ML22028A015
| ML22028A015 | |
| Person / Time | |
|---|---|
| Issue date: | 03/25/2022 |
| From: | Office of Nuclear Material Safety and Safeguards |
| To: | |
| Brenda Silda, NMSS/MSST/MSTB | |
| Shared Package | |
| ML22207A648 | List: |
| References | |
| Download: ML22028A015 (7) | |
Text
NRC FORM 653 U. S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0001 EXPIRES: (MM/DD/YYYY)
(MM-YYYY) Estimated burden per response to comply with this mandatory collection request: 36 minutes. NRC 10 CFR 32 TRANSFERS OF INDUSTRIAL requests quarterly reports to keep apprised of device movements. Send comments regarding the burden estimate to the FOIA, Library, and Information Collections Branch (T-6 A10M), U.S. Nuclear DEVICES REPORT Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.gov, and the OMB reviewer at: OMB Office of Information and Regulatory Affairs, (3150-0001), Attn: Desk (TO GENERAL LICENSEES) 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 (Continue on NRC Form 653, 653A or 653B, as appropriate) to respond to, a collection of information unless the document requesting or requiring the collection displays a currently valid OMB control number.
For each "licensee" to whom a device(s) has been transferred during the reporting period, supply the following:
Name of Vendor Reporting Period From To License Number Intermediate Person(s) (if any)
Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Name of Responsible Individual Business Telephone Number Title of Responsible Individual Information on Device(s) Transferred Date of Transfer Type of Device Model Number Serial Number Isotope Activity and Units Intermediate Person(s) (if any)
Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Name of Responsible Individual Business Telephone Number Title of Responsible Individual Information on Device(s) Transferred Date of Transfer Type of Device Model Number Serial Number Isotope Activity and Units NRC FORM 653 (MM-YYYY) Page of
NRC FORM 653 (Continued) U. S. NUCLEAR REGULATORY COMMISSION (MM-YYYY) 10 CFR 32 TRANSFERS OF INDUSTRIAL DEVICES REPORT (TO GENERAL LICENSEES) (continued)
Intermediate Person(s) (if any)
Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Name of Responsible Individual Business Telephone Number Title of Responsible Individual Information on Device(s) Transferred Date of Transfer Type of Device Model Number Serial Number Isotope Activity and Units Intermediate Person(s) (if any)
Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Name of Responsible Individual Business Telephone Number Title of Responsible Individual Information on Device(s) Transferred Date of Transfer Type of Device Model Number Serial Number Isotope Activity and Units NRC FORM 653 (MM-YYYY) Page of
NRC FORM 653 (Continued) U. S. NUCLEAR REGULATORY COMMISSION (MM-YYYY) 10 CFR 32 TRANSFERS OF INDUSTRIAL DEVICES REPORT (TO GENERAL LICENSEES) (continued)
Intermediate Person(s) (if any)
Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Name of Responsible Individual Business Telephone Number Title of Responsible Individual Information on Device(s) Transferred Date of Transfer Type of Device Model Number Serial Number Isotope Activity and Units Intermediate Person(s) (if any)
Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Name of Responsible Individual Business Telephone Number Title of Responsible Individual Information on Device(s) Transferred Date of Transfer Type of Device Model Number Serial Number Isotope Activity and Units NRC FORM 653 (MM-YYYY) Page of
NRC FORM 653A U. S. NUCLEAR REGULATORY COMMISSION (MM-YYYY) 10 CFR 32 TRANSFERS OF INDUSTRIAL DEVICES REPORT (FROM GENERAL LICENSEES)
For each "licensee" from whom a device(s) has been received during the reporting period, supply the following:
General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)
General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)
General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)
General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)
NRC FORM 653A (MM-YYYY) Page of
NRC FORM 653A (Continued) U. S. NUCLEAR REGULATORY COMMISSION (MM-YYYY) 10 CFR 32 TRANSFERS OF INDUSTRIAL DEVICES REPORT (FROM GENERAL LICENSEES) (continued)
For each "licensee" from whom a device(s) has been received during the reporting period, supply the following:
General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)
General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)
General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)
General Licensee Information Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)
NRC FORM 653A (MM-YYYY) Page of
NRC FORM 653B U. S. NUCLEAR REGULATORY COMMISSION (MM-YYYY) 10 CFR 32 TRANSFERS OF INDUSTRIAL DEVICES REPORT (LABEL CHANGES)
For each device for which required label information has been changed, supply the following:
General Licensee User Information Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Previous Serial New Serial Previous New Previous Label Label Activity Type of Device Model Number Number Number Isotope Isotope Activity and Units and Units General Licensee User Information Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Previous Serial New Serial Previous New Previous Label Label Activity Type of Device Model Number Number Number Isotope Isotope Activity and Units and Units General Licensee User Information Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Previous Serial New Serial Previous New Previous Label Label Activity Type of Device Model Number Number Number Isotope Isotope Activity and Units and Units General Licensee User Information Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Previous Serial New Serial Previous New Previous Label Label Activity Type of Device Model Number Number Number Isotope Isotope Activity and Units and Units NRC FORM 653B (MM-YYYY) Page of
NRC FORM 653B (Continued) U. S. NUCLEAR REGULATORY COMMISSION (MM-YYYY) 10 CFR 32 TRANSFERS OF INDUSTRIAL DEVICES REPORT (LABEL CHANGES) (continued)
For each device for which required label information has been changed, supply the following:
General Licensee User Information Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Previous Serial New Serial Previous New Previous Label Label Activity Type of Device Model Number Number Number Isotope Isotope Activity and Units and Units General Licensee User Information Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Previous Serial New Serial Previous New Previous Label Label Activity Type of Device Model Number Number Number Isotope Isotope Activity and Units and Units General Licensee User Information Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Previous Serial New Serial Previous New Previous Label Label Activity Type of Device Model Number Number Number Isotope Isotope Activity and Units and Units General Licensee User Information Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)
Information on Device(s) Received Previous Serial New Serial Previous New Previous Label Label Activity Type of Device Model Number Number Number Isotope Isotope Activity and Units and Units NRC FORM 653B (MM-YYYY)
Page of