ML21075A336

Enclosure 4_nrc741

ML21075A336
Person / Time
Issue date:	03/18/2021
From:	James Rubenstone NRC/NMSS/DFM/MCAB
To:
MShoemaker - NMSS/DFM/MCA - 301.415.7363
Shared Package
ML21075A325	List: ML21075A326 ML21075A327 ML21075A328 ML21075A329 ML21075A330 ML21075A331 ML21075A332 ML21075A334 ML21075A335 ML21075A336
References
Download: ML21075A336 (1)

Text

DOE/NRC FORM 741 U. S. DEPARTMENT OF ENERGY APPROVED BY OMB: NO. 3150-0003 EXPIRES: 04/30/2021 (04-2018) Previous editions are obsolete AND 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 MANDATORY DATA COLLECTION U. S. NUCLEAR REGULATORY COMMISSION accounting reports that show changes in inventory of nuclear materials. Send comments regarding burden estimate to the Information AUTHORIZED BY 10 CFR 30, 40, 50, 70, Services Branch (T-2 F43), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.

72, 74, 75, 150 Public Laws83-703, 93-438, 95-91 gov, and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0003), Office of Management and Budget, NUCLEAR MATERIAL TRANSACTION REPORT Washington, DC 20503. If a means used to impose an information collection does not display a currently valid OMB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.

1. SHIPPER'S RIS 2. RECEIVER'S RIS 3. TRANSACTION NO. 4. CORRECTION NO. 5. PROCESSING CODE 6. ACTION CODE 7. DOCUMENTATION (Only if document is classified SECRET)

a. SHIPPER b. RECEIVER a. SHIPPER b. RECEIVER PAGE OF PAGES COPY OF COPIES SERIES 8.a. NAME AND ADDRESS b. LICENSE 9.a. NAME AND ADDRESS b. LICENSE OF SHIPPER NO. NO. 10. NO OF DATA LINES 11. NATURE OF TRANSACTION NO. DISTRIBUTION OF COPIES OF RECEIVER 12.a. SHIPPED FOR ACCOUNT OF 13.a. SHIPPED TO ACCOUNT OF

b. RIS b. RIS 1 2

3 4

c. ATTENTION: c. ATTENTION:

5

d. TELEPHONE: d. TELEPHONE:

6

14. TRANSFER AUTHORITY - CONTRACT, NM DRAFT, OR ORDER NUMBER 15. EXPORT OR IMPORT TRANSFERS: LICENSE NO.

7

16. MATERIAL TYPE AND DESCRIPTION 17. 18. 19. 20. 21. 8 LINE COUNTRY OF MATERIAL OBLIGATED OBLIGATED ISOTOPE NUMBER OBLIGATION TYPE ELEMENT WEIGHT WEIGHT For Enriched Uranium Only 9 MONTH DAY YEAR

22. ACTION DATE (MM) (DD) (YYYY)

a. SHIPMENT 23a. MISCELLANEOUS b. SHIPPER'S CORRECTION

b. CONCISE NOTE ATTACHED

c. RECEIPT

c. UK REPORTABLE? YES NO

d. RECEIVER'S MEASUREMENT

e. RECEIVER'S CORRECTION

24. TOTAL GROSS WEIGHT 25. TOTAL VOLUME (Waste Transfers Only)

BACK LINE TYPE IDENTIFICATION NO. OF PROJECT MATE- COMP/ OWNER KEY MEAS. IDENT. GROSS WEIGHT NET WEIGHT ELEMENT ELEMENT WEIGHT % ISOTOPE ISOTOPE REFERENCE NO. OF INV. (ITEM/BATCH NAME) ITEMS NUMBER RIAL FACILITY CODE MEAS. k. WEIGHT LIMIT OF ISOTOPE WEIGHT LIMIT OF NUMBER CHANGE TYPE CODE POINT ERROR ERROR 1 2 3

a. b. c. d. e. f. g. h. i. j. BASIS OMP METHOD l. m. n. o. p. q. r.

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

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.

DOE/NRC FORM 741 (04-2018)