ML20214U052

Forwards Revised NRC Form-398, Personal Qualifications Statement - Licensee. Rev Made to Reflect Changes to 10CFR55,effective 870526

ML20214U052
Person / Time
Site:	Beaver Valley
Issue date:	06/04/1987
From:	Collins S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Carey J DUQUESNE LIGHT CO.
References
NUDOCS 8706110027
Download: ML20214U052 (17)

Text

_

JUN 4 1987 Docket No. 50-412 Duquesne Light Company ATTN:

Mr. J. J. Carey Senior Vice President Nuclear Group Post Office Box 4 Shippingport, Pennsylvania 15077 Gentlemen:

Enclosed is a copy of the revised NRC Form-398 (Enclosure 1), Personal Qualif-ications Statement - Licensee. This revisi.on 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 INP0 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.

8706110027 870604

{DR ADOCK 05000412

{ Y}J PDR OFFICIAL RECORD COPY OL MULTI LTR - 0077.0.0 I[

06/05/87 8

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Duquesne Light Company 2

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

Sincerely, o,,p e1 3, 3,.,. A67 Samuel J. Collins, Deputy Director Division of Reactor Projects

Enclosures:

As stated cc w/ enclosures:

T. Burns, Director Nuclear Training Public Document Room (PDR)

Local Public Document Room (LPDR)

Nuclear Safety Information Center (NSIC)

NRC Resident Inspector Commonwealth of Pennsylvania cc w/o enclosures:

J. D. Sieber, Vice President, Nuclear J. Crockett, Senior Manager, Nuclear Operations E. Ewing, Quality Assurance Manager R. J. Swiderski, Manager, Startup Group J. P. Thomas, Manager, Engineering R. E. Martin, Manager, Regulatory Affairs C. O. Richardson, Stone and Webster Engineering Corporation bec w/ enclosures:

OL Plant File Examiners RI:DRP RI:DRP R.

P Lange/mjd/gcb Keller C

s l

S/ /87 5/ /87 6/5 /87 0FFICIAL RECORD COPY OL MULTI LTR - 0077.1.0 06/05/87

- - - - ~

-- - -- ~ --_____

INSTRUCTIONS FOR COMPLETING NRC FORM 338. PERSONAL QU ALIFICATIONS STATEMENT-LICENSEE THIS IS TO INCLUDE APPLICANTS COMPLETE E ACH CATEGORY OF THE FORM COMatETELY. FOLLOwiNG THE iNSTRUCDONS BELOW TRAINING AND EXPERsENCE THAT YOU H AVE RECEIVED UP TO THE DATE OF THis APPUCATION. NC NEW ALL EDUCATION RENEW AL. UPGR AOCO. MULTI. UNIT. AND REAPPLfC ATION APPUCANTS COMPLE'E EACH CATEGORY NOTE: See item 14 TR AINiNG AND E.xPERIENCE YOU HAVE RECEIVED SINCE YOUR LAST AP9UCATlON

1. NO'CA TE ONL Y THE EDUCAT:ON SPECIFIC INSTRUCTIONS FO+t ITEMS 1119 FOR MAJCR AREAISa OF STUOY.

11-EDUCAT10N-tNOtCATE BOTH ACACEMIC ANO VOCATIONAL' TECHNICAL PCST HIGH SCHOOL EDUCATICN NG THE OEGREE CODE sNOiCATE THE NUMSER Of YEAR $ SPE NT IN EACH COLLEGE CURRICULUM ANO THE HtGHEST DEGREE RECEIVE DROVtOED FOR VOCATION AL; TECHNtCAL EDUCA TION. INCLUDE PROGRAMS SUCH AS NUCLEAR POWER SCHO CONOiTIONiNGiREFRIGER ATIO*4. O#ESEL MECHAMC SCHOOL. ETC INDICATE THE NUMBER OF MONT A CERTIFICATE OR DEGREE A AS AW AROED iF ADDITIONAL SPACE IS NEECEO. CONTINUE UNOFR ITEM 17 THE NO!CATE NE TAAIN'NG v00 H AVE RECEtVEO TO MEET THE REQUtREMENTS OF ANSI N18 li ANS 3.1 12 -TR AiNiNG. iN Tms.TE?.*

8REA ACOWN OF TRAINING eN THIS CATEGORY PARALLELS THE ANS STANDAROS PLEASE REFER TO TH INCLUCE BOTH BEGiNNtNG AND COMPLETION OATES AND THE TOTAL NUM8ER OF WEEKS SPENT IN EA TTENT TRAINtNG CLARiflC A TION ING. NUMBER OF WEEKS IS PROvtOEO. IN ADDITION TO 8EG,NN1NG AND COMPLETION OATES. TO ACCOUNT FOR INTERMI OI. THEREFORE. NE DATE COLUMNS MAY IN-(FOR EXAMPLE. FOUR WEEKS OF CLASSROOM TRAINING SPREAD OVER A TWO MONTH PERIC O'CATE A LARGER TIME SPAN TH AN THE ACTUAL NUM8ER OF WEEN.S SPENT IN FULL ilME TRAINING. TIME APPUEO FOR CANNOT BE DOUBLE COUNTEO UNDER EXPERIENCE. ITEM 13 ALL RECUAUFICATION TRAINING itVE IS TO BE ACCOUNTED FOR IN THE REQUALIFICATiON ITEM PLEASE AVOIC E CLASSROOM

!NG ALL THE TIME SPENT IN REQUAUFICATION TR AINING UNDER ITEM 12 6. REQUAUFICADON. EVEN THOUGH iT MAY I OR SIMULATOR TIME.

13-EXPERIENCE: FOR EACH PCSITION HELO. COMPLETE ITEM 16. 00 NOT OOUBLE COUNT DME. IF YOU H AO O MONTHS SHOULO REFLECT THE PROPORTIONATE AMOUNT OF TIME YOU WERE ASSIGNED TO THOSE PARTICULA THE NUMBER OF MONTHS REDORTED FOR A PARTICULAR TIME PERICO EXCEED THE NUMBER OF MONTHS THAT 14 FACIUTY OPERATOR TR AINING PROGRAM. tNOiCATE

a. GR AOUATE OF INPO ACCREDITED OPERATOR TR AINING PROGR AM. ANO b.CER-T!FIED 'CN NRC FOAM C41 OR NRC APPROVED SIMULATION FAC:UTY 15 U$ED IN THE OPER ATOR TR AINING PRO A N D 16 FXPFRiFNCF nrTAILS no NOT H AVE TO BE

!N BOTH ITEMS a ANO b. THEN ITEMS 11. EDUCATION.12. TRAINING.13 EXPEAIENCF COYPLE'EC; Ex:EPT 4E'i MMC

• TIC;G N5T IT!R lhCLUDE TriE NiPBER OF 51C%tFICANT CONTROL *ANIPULAT10N5 UhtLR ;ii312.L NOTE. INPO ACCREDITED MEANS ACCREDITATION BY THE NATIONAL NUCLEAR ACCREDITING BOARO.

ENTER THE APPROxtM ATE NUM9ER Of HOURS SINCE PREVIOUS RENEWAL OR ISSUANCE OF UCENSE lF F 15-FOR RENCWALS ONLY:

A EN EW AL 16-EXPERIENCE DETAILS. INCLUDE POSITION TITLE. TIME PEPtOO FROM/TO,FACtUTY AND A BRIEF DESCRIPTION OF OUTIES PERFORMED WHILE SERVING IN TH AT POSITION. IF MORE SPACE IS NEEOEO USE ITEM 17. OR (F NECESSARY ATTACH ADDITIONAL JN 17-COMMENTS: USE THt$ SPACE TO INCLUDE ANY EXTRA INFORMATION OR CLARIFICATION FOR OTHER ITtiMS ON THE AP I

if THE SPACE PROVIOED 15 NOT SUFFIC:ENT, YOU MAY ATTACH EXTPA INFORMATION WITH YOUR APPUCATION.

18-NRC FORM 396. CERTIFICATION OF MEDICAL EXAMINATION BY FACluTY UCENSEE. MUST ACCOMP ANY THIS APPUCATION.

19-SIGN ATURES: SIGN AND OATE ITEM 19a 08TAIN YOUR TRAINING COOROiNATOR'S SIGNATURE ANO TH AT OF YOUR SENI MENT REPRESENTATIVE ON SITE.

OETACH THESE INSTPUCTIONS AND SUBMIT THE COMPLETED NRC FORMS 338. IN TRIPUCATE (ong nal and two coonsi ANO 396 TO THE AP9ROPRI ATE REGION AL AOMINISTR ATOR.

P8lVACY ACT STATEMENT Pursuant to U.S.C. SEZateH31. enacted into law by Section 3 of the Pnvecy Act of 1974 (Public Law $3-5791, the todowing is furmened to n-dividuals who supply enformation to trie U S. Nuclear Regulatory Cornmission on NRC Form 338. This information is mainte.ned in a system of records designated as NRC 16 and desenbod et e6 Federal Register 46717 (September 21. 19811.

AUTHORITY. Section 107 and 161(4) of the Atomic Energy Act of 1%4. es amenced 442 U.S.C. 2137 and 2201 (ill.

1

2. PRINCIP AL PURPOSES. The informenon wdl be co41ected and evaluated f or determming licensing etigibility and to generete statistical data and reports on licensing actions.

3 ROUTINE USES. Information entered on thre form may be used to: (as determine of the individuet meets the requiremente of 10 CFR Port (b) provide researchers with information for statisticet evetuations related to selection. treemag. and 55 to be issued en operator's license:

enemmation of f acilrty operators: tel provide f acility management with sufficient information to enroll the individuals en the licensed operator requalification progrem; (dl provide for eneminetton and eating metenal and obtain results from contractors.

4. WHETHER OtSCLOSURE IS MANOATORY OR VOLUNTAf ' AND EFFECT ON INOtVIOU AL OF NOT PROVIDING INFORM ATION: Disclosure is vosuntary. However, if the information requested is n. i prouded. NRC ndi not be edie to evaluate whether the opptecation meets the requirements of 10 CFR Part 55 S SYSTEMS MANAGERS AND ADORESSES:

Ragional Admastrator Req.on i Regional Administrator Reg.on 15 U S. Nuclear Regutatory Cor,mru.on U.S. Nuctear Regulatory Commrssion 101 Mar.etta Street. Su.te 2W 631 Part Avenue Attanta, GA XG23 Ong of Prussaa. P A 19.a06 Regionae Admenrstrator, Reg,on til Reg.onsa Admin strator. Region IV Regional Adminrstrator. Reg.on V U S. Nuciear Regulatory Commru.on U.S. Nucie.t Requtatory Commess.on U S. Nuclear Regulatory Commess.on 7% Rooseveit Road 611 Ryan etaza Onve. Suite 1000 1450 Marie Lane. Su.te 210 G6en Etivn. tL 60137 A,tengton. TX 76011 Wainut Crees. CA 94S96

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U. S. NUCLEAR Hf GULATORY COMMISSION

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ENCLOSURE 2

SUMMARY

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 " Instructor Certification".

Item 5.d Added a new item " Facility Operator Training Iteu 14 Program" and inco.porated under this item the INP0 accreditation block (originally under Training);

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

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

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

Item 18 Changed to read "NRC Form 396, Certification of 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 information 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 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 information 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."

FOR NRC USE Under waiver category combined " Oral" and

" 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 EDUCATIDN, TRAINING, AND EXPERIENCE THAT APPLICANT HAS RECEIVED UP TO THE DATE OF THIS APPLICATION (NOTE EXCEPTION:

SEE ITEM 14).

MULTI-UNIT AND REAPPLICATION APPLICANTS ARE RENEWAL, UPGRADE, 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).

SEPARATE NRC FORM 398 FORM MUST BE SUBMITTED EACH TIME AN A

APPLICANT APPLIES FOR A LICENSE OR RENEWAL OF LICENSE.

FULL NAME AND CURRENT ADDRESS.

ITEM 1 ITEM 2 CITIZENSHIP.

If other than U.

S.

Citizen, citizenship must be specified.

ITEM 3 DATE OF BIRTH.

ITEM 4 TYPE OF APPLICATION.

"X" appilcable boxes:

1-Hot

- Applying for a license at a plant that has achieved initial criticality.

This should be completed for each appilcation.

2-Cold

- Applying for a license at ^

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 11 previously applied for a license but withdrew (write in "previously withdrew" next to New).

ALL ITEMS MUST BE COMPLETED ON A NEW APPLICATION 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.

b.

Renewal

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

ALL ITEMS MUST BE COMPLETED ON A RENEWAL APPLICATION BUT NEED ONLY INCLUDE THE EDUCATION, TRAINING AND EXPERIENCE RECEIVED SINCE THE LAST APPLICATION.

THERE IS AN EXCEPTION TO THIS - SEE ITEM 14.

c.

Upgrade

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

ALL ITEMS MUST BE CUMPLETED ON AN UPGRADE APPLICATION BUT NEED ONLY INCLUDE THE EDUCATION, TRAINING AND EXPERIENCE APPLICANT RECEIVED SINCE LAST APPLICATION.

THERE IS AN EXCEPTION TO THIS -

SEE ITEM 14.

d.

Multi-unit

- Applying for a license on more than one unit OR is a licensed operator on one unit and is applying to extend license to additional units.

(Notes all facility docket numbers are to be listed under Itens 8 and 9).

ALL ITEMS MUST BE COMPLETED ON A MULTI-UNIT APPLICATION BUT NEED ONLY INCLUDE THE EDUCATION, TRAINING AND EXPERIENCE RECEIVED SINCE LAST APPLICATION.

THERE IS AN EXCEPTION TO THIS -

SEE ITEM 14.

e.

Reappilcation

- Previously took a licensing

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exam and was denied a license and is now reapplying for that same type of Ilcense at the same facility.

The reappilcation should identify those areas in which the applicant demonstrated weaknesses during the previous examination and the additional training received to correct these specific deficiencies in Item 12.7 and/or Item 17.

ALL ITEMS MUST BE COMPLETED ON A REAPPLICATION APPLICATION BUT NEED ONLY INCLUDE THE EDUCATION, TRAINING AND EXPERIENCE RECEIVED SINCE LAST APPLICATICN.

THERE IS AN EXCEPTION TO THIS - SEE ITEM 14.

If denied a license for the 1-First first time, the applicant must wait two months from the date nf denial letter before reapplying for a license.

If denied a license for 2-Second the second time, the appilcant must wait six months from the date of denial letter before reapplying for a license.

If denied a license for 3-Third the third time, the applicant must wait two years from the date of denial letter before reapplying for a license.

f.

Walver Request

- NOTE:

Justification for any waiver request is required under Item 17.

i-Written

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

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

2-Operating

- To request a waiver on an operating exam.

3-Eligibility

- To request a waiver on ellglbility requirements.

4-Other

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

medical.

ITEM 5 TYPE OF LICENSE APPLIED FOR a.

Operator

- Applying for en operator licen'se.

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 if previously held a license (or instructor certificate).

a.

Docket Number

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

Indicate if this license was for RO or SRO.

If this was for

Instructor Certification or Limited Senior Operator, please write in.

If a denial letter was issued, a docket number was assigned and should be i n d i c a ". e d in this block.

b.

License Number

- License number (s) previously held.

License number should include the present renewal number, if any, (i.e.,

XXXXX-3).

c. Expiration Date

- Date of.11 cense expiration.

If several renewals have occurred, list only latest expiration date.

d. Facility Docket No.

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

Note:

If previously held license / instructor certification at a training center, simulator, etc.,

where there is no facility docket 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) of facility where applying for a license.

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

CURRENT POSITION AT FACILITY ITEM 10 Note license type if required a.

Plant Superintendent by position.

b.

Assistant Plant Superintendent

- Note license type if required by position.

c. Shift Supervisor

- Position requires current senior license for a 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, f.

Instructor

- Note license typs if required by position.

9 Senior Control Room Operator

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

h.

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

l.

Auxiliary 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 detailed enough to allow evaluation of position.

Note license type if required by position.

EDUCATION ITEM 11 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.

(Freshman = 0 to 1 year Sophomore = 1 to 2 years Junior = 2 to 3 years Senior = 3 to 4 years Graduate = 4 years or more)

c. Major Area (s) of Study-Fleid of engineering majored Engineering in; number of years, andi highest degree obtained.

Other

- Other field majored in; number of years, and; highest degree obtained.

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

power plant.

Includo cuch programs as nuclear power school, air conditioning / refrigeration school, diesel mechanic school, instrumentation and control maintenance, etc.

Number of Months-Calculate the approximate 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)

Certificate Received

- Indicate if certificate was received for this training.

TRAINING

- Training is indicated in weeks ITEM 12 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 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-Operatlag Practice

- Training in operating practices in the control room for which the candidate will license and at a plant referenced simulator if one is available.

Control Room Operations

- Observation of the operating practices and the operation of nuclear power plant from the central control room.

Hot license candidates must manipulate the controls under direct supervision of a licensed operator at the Individual's duty station for a variety 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 (Includes Classroom)

- Practice in manipulating plant controls during normal, abnormal and emergency conditions on a plant referenced simulator.

Simulator Name(s)

- Specify the simulator (s) where training was received.

If more than two simulators 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 organization.

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

Number of Reactivity Manipulations:

- Number of actual reactivity manipulations in which the applicant was involved broken down by plant and simulator.

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

Instruction in the duties of 4-SRO Instruction a senior operator.

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5-Extra Person on Shift - Must be a alnimum of three months on shift performing the actual duties of the licensed position applied for.

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

This should be in a structured, documented program.

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.

EXPERIENCE

- Experience is Indicated in months.

ITEM 13 For each position held, list the month / year to Cover the period you were qualified for that position.

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

Item 16 should be completed for each position held.

DO NOT DOUBLE COUNT TIME.

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

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.

Military nuclear power experience should be listed in 1-5.

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

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

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

J a) Graduate of INPO Accredited Operator Training Program "X" Yes or No if the applicant is a graduate of an INPO accredited operator training program.

(NOTE:

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

b) Certlfled on NRC Form 474 (Simulation Facility Certification) or NRC Approved Simulation Facility is Used in the Operator Training Program "X" Yes or No if, in the operator training program, a certified on NRC Form 474 or NRC approved simulation facility is used.

ITEM 1S -

FOR RENEWALS ONLY - HOURS OPERATED FACILITY:

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

Include position title, time ITEM 16

- EXPERIENCE DETAILS period (from/to), and description of duties performed while serving in that position.

Item 17 should be used if more space is needed.

This space should be used to ITEM 17

- COMMENTS complete information from previous items or clarification for other items on the appilcation form.

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

ITEM 18

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

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

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

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

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

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

4-ERS/CRW Quallfled to direct and supervise Navy Propulsion plant operations outside the maneuvering area.

Ensure description is detailed S-0THER (Specify) enough to allow evaluation.

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

Authorized to direct and supervise 7-Supervisor non-nuclear operators.

Non-nuclear power plant staff experience.

8-Plant Staff Ensure description is detailed 9-Other (Specify) enough to allow evaluation.

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 senior operator license.

12-Shift Supervisor (Licensed)

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

13-Staff / Shift Engineer (Licensed)

- Must be at the facility and involved in the day-to-day plant operational

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(engineering) staff work.

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14-Aux./ Equip. (Nonlicensed) l Operator

- Personnel used in direct support l

of plant operations as directed by licensed operators.

15-Plant Staff

- Staff work other than that i

l directly associated with plant operations.

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16-Other (Specify)

- Ensure description is detailed enough to allow evaluation.

FACILITY OPEN4 TOR TRAINING PROGRAM ITEM 14 If "Yes" is checked in BOTH a) and b) then Items 11 (Education),

i 12 (Training), 13 (Experience), and 16 (Experience Details) DO NOT to be completedi except new applications must still include the number l

have of significant control manipulations under Item 12.3.

l 11 _

l ITEM 19

- SIGNATURES REQUIRED l

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

a.

Date and signature of applicant certifying under penalty of perjury that the information provided on NRC Form 398 is true and correct.

Appilcant's signature also authorizes the NRC to submit results of examinations to appilcant's employer.

b. Date and signature of Training Coordinator AND Senior Management Representative on Site certifying, under penalty of perjury, that appilcant has successfully completed the facility licensee's requirements to be licensed as an Operator / Senior Operator pursuant to 10CFR55; and that the applicant has a need for this license to perform assigned duties.

Also certifies that facility will be available for examinations,

c. RENEWAL DNLY - Must be signed and dated by Training Coordinator AND Senior Management Representative On Site certifying, under penalty of perjury, that appilcant meets the approved requalification program (ulth any exception noted in Comments, Item 17) as required by section 50.54(1-1) of 10CFR50 and has discharged licensed responsibilities competently and safely.

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