ML21356A003
| ML21356A003 | |
| Person / Time | |
|---|---|
| Issue date: | 08/03/2022 |
| From: | NRC/OCIO |
| To: | |
| Shared Package | |
| ML21356A000 | List: |
| References | |
| Download: ML21356A003 (16) | |
Text
NRC FORM 748 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0202 EXPIRES: 09/30/2022 (10-2019) 10 CFR 20.2207 Estimated burden per response to comply with this mandatory information collection request: 9.5 minutes. NRC requires this information to populate the National Source Tracking System for certain sealed sources. Send comments regarding burden estimate to the Information Services Branch (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.
Resource@nrc.gov, and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0202), Office of NATIONAL SOURCE TRACKING TRANSACTION REPORT Management and Budget, 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. LICENSEE INFORMATION
A. LICENSEE NAME B. LICENSE NO. C. LICENSEE STREET ADDRESSD. CITYE. STATEF. ZIP CODE
- 2. TRANSACTION DATE 3A. TRANSACTION INFORMATION 3B. TRANSACTION TYPE (Check all that apply)
(Only transactions completed on the same date may be reported together on this form) NEW CORRECTIONREPORT SOURCE RECEIPTTRANSFERDISPOSAL IF CORRECTION, PREVIOUS TRANSACTION DATE: INVENTORY NEW SOURCE IMPORT EXPORT DISASSEMBLE MANUFACTURED
- 4. PREPARER INFORMATION
A. NAME OF PREPARER B. DATE PREPARED C. PREPARER PHONE D. PREPARER E-MAIL (REQUIRED FOR CONFIRMATION)
- 5. SOURCE INVENTORY DATA (Note: Only use this section for reporting initial source inventory)
A1. SOURCE MAKE B1. SOURCE MODEL C1. SOURCE SERIALD1. ISOTOPE E1. ACTIVITY AND UNIT F1. ACTIVITY DATE G1. COMMENTS NUMBER
H1. SOURCE LOCATION ADDRESS L1. SAME AS STREETI1. CITYJ1. STATEK1. ZIP CODE ADDRESS
A2. SOURCE MAKE B2. SOURCE MODEL C2. SOURCE SERIALD2. ISOTOPE E2. ACTIVITY AND UNIT F2. ACTIVITY DATE G2. COMMENTS NUMBER
H2. SOURCE LOCATION ADDRESS L2. SAME AS STREETI2. CITYJ2. STATEK2. ZIP CODE ADDRESS
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.
NRC FORM 748 (10-2019)
NRC FORM 748 U.S. NUCLEAR REGULATORY COMMISSION LICENSEE NAME LICENSE NO.
(10-2019) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)
- 5. SOURCE INVENTORY DATA (continued)
A3. SOURCE MAKE B3. SOURCE MODEL C3. SOURCE SERIALD3. ISOTOPE E3. ACTIVITY AND UNIT F3. ACTIVITY DATE G3. COMMENTS NUMBER
H3. SOURCE LOCATION ADDRESS L3. SAME AS STREETI3. CITYJ3. STATEK3. ZIP CODE ADDRESS
A4. SOURCE MAKE B4. SOURCE MODEL C4. SOURCE SERIALD4. ISOTOPE E4. ACTIVITY AND UNIT F4. ACTIVITY DATE G4. COMMENTS NUMBER
H4. SOURCE LOCATION ADDRESS L4. SAME AS STREETI4. CITYJ4. STATEK4. ZIP CODE ADDRESS
A5. SOURCE MAKE B5. SOURCE MODEL C5. SOURCE SERIAL D5. ISOTOPE E5. ACTIVITY AND UNIT F5. ACTIVITY DATE G5. COMMENTS NUMBER
H5. SOURCE LOCATION ADDRESS L5. SAME AS STREETI5. CITYJ5. STATEK5. ZIP CODE ADDRESS
A6. SOURCE MAKE B6. SOURCE MODEL C6. SOURCE SERIALD6. ISOTOPE E6. ACTIVITY AND UNIT F6. ACTIVITY DATE G6. COMMENTS NUMBER
H6. SOURCE LOCATION ADDRESS L6. SAME AS STREETI6. CITYJ6. STATEK6. ZIP CODE ADDRESS
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.
NRC FORM 748 (10-2019)
NRC FORM 748 U.S. NUCLEAR REGULATORY COMMISSION LICENSEE NAME LICENSE NO.
(10--2019) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)
- 6. SOURCE TRANSFER DATA
A1. RECEIVING LICENSEE NAME B1. RECEIVING LICENSEE C1. RECEIVING LICENSEE SHIPPING ADDRESS D1. CITY E1. STATE F1. ZIP CODE LICENSE NO.
G1. SOURCE MAKE H1. SOURCE MODEL I1. SOURCE SERIALJ1. ISOTOPE K1. ACTIVITY ANDL1. ACTIVITYM1. WASTE MANIFEST NO.N1. CONTAINER ID NUMBER UNIT DATE (For waste shipments only) (For waste shipments only)
O1. ESTIMATED ARRIVAL DATE P1. COMMENTS
A2. RECEIVING LICENSEE NAME B2. RECEIVING LICENSEE C2. RECEIVING LICENSEE SHIPPING ADDRESS D2. CITY E2. STATE F2. ZIP CODE LICENSE NO.
G2. SOURCE MAKE H2. SOURCE MODEL I2. SOURCE SERIALJ2. ISOTOPE K2. ACTIVITY ANDL2. ACTIVITYM2. WASTE MANIFEST NO.N2. CONTAINER ID NUMBER UNIT DATE (For waste shipments only) (For waste shipments only)
O2. ESTIMATED ARRIVAL DATE P2. COMMENTS
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.
NRC FORM 748 (10-2019)
NRC FORM 748 U.S. NUCLEAR REGULATORY COMMISSION LICENSEE NAME LICENSE NO.
(10-2019) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)
- 6. SOURCE TRANSFER DATA (continued)
A3. RECEIVING LICENSEE NAME B3. RECEIVING LICENSEE C3. RECEIVING LICENSEE SHIPPING ADDRESS D3. CITY E3. STATE F3. ZIP CODE LICENSE NO.
G3. SOURCE MAKE H3. SOURCE MODEL I3. SOURCE SERIALJ3. ISOTOPE K3. ACTIVITY ANDL3. ACTIVITYM3. WASTE MANIFEST NO.N3. CONTAINER ID NUMBER UNIT DATE (For waste shipments only) (For waste shipments only)
O3. ESTIMATED ARRIVAL DATE P3. COMMENTS
A4. RECEIVING LICENSEE NAME B4. RECEIVING LICENSEE C4. RECEIVING LICENSEE SHIPPING ADDRESS D4. CITY E4. STATE F4. ZIP CODE LICENSE NO.
G4. SOURCE MAKE H4. SOURCE MODEL I4. SOURCE SERIALJ4. ISOTOPE K4. ACTIVITY ANDL4. ACTIVITYM4. WASTE MANIFEST NO.N4. CONTAINER ID NUMBER UNIT DATE (For waste shipments only) (For waste shipments only)
O4. ESTIMATED ARRIVAL DATE P4. COMMENTS
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.
NRC FORM 748 (10-2019)
NRC FORM 748 U.S. NUCLEAR REGULATORY COMMISSION LICENSEE NAME LICENSE NO.
(10-2019) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)
- 7. SOURCE RECEIPT DATA
A1. SENDING LICENSEE NAME B1. SENDING LICENSEE C1. SENDING LICENSEE SHIPPING ADDRESS D1. CITY E1. STATE F1. ZIP CODE LICENSE NO.
G1. SOURCE MAKE H1. SOURCE MODEL I1. SOURCE SERIALJ1. ISOTOPE K1. ACTIVITY AND UNIT L1. ACTIVITYM1. WASTE MANIFEST NO.N1. CONTAINER ID NUMBER DATE (For waste shipments only) (For waste shipments only)
O1. SOURCE LOCATION ADDRESS P1. CITY Q1. STATE S1. SAME AS STREETR1. ZIP CODET1. COMMENTS ADDRESS
A2. SENDING LICENSEE NAME B2. SENDING LICENSEE C2. SENDING LICENSEE SHIPPING ADDRESS D2. CITY E2. STATE F2. ZIP CODE LICENSE NO.
G2. SOURCE MAKE H2. SOURCE MODEL I2. SOURCE SERIALJ2. ISOTOPE K2. ACTIVITY AND UNIT L2. ACTIVITYM2. WASTE MANIFEST NO.N2. CONTAINER ID NUMBER DATE (For waste shipments only) (For waste shipments only)
O2. SOURCE LOCATION ADDRESS P2. CITY Q2. STATE S2. SAME AS STREETR2. ZIP CODET2. COMMENTS ADDRESS
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.
NRC FORM 748 (10-2019)
NRC FORM 748 U.S. NUCLEAR REGULATORY COMMISSION LICENSEE NAME LICENSE NO.
(10-2019) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)
- 7. SOURCE RECEIPT DATA (continued)
A3. SENDING LICENSEE NAME B3. SENDING LICENSEE C3. SENDING LICENSEE SHIPPING ADDRESS D3. CITY E3. STATE F3. ZIP CODE LICENSE NO.
G3. SOURCE MAKE H3. SOURCE MODEL I3. SOURCE SERIALJ3. ISOTOPE K3. ACTIVITY AND UNIT L3. ACTIVITYM3. WASTE MANIFEST NO.N3. CONTAINER ID NUMBER DATE (For waste shipments only) (For waste shipments only)
O3. SOURCE LOCATION ADDRESS P3. CITY Q3. STATE S3. SAME AS STREETR3. ZIP CODET3. COMMENTS ADDRESS
A4. SENDING LICENSEE NAME B4. SENDING LICENSEE C4. SENDING LICENSEE SHIPPING ADDRESS D4. CITY E4. STATE F4. ZIP CODE LICENSE NO.
G4. SOURCE MAKE H4. SOURCE MODEL I4. SOURCE SERIALJ4. ISOTOPE K4. ACTIVITY AND UNIT L4. ACTIVITYM4. WASTE MANIFEST NO.N4. CONTAINER ID NUMBER DATE (For waste shipments only) (For waste shipments only)
O4. SOURCE LOCATION ADDRESS P4. CITY Q4. STATE S4. SAME AS STREETR4. ZIP CODET4. COMMENTS ADDRESS
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.
NRC FORM 748 (10-2019)
NRC FORM 748 U.S. NUCLEAR REGULATORY COMMISSION LICENSEE NAME LICENSE NO.
(10-2019) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)
- 8. SOURCE DISPOSAL DATA
A1. WASTE MANIFEST NUMBER B1. CONTAINER ID C1. METHOD OF DISPOSAL
D1. SOURCE MAKE E1. SOURCE MODEL F1. SOURCE SERIALG1. ISOTOPE H1. ACTIVITY AND UNIT I1. ACTIVITY DATE J1. COMMENTS NUMBER
K1. SOURCE DISPOSAL ADDRESS L1. CITY M1. STATE O1. SAME AS STREETN1. ZIP CODE ADDRESS
A2. WASTE MANIFEST NUMBER B2. CONTAINER ID C2. METHOD OF DISPOSAL
D2. SOURCE MAKE E2. SOURCE MODEL F2. SOURCE SERIALG2. ISOTOPE H2. ACTIVITY AND UNIT I2. ACTIVITY DATE J2. COMMENTS NUMBER
K2. SOURCE DISPOSAL ADDRESS L2. CITY M2. STATEN2. ZIP CODEO2. SAME AS STREET ADDRESS
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.
NRC FORM 748 (10-2019)
NRC FORM 748 U.S. NUCLEAR REGULATORY COMMISSION LICENSEE NAME LICENSE NO.
(10-2019) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)
- 8. SOURCE DISPOSAL DATA (continued)
A3. WASTE MANIFEST NUMBER B3. CONTAINER ID C3. METHOD OF DISPOSAL
D3. SOURCE MAKE E3. SOURCE MODEL F3. SOURCE SERIALG3. ISOTOPE H3. ACTIVITY AND UNIT I3. ACTIVITY DATE J3. COMMENTS NUMBER
K3. SOURCE DISPOSAL ADDRESS L3. CITY M3. STATE O3. SAME AS STREETN3. ZIP CODE ADDRESS
A4. WASTE MANIFEST NUMBER B4. CONTAINER ID C4. METHOD OF DISPOSAL
D4. SOURCE MAKE E4. SOURCE MODEL F4. SOURCE SERIALG4. ISOTOPE H4. ACTIVITY AND UNIT I4. ACTIVITY DATE J4. COMMENTS NUMBER
K4. SOURCE DISPOSAL ADDRESS L4. CITY M4. STATEN4. ZIP CODEO4. SAME AS STREET ADDRESS
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.
NRC FORM 748 (10-2019)
NRC FORM 748 U.S. NUCLEAR REGULATORY COMMISSION LICENSEE NAME LICENSE NO.
(10-2019) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)
- 9. NEW MANUFACTURED SOURCE DATA
A1. SOURCE MAKE B1. SOURCE MODEL C1. SOURCE SERIALD1. ISOTOPE E1. ACTIVITY AND UNITF1. COMMENTS NUMBER
G1. SOURCE LOCATION ADDRESS K1. SAME ASH1. CITYI1. STATEJ1. ZIP CODE STREET ADDRESS
A2. SOURCE MAKE B2. SOURCE MODEL C2. SOURCE SERIALD2. ISOTOPE E2. ACTIVITY AND UNITF2. COMMENTS NUMBER
G2. SOURCE LOCATION ADDRESS K2. SAME ASH2. CITYI2. STATEJ2. ZIP CODE STREET ADDRESS
A3. SOURCE MAKE B3. SOURCE MODEL C3. SOURCE SERIALD3. ISOTOPE E3. ACTIVITY AND UNITF3. COMMENTS NUMBER
G3. SOURCE LOCATION ADDRESS K3. SAME ASH3. CITYI3. STATEJ3. ZIP CODE STREET ADDRESS
A4. SOURCE MAKE B4. SOURCE MODEL C4. SOURCE SERIALD4. ISOTOPE E4. ACTIVITY AND UNITF4. COMMENTS NUMBER
G4. SOURCE LOCATION ADDRESS K4. SAME ASH4. CITYI4. STATEJ4. ZIP CODE STREET ADDRESS
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.
NRC FORM 748 (10-2019)
NRC FORM 748 U.S. NUCLEAR REGULATORY COMMISSION LICENSEE NAME LICENSE NO.
(10-2019) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)
- 10. SOURCE IMPORT DATA
A1. FOREIGN COMPANY NAME B1. IMPORT LICENSE NO. C1. FOREIGN COMPANY ADDRESS D1. CITY E1. COUNTRY
F1. SOURCE MAKE G1. SOURCE MODEL H1. SOURCE SERIALI1. ISOTOPE J1. ACTIVITY AND UNIT K1. ACTIVITY DATE L1. COMMENTS NUMBER
M1. SOURCE LOCATION ADDRESS N1. CITY O1. STATE Q1. SAME AS STREETP1. ZIP CODE ADDRESS
A2. FOREIGN COMPANY NAME B2. IMPORT LICENSE NO. C2. FOREIGN COMPANY ADDRESS D2. CITY E2. COUNTRY
F2. SOURCE MAKE G2. SOURCE MODEL H2. SOURCE SERIALI2. ISOTOPE J2. ACTIVITY AND UNIT K2. ACTIVITY DATE L2. COMMENTS NUMBER
M2. SOURCE LOCATION ADDRESS N2. CITY O2. STATEP2. ZIP CODEQ2. SAME AS STREET ADDRESS
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.
NRC FORM 748 (10-2019)
NRC FORM 748 U.S. NUCLEAR REGULATORY COMMISSION LICENSEE NAME LICENSE NO.
(10-2019) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)
- 10. SOURCE IMPORT DATA (continued)
A3. FOREIGN COMPANY NAME B3. IMPORT LICENSE NO. C3. FOREIGN COMPANY ADDRESS D3. CITY E3. COUNTRY
F3. SOURCE MAKE G3. SOURCE MODEL H3. SOURCE SERIALI3. ISOTOPE J3. ACTIVITY AND UNIT K3. ACTIVITY DATE L3. COMMENTS NUMBER
M3. SOURCE LOCATION ADDRESS N3. CITY O3. STATE Q3. SAME AS STREETP3. ZIP CODE ADDRESS
A4. FOREIGN COMPANY NAME B4. IMPORT LICENSE NO. C4. FOREIGN COMPANY ADDRESS D4. CITY E4. COUNTRY
F4. SOURCE MAKE G4. SOURCE MODEL H4. SOURCE SERIALI4. ISOTOPE J4. ACTIVITY AND UNIT K4. ACTIVITY DATE L4. COMMENTS NUMBER
M4. SOURCE LOCATION ADDRESS N4. CITY O4. STATEP4. ZIP CODEQ4. SAME AS STREET ADDRESS
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.
NRC FORM 748 (10-2019)
NRC FORM 748 U.S. NUCLEAR REGULATORY COMMISSION LICENSEE NAME LICENSE NO.
(10-2019) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)
- 11. SOURCE EXPORT DATA
A1. FOREIGN COMPANY NAME B1. EXPORT LICENSE NO. C1. ULTIMATE CONSIGNEE ADDRESS D1. CITY E1. COUNTRY
F1. SOURCE MAKE G1. SOURCE MODEL H1. SOURCE SERIALI1. ISOTOPE J1. ACTIVITY AND UNIT K1. ACTIVITY DATE L1. CONTAINER ID NUMBER
M1. COMMENTS
A2. FOREIGN COMPANY NAME B2. EXPORT LICENSE NO. C2. ULTIMATE CONSIGNEE ADDRESS D2. CITY E2. COUNTRY
F2. SOURCE MAKE G2. SOURCE MODEL H2. SOURCE SERIALI2. ISOTOPE J2. ACTIVITY AND UNIT K2. ACTIVITY DATE L2. CONTAINER ID NUMBER
M2. COMMENTS
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.
NRC FORM 748 (10-2019)
NRC FORM 748 U.S. NUCLEAR REGULATORY COMMISSION LICENSEE NAME LICENSE NO.
(10-2019) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)
- 11. SOURCE EXPORT DATA (continued)
A3. FOREIGN COMPANY NAME B3. EXPORT LICENSE NO. C3. ULTIMATE CONSIGNEE ADDRESS D3. CITY E3. COUNTRY
F3. SOURCE MAKE G3. SOURCE MODEL H3. SOURCE SERIALI3. ISOTOPE J3. ACTIVITY AND UNIT K3. ACTIVITY DATE L3. CONTAINER ID NUMBER
M3. COMMENTS
A4. FOREIGN COMPANY NAME B4. EXPORT LICENSE NO. C4. ULTIMATE CONSIGNEE ADDRESS D4. CITY E4. COUNTRY
F4. SOURCE MAKE G4. SOURCE MODEL H4. SOURCE SERIALI4. ISOTOPE J4. ACTIVITY AND UNIT K4. ACTIVITY DATE L4. CONTAINER ID NUMBER
M4. COMMENTS
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.
NRC FORM 748 (10-2019)
NRC FORM 748 U.S. NUCLEAR REGULATORY COMMISSION LICENSEE NAME LICENSE NO.
(10-2019) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)
- 12. SOURCE DISASSEMBLE DATA
A1. SOURCE MAKE B1. SOURCE MODEL C1. SOURCE SERIALD1. ISOTOPE E1. ACTIVITYF1. ACTIVITY G1. DISASSEMBLE H1. COMMENTS NUMBER AND UNIT DATE DATE
I1. SOURCE LOCATION ADDRESS M1. SAME ASJ1. CITYK1. STATEL1. ZIP CODE STREET ADDRESS
A2. SOURCE MAKE B2. SOURCE MODEL C2. SOURCE SERIALD2. ISOTOPE E2. ACTIVITYF2. ACTIVITY G2. DISASSEMBLE H2. COMMENTS NUMBER AND UNIT DATE DATE
I2. SOURCE LOCATION ADDRESS M2. SAME ASJ2. CITYK2. STATEL2. ZIP CODE STREET ADDRESS
A3. SOURCE MAKE B3. SOURCE MODEL C3. SOURCE SERIALD3. ISOTOPE E3. ACTIVITYF3. ACTIVITY G3. DISASSEMBLE H3. COMMENTS NUMBER AND UNIT DATE DATE
I3. SOURCE LOCATION ADDRESS M3. SAME ASJ3. CITYK3. STATEL3. ZIP CODE STREET ADDRESS
A4. SOURCE MAKE B4. SOURCE MODEL C4. SOURCE SERIALD4. ISOTOPE E4. ACTIVITYF4. ACTIVITY G4. DISASSEMBLE H4. COMMENTS NUMBER AND UNIT DATE DATE
I4. SOURCE LOCATION ADDRESS M4. SAME ASJ4. CITYK4. STATEL4. ZIP CODE STREET ADDRESS
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.
NRC FORM 748 (10-2019)
NRC FORM 748 U.S. NUCLEAR REGULATORY COMMISSION LICENSEE NAME LICENSE NO.
(10-2019) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)
- 12. SOURCE DISASSEMBLE DATA (continued)
A5. SOURCE MAKE B5. SOURCE MODEL C5. SOURCE SERIALD5. ISOTOPE E5. ACTIVITYF5. ACTIVITY G5. DISASSEMBLE H5. COMMENTS NUMBER AND UNIT DATE DATE
I5. SOURCE LOCATION ADDRESS M5. SAME ASJ5. CITYK5. STATEL5. ZIP CODE STREET ADDRESS
A6. SOURCE MAKE B6. SOURCE MODEL C6. SOURCE SERIALD6. ISOTOPE E6. ACTIVITYF6. ACTIVITY G6. DISASSEMBLE H6. COMMENTS NUMBER AND UNIT DATE DATE
I6. SOURCE LOCATION ADDRESS M6. SAME ASJ6. CITYK6. STATEL6. ZIP CODE STREET ADDRESS
A7. SOURCE MAKE B7. SOURCE MODEL C7. SOURCE SERIALD7. ISOTOPE E7. ACTIVITYF7. ACTIVITY G7. DISASSEMBLE H7. COMMENTS NUMBER AND UNIT DATE DATE
I7. SOURCE LOCATION ADDRESS M7. SAME ASJ7. CITYK7. STATEL7. ZIP CODE STREET ADDRESS
A8. SOURCE MAKE B8. SOURCE MODEL C8. SOURCE SERIALD8. ISOTOPE E8. ACTIVITYF8. ACTIVITY G8. DISASSEMBLE H8. COMMENTS NUMBER AND UNIT DATE DATE
I8. SOURCE LOCATION ADDRESS M8. SAME ASJ8. CITYK8. STATEL8. ZIP CODE STREET ADDRESS
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.
NRC FORM 748 (10-2019)
INSTRUCTIONS TO NRC AND AGREEMENT STATE LICENSEES FOR REPORTING HIGH-RISK SEALED SOURCE TRANSACTIONS The completed form is considered to be Official Use Only - Security Related Information; it is not considered to be Safeguards Information.
Use an addendum sheet for reporting additional sources.
- 7. Source Receipt Data - For Receipt transaction reports, all fields in Section 7 are Note to Licensees: This form may be used to report source transactions in lieu of required EXCEPT M. Waste Manifest Number, N. Container ID, and T. Comments. If using the NSTS online application. Sections 1-4 on Page 1 of the form are required the licensee is reporting multiple sources on the Receipt transaction at the same for all source transaction types. Sections 5-12 should only be populated for the Source Location Address, the location address information may be populated once, associated Transaction Type (3B) selected. For example, when reporting a Source and referenced in the Comments block for the additional sources.
Transfer and a Source Export, Sections 6 and 11 should be populated. Multiple 8. Source Disposal Data - For Disposal transaction reports, all fields in Section 8 are Transaction Types may be selected if they occur on the same Transaction Date, and required EXCEPT J. Comments. If the licensee is reporting multiple sources on the should be reported on NRC Form 748. Licensees reporting only one transaction type Disposal transaction at the same Source Disposal Address, the source disposal may use the condensed form for the Transaction Type. For example, when reporting address information may be populated once, and referenced in the Comments block a Source Receipt, NRC Form 748c should be used. for the additional sources.
- 1. Licensee Information - Enter the name, license number, and street address of 9. New Manufactured Source Data - For New Manufactured Source transaction the licensed facility. reports, all fields in Section 9 are required EXCEPT F. Comments. If the licensee is
- 2. Transaction Date - Enter the date the transaction occurred, which would be the date reporting multiple sources on the Manufacturer transaction at the same Source of the transfer, receipt, manufacture, etc. Location Address, the location address information may be populated once, and
- 3. Transaction Information and Transaction Type - Indicate if this is a new transactionreferenced in the Comments block for the additional sources.
or a correction. For corrections, select the date of the previously submitted 10. Source Import Data - For Import Source transaction reports, all fields are required transaction that the correction should be associated with. Select the Transaction EXCEPT L. Comments. If the licensee is reporting multiple sources on the Import Type. Report Source should only be used for initial inventory submissions, or to transaction at the same Source Location Address, the location address information report a source excluded from the initial inventory submission. Dispose Source may be populated once, and referenced in the Comments block for the additional should only be used by a Disposal Licensee. If you are sending your source back to sources.
the manufacturer, or sending it to a disposal facility, the transaction should be 11. Source Export Data - For Export Source transaction reports, all fields are required recorded as a Transfer. Multiple Transaction Types may be selected if they occur on EXCEPT M. Comments. If the licensee is reporting multiple sources on the Export the same Transaction Date. transaction to the same Foreign Company/Foreign Address, the information in cells
- 4. Preparer Information - An email address is required for a confirmation. ForA-E may be populated once, and referenced in the Comments block for the regulatory purposes, your source transaction report is not considered complete additional sources.
without a confirmation from the NSTS Help Desk that the transaction report has 12. Source Disassemble Data - For Disassemble Source transaction reports, all fields been received. are required EXCEPT H. Comments. If the licensee is reporting multiple sources on
- 5. Source Inventory Data - This section should only be used for initial inventory the Disassemble transaction at the same Source Location Address, the location submissions. The Make, Model, and Serial Number refer to the Source, not the address information may be populated once, and referenced in the Comments block Device. All fields are required in Section 5 EXCEPT G. Comments. If the licensee is for the additional sources.
reporting multiple sources on the Source Inventory transaction at the same Source Location Address, the location address information may be populated once, and DISTRIBUTION referenced in the Comments block for the additional sources. For most timely processing, click the "Submit by Email" button on page 1.
- 6. Source Transfer Data - For Transfer transaction reports, all fields in Section 6 are You may also:
required EXCEPT M. Waste Manifest Number, N. Container ID, and P. Comments. If > manually submit this form by email to: NSTSFax.Resource@nrc.gov, the licensee is reporting multiple sources on the Transfer transaction to the same > FAX to: 1-888-821-2534, or Receiving Licensee, the receiving licensee information may be populated once, and > mail to: NSTS Help Desk referenced in the Comments block for the additional sources. 30 West Gude Drive, Suite 300 Rockville, MD 20850