ML22167A164

OMB Copy NRC Form 314

ML22167A164
Person / Time
Issue date:	08/03/2022
From:	Office of Nuclear Material Safety and Safeguards
To:
Gianni Nelson, 301-415-3550
Shared Package
ML22167A160	List: ML22167A164
References
OMB 3150-0028
Download: ML22167A164 (2)

Text

NRC FORM 314 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0028 EXPIRES: 03/31/2023 (06-23-2022) Estimated burden per response to comply with this mandatory collection request: 30 minutes. This submittal is used by NRC as part 10 CFR 30.36(j)(1); of the basis for its determination that the facility is released for unrestricted use. Send comments regarding burden estimate to the 40.42(j)(1); 70.38(j)(1); FOIA, Library, and Information Collections Branch (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, and 72.54(k)(5)(1)(1) CERTIFICATE OF DISPOSITION or by e-mail to Infocollects.Resource@nrc.gov, and the OMB reviewer at: OMB Office of Information and Regulatory Affairs, OF MATERIALS (3150-0028), 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.

Licensee Name and Address License Number Expiration Date

Docket Number

A. LICENSE STATUS (Check the appropriate box)

This license has expired. This license has not yet expired; please terminate it.

B. DISPOSAL OF RADIOACTIVE MATERIAL (Check the appropriate boxes and complete as necessary. If additional space is needed, provide attachments)

The licensee, or any individual executing this certificate on behalf of the licensee, certifies that:

1. No radioactive materials have ever been procured or possessed by the licensee.

2. All activities authorized by this license have ceased, and all radioactive materials procured and/or possessed by the licensee under this license number cited above have been disposed of in the following manner.

a. Transfer of radioactive materials to the licensee listed below:

b. Disposal of radioactive materials:

1. Directly by the licensee:

2. By licensed disposal site:

3. By waste contractor:

c. All radioactive materials have been removed such that any remaining residual radioactivity is within the limits of 10 CFR Part 20, Subpart E, and is ALARA.

C. SURVEYS PERFORMED AND REPORTED

1. A radiation survey was conducted by the licensee. The survey confirms:

a. the absence of licensed radioactive materials

b. that any remaining residual radioactivity is within the limits of 10 CFR 20, Subpart E, and is ALARA.

2. A copy of the radiation survey results: Date

a. is attached; or b. is not attached (Provide explanation); or c. was forwarded to the NRC on:

3. A radiation survey is not required as only sealed sources were ever possessed under this license, and

a. The results of the latest leak test are attached; and/or b. No leaking sources have ever been identified.

The person to be contacted regarding the information provided on this form:

Name Title Telephone (Include Area Code) E-mail Address

Mail all future correspondence regarding this license to:

C. CERTIFYING OFFICIAL I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT Printed Name and Title Signature Date

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 RESPECT. 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.

CERTIFICATE OF DISPOSITION OF MATERIALS PLEASE READ THESE INSTRUCTIONS BEFORE COMPLETING NRC FORM 314.

Subpart E of 10 CFR Part 20 establishes the radiological criteria for license terminations/decommissioning of facilities licensed under 10 CFR Parts 30, 40, 50, 60, 61, 70, and 72, as well as other facilities subject to the Commission's jurisdiction under the Atomic Energy Act of 1954, as amended, and the Energy Reorganization Act of 1974, as amended.

INSTRUCTIONS Section B, Item 2.

Licensees should describe the specific radioactive material transfer actions. If radioactive wastes were generated in terminating this license, the licensee should describe the disposal actions taken, including the disposition of low-level radioactive waste, mixed waste, greater-than-Class-C waste, and sealed sources.

Section B, Item 2.a.

The information provided concerning the transfer of radioactive material to another licensee should specify the date of the transfer, the name of the licensee recipient, an individual contact name and telephone number for the licensee recipient, and the recipient's NRC or Agreement State license number.

Section B, Item 2.b.

For disposal of radioactive materials, licensees should describe the specific disposal method or procedure (e.g., decay-in-storage). For those cases when radioactive materials are disposed of by a licensed disposal site or by a waste contractor, the licensee should specify the name, address, and telephone number of the licensed disposal site operator or waste contractor.

Section B, Item 2.c.

"Residual radioactivity," as defined in 10 CFR 20.1003, means radioactivity in areas' (structures, materials, soils, etc.) remaining as a result of activities (licensed and unlicensed) under the licensee's control from sources used by the licensee, excluding background radiation. ALARA is defined in 10 CFR 20.1003.

FILE CERTIFICATES AS FOLLOWS:

IF YOU ARE LOCATED IN: IF YOU ARE LOCATED IN:

ALABAMA, CONNECTICUT, DELAWARE, DISTRICT OF ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, COLUMBIA, FLORIDA, GEORGIA, KENTUCKY, MAINE, COLORADO, HAWAII, IDAHO, KANSAS, LOUISIANA, MARYLAND, MASSACHUSETTS, NEW HAMPSHIRE, NEW MISSISSIPPI, MONTANA, NEBRASKA, NEVADA, NEW JERSEY, NEW YORK, NORTH CAROLINA, PENNSYLVANIA, MEXICO, NORTH DAKOTA, OKLAHOMA, OREGON, PUERTO RICO, RHODE ISLAND, SOUTH CAROLINA, PACIFIC TRUST TERRITORIES, SOUTH DAKOTA, TEXAS, TENNESSEE, VERMONT, VIRGINIA, VIRGIN ISLANDS, OR UTAH, WASHINGTON, OR WYOMING.

WEST VIRGINIA. SEND CERTIFICATES TO:

SEND CERTIFICATES TO:

LICENSING ASSISTANCE TEAM MATERIALS LICENSING BRANCH DIVISION OF RADIOLOGICAL SAFETY AND SECURITY DIVISION OF RADIOLOGICAL SAFETY AND SECURITY U.S. NUCLEAR REGULATORY COMMISSION, REGION I U.S. NUCLEAR REGULATORY COMMISSION, REGION IV 475 ALLENDALE ROAD, SUITE 102 1600 E. LAMAR BOULEVARD KING OF PRUSSIA, PA 19406-1415 ARLINGTON, TX 76011-4511 R1DRSSMail.Resource@nrc.gov r4licensingactionsubmittals@nrc.gov

• Note: The preferred method to submit NRC Form 314 is e-mail. *Note: The preferred method to submit NRC Form 314 is e-mail.

ILLINOIS, INDIANA, IOWA, MICHIGAN, MINNESOTA, MISSOURI, OHIO, OR WISCONSIN, SEND CERTIFICATES TO:

MATERIALS LICENSING BRANCH U.S. NUCLEAR REGULATORY COMMISSION, REGION III 2443 WARRENVILLE ROAD, SUITE 210 LISLE, IL 60532-4352 R3DNMSMAIL.Resource@nrc.gov

• Note: The preferred method to submit NRC Form 314 is e-mail.