOULO REFLECT THE PROPORTIONATE AMOUNT OF TIME YOU WERE ASSIGNED TO THOSE PART THE NUMBER OF MONTHS REPORTED FOR A PARTICULAR TIME PERIOD EXCEED THE NUMBER OF MONTHS T 14 FACIUTY OPER ATOR TR AINING PROGR AM. INDICATE e GRAOUATE OFINPO ACCREDITED OPERATOR TRAIN TIFIED (ON NRC FORM 474) OR NRC app 540VED SIMULATION FACluTY 15 USEO IN THE OPERATOR TRAINING PROGRAM. IF YES IS CHEC IN SOTH ITEMS e ANO 0. THEN ITEMS 11. EDUCATION.12. TRAINING.13. EXPERIENCE AND 16 FXPERisNCF OE COVPLETEO; Enpf G APMcMl;;G Posi 371LL IELUCE Tri[ istratR OF 51WFICANT CONTROL PWI!PtlUlTIONS UNotR ITEM 12.3.

NOTE: INPO ACCREDITED MEANS ACCRE0lTATION SY THE NATIONAL NVCLEAR ACCREDITING BOARO.

15-FOR RENEWALS ONLY; ENTER THE APPROXIMATE NUM8ER OF HOLRS SINCE PREVIOUS RENEWAL OR (SSUANCE OF UCENSE 1F FIR R ENEWAL.

INCLUDE POSITION TITLE. TIME PERIOO-FROWTO,FACiUTY. AND A BRIEF DESCRIPTION OF QUTIES PERFORMEO 16-EXPERIENCE DETAILS:

WHILE SERVtNG IN TH AT POSITION. IF MORE SPACE IS NEEDEO. USE ITEM 17, OR IF NECESSARY ATTACH ACOtTIONAL INFORMATION.

17-COMMENTS: USE TH S SPACE TO INCLUCE ANY EXTRA INFORMATION OR CLARIFICATION FOR OTHER ITEMS ON IF THE SPACE PROVICEO l$ NOT SUFFIC:ENT. YOU MAY ATTACH EXTRA INFORMATION WITH YOUR APPUCATION, 18-NRC FORM 295. CERTIFICATION OF MEDICAL EXAMINATION SY FACluTY UCENSEE. MUST ACCOMP ANY THIS APPUCA 19-SIGNATURES. SIGN AND OATE ITEM 19e. 08TAIN YOUR TRAINING COOR0lNATOR'S SIGNATURE ANO THAT OF YO MENT REPRESENTATIVE ON SITE.

OETACH THESE INSTRUCTIONS AND SUBMIT THE COMPLETED NRC FORMS 398. IN TRIPUCATE fong. net erws %c copaest ANO 296 TO THE APPROPRIATE REGIONAL ADMINISTRATOR.

PRIVACY ACT STATEMENT Pursuant to U.S.C. 552eie431. enacted mto law by Section 3 of the Pnvecy Act of 1974 IPublic Law $3-5711. the fo4 towing is furnished to in-dividuals who supply informetson to the U.S. Nucteer Regulatory Commiesson on NRC Form 3S8. This information is me.ntained in a system of records designated as NRC 16 and desenbed et e6 Federet Regester e6717 (September 21. 19611.

1 AUTHORITY. Section 107 and 141141 of the Atom.c Energy Act of 1964. se amended 442 U.S.C. 2177 and 2201 till.

2. PRINCIPAL PURPOSES. The mformenon will be collected end evolueted Jor determming licensing eligebeesty and to generate statistices date and reports on licensmg actions.

3 ROUTINE USES. Information entered on thee form may be used to: (el determme if the mdividual meets the requiremente of 10 CFR Part 56 to be issued en operator a license: lbl provide resserchers with information for statistical evolustions retened to selection. tremang, and e nemmetion of f ecierty operators: Ici provide f ec 46ty managemervt with sufficient information to enroll the indeveduele in the licensed operator requalification program; (d) provide fot enemination and testing metenal and obtain resulte from contractors.

4 WHETHER OISCLOSURE IS M ANDATORY OR VOLUNTARY AND EFFECT ON INOlVIOUAL OF NOT PROVIDING INFORM ATION: Disc is vo6untary. However if the information requested is not provided. NRC will not be able to evaluate whether the oppe. cation meets the requirements of 10 CFR Part 55 5 SYSTEMS MANAGERS ANO ADORESSES.

Regional Admanestrator. Regen 4 Regional Admenestrator, Region in U S. Nuclear Reguutory Ccmmess.on U.S. Nucteer Regulatory Commes on 631 Pers Avenue 101 Mariette Street. Sv.te 27J0 Attente. GA Jin23 King of Prustaa PA 19e06 Regono6 Adm n'strator Reg.on 111 Rogsonas Admoestrator. Regen IV Regiones Admarustrator. Re9'on V U.S. Nucseer Requietary Commrss,on U S. Nucheer Requatory Commmaon U S Nuclear Requietory Cornmession 7% Rooseveet Road 611 Ryan PteJe Drive. Su.se 1000 le50 Maria Lane Suite 210 Glen Ellvn tL F0137 Anegron. TX 76011 Weinut Creen. CA 9e596

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ENCLOSURE 2 SUttiARY OF CHANGES TO NRC FORM 398 Moved "New" to below " Hot" and " Cold". '

Item 4.a Combined " Oral" an'd " Simulator" into " Operating". -

Item 4.f Deleted " Instruct.:+ Certification".

Item 5.d Added a new item " Facility Operator Training Item 14 Program" and incorporated under this item the INPO accreditation hiock (originally under Training);

added a block for NRC approved or NRC Fom 474 certified simulation facility.

Added a new item "For Renewals Only. Hours Operated Item 15 Facility". (This was originally under Experience).

Renumbered previous items 14 through 17 to 16 Items 16 through 19 through 19.

Changed to read "NRC Form 396, Certification of Item 18 Medical Examination by Facility Licensee is attached" to indicate that in order for the application to be complete the NRC Fom must be attached.

Any false statement or omissions in this document, Statement Added including attachments, may be subject to civil and criminal sanctions.

Changed the wording to read "... certify under Item 19.a penalty of perjury that the infomation in this document and attachments is true and correct.

I also..."

Changed the wording to read "... has Item 19.b successfully completed the facility licensee's requirements to be licensed as an Operator / Senior l

Operator pursuant..." Also added the wording "I also certify under penalty of perjury that the infomation in this document and attachments is true and correct." Changed signature block from

" Highest Level Of Corporate Management for Plant Operation" to " Senior Management Representative On Site."

Added the wording "I also certify under penalty Item 19.c of perjury that the infomation in this document and j

attachments is true and correct. Changed signature block from " Highest Level of Corporate Management l

for Plant Operation" to " Senior Management Representative On Site."

Under waiver category combined " Oral" and FOR NRC USE

" Simulator" into " Operating".

ENCLOSURE 3 PERSONAL QUALIFICATIONS STATEMENT - LICENSEE NRC FORM 398 (REV 4/87)

NEW APPLICANTS ARE TO COMPLETE EACH ITEM OF THE NRC FORM 398 COMPLETELY, FOLLOWING INSTRUCTIONS BELOW.

THIS IS TO INCLUDE ALL EDUCATION, TRAINING, AND EXPERIENCE THAT APPLICANT HAS RECEIVED UP TO THE DATE OF THIS APPLICATION (NOTE EXCEPTION:

SEE ITEM 14).

~

RENEWAL, UPGRADE, MULTI-UNIT AND REAPPLICATION APPLICANTS ARE TO COMPLETE EACH ITEM OF THE NRC FORM 398 EXCEPT INDICATE ONLY THE EDUCATION, TRAINING, AND EXPERIENCE RECEIVED SINCE LAST APPLICATION (NOTE EXCEPTION: SEE ITEM 14).

d A SEPARATE NRC FORM 398 FORM MUST BE SUBMITTED EACH TIME AN APPLICANT APPLIES FOR A LICENSE OR RENEWAL OF LICENSE.

l FULL NAME AND CURRENT ADDRESS.

ITEM i CITIZENSHIP.

If other than U.

5. Citizen, ITEM 2 citizenship must be specified.

DATE OF BIRTH.

ITEM 3 TYPE OF APPLICATION.

ITEM 4 "X"

appilcable boxes Applying for a license at 1-Hot a plant that has schleved initial criticality.

This should be completed for each appilcation.

Applying for a license at i

2-Cold a plant that has not achieved initial criticality. This should be completed for each appilcation.

~

Applying for the first time

a. New at this facility OR If previously applied for a license but withdrew (write in "previously withdrew" next to New).

ALL ITEMS MUST BE COMPLETED ON A NEW APPLICATION l

AND SHOULD INCLUDE ALL EDUCATION, TRAINING AND EXPERIENCE RECEIVED UP TO THE DATE OF THIS APPLICATION.

THERE IS AN EXCEPTION TO THIS - SEE ITEM 14.

I i

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b. Renewal

- Now holds a license and is renewing that same type of Ilconse.

ALL ITEMS MUST BE i

COMPLETED ON A RENEWAL r

APPLICATION BUT NEED ONLY INCLUDE THE EDUCATION, TRAINING AND EXPERIENCE RECEIVED SINCE THE LAST APPLICATION.

THERE IS AN EXCEPTION TO TNIS - SEE ITEM 14.

\\

c. Upgrade

- Now holds an operator's license and is applying for a senior operator's license.

ALL ITEMS MUST BE COMPLETED ON j

AN UPGRADE APPLICATION BUT NEED ONLY INCLUDE THE EDUCATION, TRAINING AND EXPERIENCE APPLICANT l

RECEIVED SINCE LAST APPLICATION.

THERE IS AN EXCEPTION TO THIS -

i SEE ITEM 14.

j

d. Multi-unit

- Applying for a license on i

more than one Unit OR i

is a licensed operator on one unit and is applying to extend license to additional units.

(Notes all facility docket t

numbers are to be listed under Items 8 and 9).

ALL ITEMS MUST BE COMPLETED ON A MULTI-UNIT APPLICATION BUT NEED ONLY INCLUDE l

THE EDUCATION, TRAINING AND I

EXPERIENCE RECEIVED SINCE LAST APPLICATION.

j THERE IS AN EXCEPTION TO THIS -

SEE ITEM 14.

j j

e. Reappilcation

- Previously took a licensing i

exam and was denied a license i

and i s now reapplying for that same type of Ilconse at the same facility.

The reappilcation should identify those areas In which the applicant demonstrated weaknesses

)

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during the previous examination and the additional training l

received to correct these i

specific deficiencies in Item 12.7 and/or Item 17.

ALL l;

ITEMS MUST BE COMPLETED ON A i

REAPPLICATION APPLICATION BUT NEED ONLY INCLUDE THE EDUCATION, TRAINING AND EXPERIENCE RECEIVED SINCE LAST APPLICATION.

THERE IS AN EXCEPTION TO THIS - SEE ITEM 14.

4

- m

1-First

- If denied a license for the first time, the appilcant must Walt two months from the date of denial letter before reapplying for a license.

2-Second

- If denied a license for the second time, the appilcant must wait six months from the date of dental letter before reapplying for a license.

3-Third

- If denied a license for the third time, the appilcant must wait two years from the date of dental letter before reapplying for a license.

f. Walver Request

- NOTE:

Justification for any walver request is required under Item 17.

1-Written

- To request a waiver on entire written exam or on part of the written exam.

(Category (s) for which walver requested should be specified in space provided.)

2-Operating

- To request a waiver on an operating exam.

3-Eligibility

- To request a walver on eligibility requirements.

4-Other

- To request any other walver, i.e.,

medical.

TYPE OF LICENSE APPLIED FOR ITEM S

a. Operator

- Applying for en operator license.

b.

Senior Operator

- Applying for a senior operator license.

c. Limited SRO

- Applying for a limited senior operator license (e.g. fuel handler).

PREVIOUS LICENSE (S) HELD ITEM 6

- To be completed 11 prevlcusly held a license (or Instructor certificate).

a.

Docket Number

- Docket number assigned for previous license (s) held (55-XXXXX).

Indicate 11 this license was for RO or SRO.

If this was for

Instructsr Cortificotten er Llolted Senior Operator, please write in.

If a denial letter was issued, e docket number was assigned and should be Indicated in this block.

b. License Number

- License number (s) previously held.

License number should include the present renewal number, if any, (i.e.r XXXXX-5).

c. Expiration Date Date of Ilconse emptrstloa.

If several renewels have occurred, inst only latest expiration date.

d. Facility Docket No.

Docket number of facility where applicent held license (50-XXX).

Notet If previously held license / instructor certification et a training centere simulatore etc.,

where there is no facility dicket number, write in the name.

ITEM 7 NAME OF APPLICANT'S EMPLOYER Name and address of current employer.

ITEM 8 NAME OF APPLICANT'S FACILITY Name and docket number (50-XXX) l of facility where applying for a license.

ITEM 9 ADDITIONAL FACILITY DOCKETS If applying for multi-unit license ALL spplicable additional docket numbers must be entered.

ITEM 10 CURRENT POSITION AT FACILITY

e. Plant Superintendent Note license type 11 required by position.

b.

Assistent Plant Superintendent Note license type 11 required by position.

c. Shift Supervisor Position requires current senior license for e plant with fuel in the reactor.

d. Staff Engineer Note license type if required by position.

e.

Shift Technical Advisor / Shift Engineer-Note license type if required by position.

Note license typs if required f.

Instructor by position.

g. Senior Control Room Operator

- Position requires current senior license for a plant with fuel in the reactor.

h. Control Room Operator - Posit'lon requires current operator license for a plant with fuel in reactor.

l. Auxl11ery Unit Operator / Trainee /

Turbine Building /

Equipment Operator (non-licensed operator)- Ensure description is detailed enough to allow evaluation of position.

J. Other (Specify)

- Ensure description is detalled enough to allow evaluation of position.

Note license type 11 required by position.

ITEM 11 EDUCATION

a. High School Graduate

- Graduated from high school.

GED Equivalency

- Received GED equivalency.

No

- Did not complete high school.

b. Number of Years of College

- Number of years of college successfully completed.

L7reshmana 0 to 1 year Sophomores 1 to 2 years Junior = 2 to 3 years l

Seniors 3 to 4 years Graduate = 4 years or more)

c. Major Ares (s) of Study-l Engineering

- Fleid of engineering majored j

int number of years, ands highest degree obtained.

Other

- Other fleid majored Int l

i number of years, ands highest l

degree obtained.

i

d. Vocational / Technical Type of Training-Vocational / technical training schools, including military schools, appilcable to the operation of a L

pO Or p1 Cat.

Incled3 such programs as nuclear power school, air conditioning / refrigeration school, diesel mechanic school, Instrumentation and control maintenance, etc.

Number of Months-Calculate the approulmate number of full months appilcant received actual training.

(4 weeks, 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> / day = 1 month) l Raceived

- Indicate

-f certificate was received for this training.

ITEM 12 TRAINING

- Training Is indicated in weeks based upon 40 hours4.62963e-4 days <br />0.0111 hours <br />6.613757e-5 weeks <br />1.522e-5 months <br /> per week.

Indicate training received to meet the requirements of ANSI N18.1/ANS3.1.

The breakdown below parallels the ANS standards.

Beginning and completion dates and the total number of weeks spent in each type of training must be included.

The number of weeks is provided to account for Intermittent training (for example, four weeks of classroom training spread over a two month period).

Therefore, the date column 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 i

counted under Experience, Item 13.

REQUALIFICATION training time is be accounted for in Item 12.6.

1-Nuclear Power Fundamentals (Classroom)

- Fundamental course that covers the theory of the nuclear fission process and reactor operations.

2-Plant Systems

- Systems Instruction to include both observation and classroom work.

This Instruction is plant specific.

Classroom

- Instruction covering nuclear power plant systems and system and component malfunctions.

Observation

- Planned systematic observation training on accessible plant equipment.

_, ~ _ _ _ _ _ _

3-Operating Practice Training in operating practices in the control room for which the h

candidate will license and at a plant referenced simulator if one is avellable.

Control Room Operations Observation of the operating practices and the operation of nuclear power plant from the central control room.

Hot Ilconse candidates must manipulate the controls under direct supervision of a licensed operator at the Individual's duty station for a verlety of plant operations.

Cold license candidates are to participate in the plant preoperational testing program.

Actual time assigned to the operating shift should be counted in 12.5 below.

Simulator Operations Practice in manipulating plant (Includes Classroom) controls during normale abnormal and emergency conditions on a plant referenced simulator.

$1mulator Name(s)

Specify the simulator (s) where training was received.

If more than two simuistors specify the two most recent only.

Startup Certification Completed "X"

Yes or No.

(Notes For facilities with plant referenced simulators, certification of startup training will be provided by the facility organlaation.

For those facilities without a plant referenced simulator, startup certification must be obtained from the orgenlaation at which the startup demonstration was performed.)

Number of Reactivity Manipulationst Number of actual reactivity manipulations in which the appilcant was involved broken down by plant and simulator.

(Details should be provided in Comments, Item 17.)

4-SRO Instruction

- Instruction in the dutles of a senior operator.

.B.

5-Extra Person on Shift - Must be a alnlaum of three months on shift performing the actunt i

duties of the Alconsed position applied for.

These duties are performed under the direct supervision of Ilconsed personnel on normal shift rotation.

This should be in a structured, documented proDram.

Do not double count this time in 12.3 or as operating experience.

6-Requalification

- ALL requalifications training, including classroom and simulator time.

7-Other (Specify)

- Ensure description is detailed enough to allow evaluation.

Include number of research reactor startups, if performed.

t ITEM 13 EXPERIENCE

- Experience is indicated in months.

For each position held, IIst the month / year to cover the period you were quellfled for that position.

The number of months must reflect the time spent actually exercising the respon-sibilltles of that position.

Item 16 should be completed for each position held.

DO NOT DOUBLE COUNT TIME.

If there were overlapping dutles, the number of months should reflect the proportionate amount of time assigned to those particular dutles.

In no case should the number of months reported for a particular time period exceed the number of months that are in that time period.

Also, do not count time in training.

Ml11tery nuclear power experience should be ilsted in 1-5.

NAVY Non-nuclear allitary power experience should be listed under Fossil 6-9.

1-RO Quallfled to operate the controls of a Navy Propulslon or training reactor.

2-E00W/PPWO Authorized to supervise the operation of Navy Propulsion plants.

a) Graduate of INPO Accredited Operator Training Program "X" Yes or No 11 the appilcant J

ls a graduate of an INPD accredited operator training program.

(NOTE INPO accredited means accreditation by the National Nuclear Accrediting Board.)

I b) Certifled on NRC Form 474 (Simuistion Facility Certification) or NRC Approved Simulation Facility is Used i n the Operator Training Program "X" Yes or No if, in the operator training program, a certifled on NRC Form 474 or NRC approved slaviation facility is used.

ITEM 15 -

FOR RENEWALS ONLY - HOURS I

OPERATED FACILITY:

- The approximate number of hours appilcant has operated the facility under his existing Ilconse.

ITEM 16

- EXPERIENCE DETAILS

- Include position title, time period (from/to), and description of duties performed while serving in that position.

Item 17 should be used if more space is needed.

l ITEM 17

- COMMENTS

- This space should be used to complete Information from previous i

i ltems or clarlfication for other items on the appilcation form.

If space provided is not sufficiente extra pages may be attached to application.

ITEM 18

- NRC FORM 396, CERTIFICATION OF MEDICAL EXAMINATION SY FACILITY LICENSEE

- Any appilcation for a license or renewal of alconse is not complete without NRC Form 396.

A medical is good for six months from the date the physician signs i

It.

For applications following a voluntary withdrawal or license denial or an upgrade application, walvers may be granted on a case basis 11 the original medical evaluation was performed within one year.

If walver is requested, Item 4.f.4 should be marked.

l m.-.

m....,___.

9 3-EWS/PPWS Quellflod to direct and supervise the operations of a Navy Propulsion plant.

4-ERS/CRW Quellflod to direct and supervise Navy Propulsion plant operations outside the i

seneuvering eres.

5-0THER (Specify)

Ensure description is detailed enough to allow evolustion.

l FOSSIL i

6-Operator Navy or commercial non-nuclear propulslen/ power plant operation.

7-Supervisor Authorised to direct and supervise non-nucteer operators.

s-Plant Staff Non-nuclear power plant staff experience.

9-Other (Specify)

Ensure description is detalled I

enough to allow evolustion.

COMMERCIAL NUCLEAR (Including Research/ Test Reactor) 10-Reactor Operator (Licensed)

- Must hold or have held valid NRC operator license.

11-Senior Operator (Licensed)

- Must hold or have held valid NRC l

senior operator license.

12-Shift Supervisor (Licensed)

- Must hold or have held valid NRC senior operator license.

13-Steff/ Shift Engineer (Licensed)

- Must be et the facility and Involved in the day-to-day plant operational (engineering) staff work.

14-Aux./ Equip. (Nonlleensed)

Operator

- Personnel used in direct support of plant operations as directed by licensed operators.

Staff work other then that 15-Plant Staff directly associated with plant operations.

1 16-Other (Specify)

- Ensure description is detalled enough to allow evolustion.

FACILITY OPERATOR TRAINING PROGRAM ITEM 14 If "Yes" is checked Iri 30TN a) and b) then Items 11 (Education),

12 (Trelning), 13 (Experience), and 16 (Emperience Details) DO NOT have to be completed except new applications must still include the number of significant control manipulations under Item 12.3.

I

11 ITEM 19

- $1GNATURES REQUIRED Any falso statement or ommission in this documente including ettechments, coy be subject to civil and criminal sanctions.

e. Date and signature of appilcent certifying under penalty of perjury that the informetlen provided on NRC Form 398 Is true and correct.

Appilcant's signature also autherlaes the NRC to submit results of eneminettons to applicant's employer.

b.

Date end signature of Trelning Coordinator AND Senior Menegement Representative on Site certifyinge under penalty of perjury, that oppilcent has successfully completed the facility licensee's requirements to be licensed as en Operator / Senior Operator pursuant to 10CFR558 and that the opplicent has a need for this license to perform assigned duties.

Also certifies that facility will be evellebte for eneminations,

c. RENEWAL ONLY - Must be signed and dated by Training Coordinator AND Senior Mensgement Representative On Site certifyinge under penalty of perjurye that oppilcent meets the approved requellfication program (with any exception noted in Commentse Item 17) as required by section 50.54(1-1) of 10CFR50 and has discharged licensed responsibilities competently and safely.

.