ML21340A017

OMB 3150-0036, NRC Form 830

ML21340A017
Person / Time
Issue date:	03/04/2022
From:	NRC/OCIO
To:
Baker S
Shared Package
ML21340A014	List: ML21340A017 ML21340A019 ML21340A020 ML21340A028 ML21340A103
References
OMB 3150-0036
Download: ML21340A017 (1)

Text

NRC FORM 830 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0036 EXPIRES: (MM/DD/YYYY)

(MM-YYYY) 10 CFR 110.50(c)(3)(ii) Estimated burden per response to comply with this mandatory collection request: 30 minutes. This form allows the NRC to request additional information from licensees to determine whether a license should be revoked, suspended, or modified. Send comments regarding burden estimate to the FOIA, Library, and Information Collections Branch, (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-001, or by REPORT OF IMPORT e-mail to Infocollects.Resource@nrc.gov, and the OMB reviewer at: OMB Office of Information and Regulatory Affairs, (3150-0036), Attn: Desk Officer for the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 20503; e-mail: oira_submission@omb.eop.gov. The NRC may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the document requesting or requiring the collection displays a currently valid OMB control number.

ADVANCED NOTIFICATION OF SEND COMPLETED FORM TO:

SHIPMENT OF CATEGORY 1 AND/OR 2 RADIOACTIVE SOURCES U.S. Nuclear Regulatory Commission In accordance with 10 CFR Part 110.50(c)(3)(ii) ATTN: Headquarters Operation Center of the U.S. NRC Regulations Email: hoo.hoc@nrc.gov (Preferred Reporting Method)

Fax: (301) 816-5151 (Alternative Reporting Method)

Reference Number:

Name of individual and licensee making the A

notification; address and telephone number:

Recipient name, location, and address B

(if different than above):

Name, location, address, contact name and C

telephone number for exporting facility:

Radionuclide(s) and activity level in TBq, both D for single and aggregate shipments:

Total Activity Level (TBq):

Make, model and serial number, for any E

Category 1 and 2 sealed sources, if available:

F End-use in the U.S.:

Shipment date from the exporting facility:

(MM/DD/YYYY)

G Estimated arrival date at the end use location:

(MM/DD/YYYY)

NRC or agreement state license number to possess the import in the U.S.:

H Expiration date of license: (MM/DD/YYYY)

Comments:

NRC Form 830 (MM-YYYY)