ML21356A003

From kanterella
Jump to navigation Jump to search
NRC Form 748, National Source Tracking Transaction Report
ML21356A003
Person / Time
Issue date: 08/03/2022
From:
NRC/OCIO
To:
Shared Package
ML21356A000 List:
References
Download: ML21356A003 (16)
v • d • e


Text

Submit by Email 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 ADDRESS D. CITY E. STATE F. 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 CORRECTION REPORT SOURCE TRANSFER RECEIPT DISPOSAL INVENTORY IF CORRECTION, PREVIOUS TRANSACTION DATE:

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 SERIAL D1. ISOTOPE E1. ACTIVITY AND UNIT F1. ACTIVITY DATE G1. COMMENTS NUMBER H1. SOURCE LOCATION ADDRESS I1. CITY J1. STATE K1. ZIP CODE L1. SAME AS STREET ADDRESS A2. SOURCE MAKE B2. SOURCE MODEL C2. SOURCE SERIAL D2. ISOTOPE E2. ACTIVITY AND UNIT F2. ACTIVITY DATE G2. COMMENTS NUMBER H2. SOURCE LOCATION ADDRESS I2. CITY J2. STATE K2. ZIP CODE L2. 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)

5. SOURCE INVENTORY DATA (continued)

A3. SOURCE MAKE B3. SOURCE MODEL C3. SOURCE SERIAL D3. ISOTOPE E3. ACTIVITY AND UNIT F3. ACTIVITY DATE G3. COMMENTS NUMBER H3. SOURCE LOCATION ADDRESS I3. CITY J3. STATE K3. ZIP CODE L3. SAME AS STREET ADDRESS A4. SOURCE MAKE B4. SOURCE MODEL C4. SOURCE SERIAL D4. ISOTOPE E4. ACTIVITY AND UNIT F4. ACTIVITY DATE G4. COMMENTS NUMBER H4. SOURCE LOCATION ADDRESS I4. CITY J4. STATE K4. ZIP CODE L4. SAME AS STREET 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 I5. CITY J5. STATE K5. ZIP CODE L5. SAME AS STREET ADDRESS A6. SOURCE MAKE B6. SOURCE MODEL C6. SOURCE SERIAL D6. ISOTOPE E6. ACTIVITY AND UNIT F6. ACTIVITY DATE G6. COMMENTS NUMBER H6. SOURCE LOCATION ADDRESS I6. CITY J6. STATE K6. ZIP CODE L6. 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)

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 SERIAL J1. ISOTOPE K1. ACTIVITY AND L1. ACTIVITY M1. 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 SERIAL J2. ISOTOPE K2. ACTIVITY AND L2. ACTIVITY M2. 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 SERIAL J3. ISOTOPE K3. ACTIVITY AND L3. ACTIVITY M3. 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 SERIAL J4. ISOTOPE K4. ACTIVITY AND L4. ACTIVITY M4. 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 SERIAL J1. ISOTOPE K1. ACTIVITY AND UNIT L1. ACTIVITY M1. WASTE MANIFEST NO. N1. CONTAINER ID NUMBER DATE (For waste shipments only) (For waste shipments only)

O1. SOURCE LOCATION ADDRESS P1. CITY Q1. STATE R1. ZIP CODE S1. SAME AS STREET T1. 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 SERIAL J2. ISOTOPE K2. ACTIVITY AND UNIT L2. ACTIVITY M2. WASTE MANIFEST NO. N2. CONTAINER ID NUMBER DATE (For waste shipments only) (For waste shipments only)

O2. SOURCE LOCATION ADDRESS P2. CITY Q2. STATE R2. ZIP CODE S2. SAME AS STREET T2. 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 SERIAL J3. ISOTOPE K3. ACTIVITY AND UNIT L3. ACTIVITY M3. WASTE MANIFEST NO. N3. CONTAINER ID NUMBER DATE (For waste shipments only) (For waste shipments only)

O3. SOURCE LOCATION ADDRESS P3. CITY Q3. STATE R3. ZIP CODE S3. SAME AS STREET T3. 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 SERIAL J4. ISOTOPE K4. ACTIVITY AND UNIT L4. ACTIVITY M4. WASTE MANIFEST NO. N4. CONTAINER ID NUMBER DATE (For waste shipments only) (For waste shipments only)

O4. SOURCE LOCATION ADDRESS P4. CITY Q4. STATE R4. ZIP CODE S4. SAME AS STREET T4. 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 SERIAL G1. ISOTOPE H1. ACTIVITY AND UNIT I1. ACTIVITY DATE J1. COMMENTS NUMBER K1. SOURCE DISPOSAL ADDRESS L1. CITY M1. STATE N1. ZIP CODE O1. SAME AS STREET ADDRESS A2. WASTE MANIFEST NUMBER B2. CONTAINER ID C2. METHOD OF DISPOSAL D2. SOURCE MAKE E2. SOURCE MODEL F2. SOURCE SERIAL G2. ISOTOPE H2. ACTIVITY AND UNIT I2. ACTIVITY DATE J2. COMMENTS NUMBER K2. SOURCE DISPOSAL ADDRESS L2. CITY M2. STATE N2. ZIP CODE O2. 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 SERIAL G3. ISOTOPE H3. ACTIVITY AND UNIT I3. ACTIVITY DATE J3. COMMENTS NUMBER K3. SOURCE DISPOSAL ADDRESS L3. CITY M3. STATE N3. ZIP CODE O3. SAME AS STREET ADDRESS A4. WASTE MANIFEST NUMBER B4. CONTAINER ID C4. METHOD OF DISPOSAL D4. SOURCE MAKE E4. SOURCE MODEL F4. SOURCE SERIAL G4. ISOTOPE H4. ACTIVITY AND UNIT I4. ACTIVITY DATE J4. COMMENTS NUMBER K4. SOURCE DISPOSAL ADDRESS L4. CITY M4. STATE N4. ZIP CODE O4. 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 SERIAL D1. ISOTOPE E1. ACTIVITY AND UNIT F1. COMMENTS NUMBER G1. SOURCE LOCATION ADDRESS H1. CITY I1. STATE J1. ZIP CODE K1. SAME AS STREET ADDRESS A2. SOURCE MAKE B2. SOURCE MODEL C2. SOURCE SERIAL D2. ISOTOPE E2. ACTIVITY AND UNIT F2. COMMENTS NUMBER G2. SOURCE LOCATION ADDRESS H2. CITY I2. STATE J2. ZIP CODE K2. SAME AS STREET ADDRESS A3. SOURCE MAKE B3. SOURCE MODEL C3. SOURCE SERIAL D3. ISOTOPE E3. ACTIVITY AND UNIT F3. COMMENTS NUMBER G3. SOURCE LOCATION ADDRESS H3. CITY I3. STATE J3. ZIP CODE K3. SAME AS STREET ADDRESS A4. SOURCE MAKE B4. SOURCE MODEL C4. SOURCE SERIAL D4. ISOTOPE E4. ACTIVITY AND UNIT F4. COMMENTS NUMBER G4. SOURCE LOCATION ADDRESS H4. CITY I4. STATE J4. ZIP CODE K4. 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 A1. FOREIGN COMPANY NAME B1. IMPORT LICENSE NO. C1. FOREIGN COMPANY ADDRESS D1. CITY E1. COUNTRY F1. SOURCE MAKE G1. SOURCE MODEL H1. SOURCE SERIAL I1. ISOTOPE J1. ACTIVITY AND UNIT K1. ACTIVITY DATE L1. COMMENTS NUMBER M1. SOURCE LOCATION ADDRESS N1. CITY O1. STATE P1. ZIP CODE Q1. SAME AS STREET 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 SERIAL I2. ISOTOPE J2. ACTIVITY AND UNIT K2. ACTIVITY DATE L2. COMMENTS NUMBER M2. SOURCE LOCATION ADDRESS N2. CITY O2. STATE P2. ZIP CODE Q2. 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 SERIAL I3. ISOTOPE J3. ACTIVITY AND UNIT K3. ACTIVITY DATE L3. COMMENTS NUMBER M3. SOURCE LOCATION ADDRESS N3. CITY O3. STATE P3. ZIP CODE Q3. SAME AS STREET 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 SERIAL I4. ISOTOPE J4. ACTIVITY AND UNIT K4. ACTIVITY DATE L4. COMMENTS NUMBER M4. SOURCE LOCATION ADDRESS N4. CITY O4. STATE P4. ZIP CODE Q4. 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 SERIAL I1. 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 SERIAL I2. 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 SERIAL I3. 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 SERIAL I4. 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 SERIAL D1. ISOTOPE E1. ACTIVITY F1. ACTIVITY G1. DISASSEMBLE H1. COMMENTS NUMBER AND UNIT DATE DATE I1. SOURCE LOCATION ADDRESS J1. CITY K1. STATE L1. ZIP CODE M1. SAME AS STREET ADDRESS A2. SOURCE MAKE B2. SOURCE MODEL C2. SOURCE SERIAL D2. ISOTOPE E2. ACTIVITY F2. ACTIVITY G2. DISASSEMBLE H2. COMMENTS NUMBER AND UNIT DATE DATE I2. SOURCE LOCATION ADDRESS J2. CITY K2. STATE L2. ZIP CODE M2. SAME AS STREET ADDRESS A3. SOURCE MAKE B3. SOURCE MODEL C3. SOURCE SERIAL D3. ISOTOPE E3. ACTIVITY F3. ACTIVITY G3. DISASSEMBLE H3. COMMENTS NUMBER AND UNIT DATE DATE I3. SOURCE LOCATION ADDRESS J3. CITY K3. STATE L3. ZIP CODE M3. SAME AS STREET ADDRESS A4. SOURCE MAKE B4. SOURCE MODEL C4. SOURCE SERIAL D4. ISOTOPE E4. ACTIVITY F4. ACTIVITY G4. DISASSEMBLE H4. COMMENTS NUMBER AND UNIT DATE DATE I4. SOURCE LOCATION ADDRESS J4. CITY K4. STATE L4. ZIP CODE M4. 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)

12. SOURCE DISASSEMBLE DATA (continued)

A5. SOURCE MAKE B5. SOURCE MODEL C5. SOURCE SERIAL D5. ISOTOPE E5. ACTIVITY F5. ACTIVITY G5. DISASSEMBLE H5. COMMENTS NUMBER AND UNIT DATE DATE I5. SOURCE LOCATION ADDRESS J5. CITY K5. STATE L5. ZIP CODE M5. SAME AS STREET ADDRESS A6. SOURCE MAKE B6. SOURCE MODEL C6. SOURCE SERIAL D6. ISOTOPE E6. ACTIVITY F6. ACTIVITY G6. DISASSEMBLE H6. COMMENTS NUMBER AND UNIT DATE DATE I6. SOURCE LOCATION ADDRESS J6. CITY K6. STATE L6. ZIP CODE M6. SAME AS STREET ADDRESS A7. SOURCE MAKE B7. SOURCE MODEL C7. SOURCE SERIAL D7. ISOTOPE E7. ACTIVITY F7. ACTIVITY G7. DISASSEMBLE H7. COMMENTS NUMBER AND UNIT DATE DATE I7. SOURCE LOCATION ADDRESS J7. CITY K7. STATE L7. ZIP CODE M7. SAME AS STREET ADDRESS A8. SOURCE MAKE B8. SOURCE MODEL C8. SOURCE SERIAL D8. ISOTOPE E8. ACTIVITY F8. ACTIVITY G8. DISASSEMBLE H8. COMMENTS NUMBER AND UNIT DATE DATE I8. SOURCE LOCATION ADDRESS J8. CITY K8. STATE L8. ZIP CODE M8. 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)

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 transaction referenced 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. For A-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

> mail to: NSTS Help Desk Receiving Licensee, the receiving licensee information may be populated once, and 30 West Gude Drive, Suite 300 referenced in the Comments block for the additional sources. Rockville, MD 20850

Retrieved from "https://kanterella.com/w/index.php?title=ML21356A003&oldid=3460229"