ML22186A232

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NRC 748 Long Form (OMB Copy)(07-01-2022) Fm
ML22186A232
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Issue date: 07/01/2022
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1. LICENSEE INFORMATION NRC FORM 748 (MM-DD-YYYY) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748 (MM-DD-YYYY)

APPROVED BY OMB: NO. 3150-0202 EXPIRES: (MM/DD/YYYY)

A. LICENSEE NAME B. LICENSE NO.

C. LICENSEE STREET ADDRESS A. NAME OF PREPARER B. DATE PREPARED C. PREPARER PHONE

4. PREPARER INFORMATION (Only transactions completed on the same date may be reported together on this form)

NEW CORRECTION 3B. TRANSACTION TYPE (Check all that apply)

REPORT SOURCE RECEIPT TRANSFER DISASSEMBLE DISPOSAL NEW SOURCE MANUFACTURED IF CORRECTION, PREVIOUS TRANSACTION DATE:

EXPORT IMPORT D. PREPARER E-MAIL (REQUIRED FOR CONFIRMATION)

A1. SOURCE MAKE B1. SOURCE MODEL C1. SOURCE SERIAL NUMBER D1. ISOTOPE E1. ACTIVITY AND UNIT F1. ACTIVITY DATE G1. COMMENTS H1. SOURCE LOCATION ADDRESS L1. SAME AS STREET ADDRESS 3A. TRANSACTION INFORMATION

2. TRANSACTION DATE F. ZIP CODE E. STATE D. CITY K1. ZIP CODE J1. STATE I1. CITY A2. SOURCE MAKE B2. SOURCE MODEL C2. SOURCE SERIAL NUMBER D2. ISOTOPE E2. ACTIVITY AND UNIT F2. ACTIVITY DATE G2. COMMENTS H2. SOURCE LOCATION ADDRESS L2. SAME AS STREET ADDRESS K2. ZIP CODE J2. STATE I2. CITY INVENTORY
5. SOURCE INVENTORY DATA (Note: Only use this section for reporting initial source inventory)

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.

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 FOIA, Library, and Information Collections Branch (T-6 A10M), U.S. Nuclear 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, (3150-0202), 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.

Submit by Email

NRC FORM 748 (MM-DD-YYYY) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)

U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748 (MM-DD-YYYY)

LICENSE NO.

LICENSEE NAME

5. SOURCE INVENTORY DATA (continued)

A3. SOURCE MAKE B3. SOURCE MODEL C3. SOURCE SERIAL NUMBER D3. ISOTOPE E3. ACTIVITY AND UNIT F3. ACTIVITY DATE G3. COMMENTS H3. SOURCE LOCATION ADDRESS L3. SAME AS STREET ADDRESS K3. ZIP CODE J3. STATE I3. CITY A4. SOURCE MAKE B4. SOURCE MODEL C4. SOURCE SERIAL NUMBER D4. ISOTOPE E4. ACTIVITY AND UNIT F4. ACTIVITY DATE G4. COMMENTS H4. SOURCE LOCATION ADDRESS L4. SAME AS STREET ADDRESS K4. ZIP CODE J4. STATE I4. CITY B5. SOURCE MODEL C5. SOURCE SERIAL NUMBER D5. ISOTOPE E5. ACTIVITY AND UNIT F5. ACTIVITY DATE G5. COMMENTS H5. SOURCE LOCATION ADDRESS L5. SAME AS STREET ADDRESS K5. ZIP CODE J5. STATE I5. CITY A6. SOURCE MAKE B6. SOURCE MODEL C6. SOURCE SERIAL NUMBER D6. ISOTOPE E6. ACTIVITY AND UNIT F6. ACTIVITY DATE G6. COMMENTS H6. SOURCE LOCATION ADDRESS L6. SAME AS STREET ADDRESS K6. ZIP CODE J6. STATE I6. CITY A5. SOURCE MAKE 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 (MM-DD-YYYY) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)

U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748 (MM-DD-YYYY)

LICENSE NO.

LICENSEE NAME

6. SOURCE TRANSFER DATA G1. SOURCE MAKE H1. SOURCE MODEL I1. SOURCE SERIAL NUMBER J1. ISOTOPE K1. ACTIVITY AND UNIT L1. ACTIVITY DATE P1. COMMENTS M1. WASTE MANIFEST NO.

(For waste shipments only)

C1. RECEIVING LICENSEE SHIPPING ADDRESS B1. RECEIVING LICENSEE LICENSE NO.

A1. RECEIVING LICENSEE NAME N1. CONTAINER ID (For waste shipments only)

O1. ESTIMATED ARRIVAL DATE F1. ZIP CODE E1. STATE D1. CITY G2. SOURCE MAKE H2. SOURCE MODEL I2. SOURCE SERIAL NUMBER J2. ISOTOPE K2. ACTIVITY AND UNIT L2. ACTIVITY DATE P2. COMMENTS M2. WASTE MANIFEST NO.

(For waste shipments only)

C2. RECEIVING LICENSEE SHIPPING ADDRESS B2. RECEIVING LICENSEE LICENSE NO.

A2. RECEIVING LICENSEE NAME N2. CONTAINER ID O2. ESTIMATED ARRIVAL DATE F2. ZIP CODE E2. STATE D2. CITY (For waste shipments only)

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 (MM-DD-YYYY) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)

U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748 (MM-DD-YYYY)

LICENSE NO.

LICENSEE NAME

6. SOURCE TRANSFER DATA (continued)

G3. SOURCE MAKE H3. SOURCE MODEL I3. SOURCE SERIAL NUMBER J3. ISOTOPE K3. ACTIVITY AND UNIT L3. ACTIVITY DATE P3. COMMENTS M3. WASTE MANIFEST NO.

(For waste shipments only)

C3. RECEIVING LICENSEE SHIPPING ADDRESS B3. RECEIVING LICENSEE LICENSE NO.

A3. RECEIVING LICENSEE NAME N3. CONTAINER ID (For waste shipments only)

O3. ESTIMATED ARRIVAL DATE F3. ZIP CODE E3. STATE D3. CITY G4. SOURCE MAKE H4. SOURCE MODEL I4. SOURCE SERIAL NUMBER J4. ISOTOPE K4. ACTIVITY AND UNIT L4. ACTIVITY DATE P4. COMMENTS M4. WASTE MANIFEST NO.

(For waste shipments only)

C4. RECEIVING LICENSEE SHIPPING ADDRESS B4. RECEIVING LICENSEE LICENSE NO.

A4. RECEIVING LICENSEE NAME N4. CONTAINER ID O4. ESTIMATED ARRIVAL DATE F4. ZIP CODE E4. STATE D4. CITY (For waste shipments only)

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 (MM-DD-YYYY) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)

U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748 (MM-DD-YYYY)

LICENSE NO.

LICENSEE NAME

7. SOURCE RECEIPT DATA G1. SOURCE MAKE H1. SOURCE MODEL I1. SOURCE SERIAL NUMBER J1. ISOTOPE K1. ACTIVITY AND UNIT L1. ACTIVITY DATE T1. COMMENTS M1. WASTE MANIFEST NO.

C1. SENDING LICENSEE SHIPPING ADDRESS B1. SENDING LICENSEE LICENSE NO.

A1. SENDING LICENSEE NAME N1. CONTAINER ID O1. SOURCE LOCATION ADDRESS F1. ZIP CODE E1. STATE D1. CITY R1. ZIP CODE P1. CITY Q1. STATE S1. SAME AS STREET ADDRESS G2. SOURCE MAKE H2. SOURCE MODEL I2. SOURCE SERIAL NUMBER J2. ISOTOPE K2. ACTIVITY AND UNIT L2. ACTIVITY DATE T2. COMMENTS M2. WASTE MANIFEST NO.

C2. SENDING LICENSEE SHIPPING ADDRESS B2. SENDING LICENSEE LICENSE NO.

A2. SENDING LICENSEE NAME N2. CONTAINER ID O2. SOURCE LOCATION ADDRESS F2. ZIP CODE E2. STATE D2. CITY R2. ZIP CODE P2. CITY Q2. STATE S2. SAME AS STREET ADDRESS (For waste shipments only)

(For waste shipments only)

(For waste shipments only)

(For waste shipments only)

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 (MM-DD-YYYY) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)

U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748 (MM-DD-YYYY)

LICENSE NO.

LICENSEE NAME

7. SOURCE RECEIPT DATA (continued)

G3. SOURCE MAKE H3. SOURCE MODEL I3. SOURCE SERIAL NUMBER J3. ISOTOPE K3. ACTIVITY AND UNIT L3. ACTIVITY DATE T3. COMMENTS M3. WASTE MANIFEST NO.

C3. SENDING LICENSEE SHIPPING ADDRESS B3. SENDING LICENSEE LICENSE NO.

A3. SENDING LICENSEE NAME N3. CONTAINER ID O3. SOURCE LOCATION ADDRESS F3. ZIP CODE E3. STATE D3. CITY R3. ZIP CODE P3. CITY Q3. STATE S3. SAME AS STREET ADDRESS G4. SOURCE MAKE H4. SOURCE MODEL I4. SOURCE SERIAL NUMBER J4. ISOTOPE K4. ACTIVITY AND UNIT L4. ACTIVITY DATE T4. COMMENTS M4. WASTE MANIFEST NO.

C4. SENDING LICENSEE SHIPPING ADDRESS B4. SENDING LICENSEE LICENSE NO.

A4. SENDING LICENSEE NAME N4. CONTAINER ID O4. SOURCE LOCATION ADDRESS F4. ZIP CODE E4. STATE D4. CITY R4. ZIP CODE P4. CITY Q4. STATE S4. SAME AS STREET ADDRESS (For waste shipments only)

(For waste shipments only)

(For waste shipments only)

(For waste shipments only)

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 (MM-DD-YYYY) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)

U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748 (MM-DD-YYYY)

LICENSE NO.

LICENSEE NAME

8. SOURCE DISPOSAL DATA D1. SOURCE MAKE E1. SOURCE MODEL F1. SOURCE SERIAL NUMBER G1. ISOTOPE H1. ACTIVITY AND UNIT I1. ACTIVITY DATE J1. COMMENTS B1. CONTAINER ID A1. WASTE MANIFEST NUMBER K1. SOURCE DISPOSAL ADDRESS C1. METHOD OF DISPOSAL N1. ZIP CODE L1. CITY M1. STATE O1. SAME AS STREET ADDRESS D2. SOURCE MAKE E2. SOURCE MODEL F2. SOURCE SERIAL NUMBER G2. ISOTOPE H2. ACTIVITY AND UNIT I2. ACTIVITY DATE J2. COMMENTS B2. CONTAINER ID A2. WASTE MANIFEST NUMBER K2. SOURCE DISPOSAL ADDRESS C2. METHOD OF DISPOSAL N2. ZIP CODE L2. CITY M2. STATE ADDRESS O2. SAME AS STREET 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 (MM-DD-YYYY) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)

U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748 (MM-DD-YYYY)

LICENSE NO.

LICENSEE NAME

8. SOURCE DISPOSAL DATA (continued)

D3. SOURCE MAKE E3. SOURCE MODEL F3. SOURCE SERIAL NUMBER G3. ISOTOPE H3. ACTIVITY AND UNIT I3. ACTIVITY DATE J3. COMMENTS B3. CONTAINER ID A3. WASTE MANIFEST NUMBER K3. SOURCE DISPOSAL ADDRESS C3. METHOD OF DISPOSAL N3. ZIP CODE L3. CITY M3. STATE O3. SAME AS STREET ADDRESS D4. SOURCE MAKE E4. SOURCE MODEL F4. SOURCE SERIAL NUMBER G4. ISOTOPE H4. ACTIVITY AND UNIT I4. ACTIVITY DATE J4. COMMENTS B4. CONTAINER ID A4. WASTE MANIFEST NUMBER K4. SOURCE DISPOSAL ADDRESS C4. METHOD OF DISPOSAL N4. ZIP CODE L4. CITY M4. STATE ADDRESS O4. SAME AS STREET 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 (MM-DD-YYYY) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)

U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748 (MM-DD-YYYY)

LICENSE NO.

LICENSEE NAME

9. NEW MANUFACTURED SOURCE DATA A1. SOURCE MAKE B1. SOURCE MODEL C1. SOURCE SERIAL NUMBER D1. ISOTOPE E1. ACTIVITY AND UNIT G1. SOURCE LOCATION ADDRESS K1. SAME AS STREET ADDRESS F1. COMMENTS J1. ZIP CODE I1. STATE H1. CITY A2. SOURCE MAKE B2. SOURCE MODEL C2. SOURCE SERIAL NUMBER D2. ISOTOPE E2. ACTIVITY AND UNIT G2. SOURCE LOCATION ADDRESS K2. SAME AS STREET ADDRESS F2. COMMENTS J2. ZIP CODE I2. STATE H2. CITY A3. SOURCE MAKE B3. SOURCE MODEL C3. SOURCE SERIAL NUMBER D3. ISOTOPE E3. ACTIVITY AND UNIT G3. SOURCE LOCATION ADDRESS K3. SAME AS STREET ADDRESS F3. COMMENTS J3. ZIP CODE I3. STATE H3. CITY A4. SOURCE MAKE B4. SOURCE MODEL C4. SOURCE SERIAL NUMBER D4. ISOTOPE E4. ACTIVITY AND UNIT G4. SOURCE LOCATION ADDRESS K4. SAME AS STREET ADDRESS F4. COMMENTS J4. ZIP CODE I4. STATE H4. CITY 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 (MM-DD-YYYY) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)

U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748 (MM-DD-YYYY)

LICENSE NO.

LICENSEE NAME

10. SOURCE IMPORT DATA F1. SOURCE MAKE G1. SOURCE MODEL H1. SOURCE SERIAL NUMBER I1. ISOTOPE J1. ACTIVITY AND UNIT K1. ACTIVITY DATE L1. COMMENTS C1. FOREIGN COMPANY ADDRESS B1. IMPORT LICENSE NO.

A1. FOREIGN COMPANY NAME M1. SOURCE LOCATION ADDRESS E1. COUNTRY D1. CITY P1. ZIP CODE N1. CITY O1. STATE Q1. SAME AS STREET ADDRESS F2. SOURCE MAKE G2. SOURCE MODEL H2. SOURCE SERIAL NUMBER I2. ISOTOPE J2. ACTIVITY AND UNIT K2. ACTIVITY DATE L2. COMMENTS C2. FOREIGN COMPANY ADDRESS B2. IMPORT LICENSE NO.

A2. FOREIGN COMPANY NAME M2. SOURCE LOCATION ADDRESS E2. COUNTRY D2. CITY P2. ZIP CODE N2. CITY O2. STATE 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 (MM-DD-YYYY) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)

U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748 (MM-DD-YYYY)

LICENSE NO.

LICENSEE NAME

10. SOURCE IMPORT DATA (continued)

F3. SOURCE MAKE G3. SOURCE MODEL H3. SOURCE SERIAL NUMBER I3. ISOTOPE J3. ACTIVITY AND UNIT K3. ACTIVITY DATE L3. COMMENTS C3. FOREIGN COMPANY ADDRESS B3. IMPORT LICENSE NO.

A3. FOREIGN COMPANY NAME M3. SOURCE LOCATION ADDRESS E3. COUNTRY D3. CITY P3. ZIP CODE N3. CITY O3. STATE Q3. SAME AS STREET ADDRESS F4. SOURCE MAKE G4. SOURCE MODEL H4. SOURCE SERIAL NUMBER I4. ISOTOPE J4. ACTIVITY AND UNIT K4. ACTIVITY DATE L4. COMMENTS C4. FOREIGN COMPANY ADDRESS B4. IMPORT LICENSE NO.

A4. FOREIGN COMPANY NAME M4. SOURCE LOCATION ADDRESS E4. COUNTRY D4. CITY P4. ZIP CODE N4. CITY O4. STATE 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 (MM-DD-YYYY) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)

U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748 (MM-DD-YYYY)

LICENSE NO.

LICENSEE NAME

11. SOURCE EXPORT DATA F1. SOURCE MAKE G1. SOURCE MODEL H1. SOURCE SERIAL NUMBER I1. ISOTOPE J1. ACTIVITY AND UNIT K1. ACTIVITY DATE L1. CONTAINER ID C1. ULTIMATE CONSIGNEE ADDRESS B1. EXPORT LICENSE NO.

A1. FOREIGN COMPANY NAME M1. COMMENTS E1. COUNTRY D1. CITY F2. SOURCE MAKE G2. SOURCE MODEL H2. SOURCE SERIAL NUMBER I2. ISOTOPE J2. ACTIVITY AND UNIT K2. ACTIVITY DATE L2. CONTAINER ID C2. ULTIMATE CONSIGNEE ADDRESS B2. EXPORT LICENSE NO.

A2. FOREIGN COMPANY NAME M2. COMMENTS E2. COUNTRY D2. CITY 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 (MM-DD-YYYY) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)

U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748 (MM-DD-YYYY)

LICENSE NO.

LICENSEE NAME

11. SOURCE EXPORT DATA (continued)

F3. SOURCE MAKE G3. SOURCE MODEL H3. SOURCE SERIAL NUMBER I3. ISOTOPE J3. ACTIVITY AND UNIT K3. ACTIVITY DATE L3. CONTAINER ID C3. ULTIMATE CONSIGNEE ADDRESS B3. EXPORT LICENSE NO.

A3. FOREIGN COMPANY NAME M3. COMMENTS E3. COUNTRY D3. CITY F4. SOURCE MAKE G4. SOURCE MODEL H4. SOURCE SERIAL NUMBER I4. ISOTOPE J4. ACTIVITY AND UNIT K4. ACTIVITY DATE L4. CONTAINER ID C4. ULTIMATE CONSIGNEE ADDRESS B4. EXPORT LICENSE NO.

A4. FOREIGN COMPANY NAME M4. COMMENTS E4. COUNTRY D4. CITY 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 (MM-DD-YYYY) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)

U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748 (MM-DD-YYYY)

LICENSE NO.

LICENSEE NAME

12. SOURCE DISASSEMBLE DATA A1. SOURCE MAKE B1. SOURCE MODEL C1. SOURCE SERIAL NUMBER D1. ISOTOPE E1. ACTIVITY I1. SOURCE LOCATION ADDRESS M1. SAME AS STREET ADDRESS H1. COMMENTS L1. ZIP CODE K1. STATE J1. CITY A2. SOURCE MAKE B2. SOURCE MODEL C2. SOURCE SERIAL NUMBER D2. ISOTOPE E2. ACTIVITY AND UNIT I2. SOURCE LOCATION ADDRESS M2. SAME AS STREET ADDRESS H2. COMMENTS L2. ZIP CODE K2. STATE J2. CITY A3. SOURCE MAKE B3. SOURCE MODEL C3. SOURCE SERIAL NUMBER D3. ISOTOPE E3. ACTIVITY AND UNIT I3. SOURCE LOCATION ADDRESS M3. SAME AS STREET ADDRESS H3. COMMENTS L3. ZIP CODE K3. STATE J3. CITY A4. SOURCE MAKE B4. SOURCE MODEL C4. SOURCE SERIAL NUMBER D4. ISOTOPE E4. ACTIVITY AND UNIT I4. SOURCE LOCATION ADDRESS M4. SAME AS STREET ADDRESS H4. COMMENTS L4. ZIP CODE K4. STATE J4. CITY G1. DISASSEMBLE DATE F1. ACTIVITY DATE G2. DISASSEMBLE DATE F2. ACTIVITY DATE G3. DISASSEMBLE DATE F3. ACTIVITY DATE G4. DISASSEMBLE DATE F4. ACTIVITY DATE AND UNIT 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 (MM-DD-YYYY) 10 CFR 20.2207 NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)

U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748 (MM-DD-YYYY)

LICENSE NO.

LICENSEE NAME

12. SOURCE DISASSEMBLE DATA (continued)

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

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.

Note to Licensees: This form may be used to report source transactions in lieu of using the NSTS online application. Sections 1-4 on Page 1 of the form are required for all source transaction types. Sections 5-12 should only be populated for the associated Transaction Type (3B) selected. For example, when reporting a Source Transfer and a Source Export, Sections 6 and 11 should be populated. Multiple Transaction Types may be selected if they occur on the same Transaction Date, and should be reported on NRC Form 748. Licensees reporting only one transaction type may use the condensed form for the Transaction Type. For example, when reporting a Source Receipt, NRC Form 748c should be used.

1.

Licensee Information - Enter the name, license number, and street address of the licensed facility.

2.

Transaction Date - Enter the date the transaction occurred, which would be the date of the transfer, receipt, manufacture, etc.

3.

Transaction Information and Transaction Type - Indicate if this is a new transaction or a correction. For corrections, select the date of the previously submitted transaction that the correction should be associated with. Select the Transaction Type. Report Source should only be used for initial inventory submissions, or to report a source excluded from the initial inventory submission. Dispose Source should only be used by a Disposal Licensee. If you are sending your source back to the manufacturer, or sending it to a disposal facility, the transaction should be recorded as a Transfer. Multiple Transaction Types may be selected if they occur on the same Transaction Date.

4.

Preparer Information - An email address is required for a confirmation. For regulatory purposes, your source transaction report is not considered complete without a confirmation from the NSTS Help Desk that the transaction report has been received.

5.

Source Inventory Data - This section should only be used for initial inventory submissions. The Make, Model, and Serial Number refer to the Source, not the Device. All fields are required in Section 5 EXCEPT G. Comments. If the licensee is reporting multiple sources on the Source Inventory transaction at the same Source Location Address, the location address information may be populated once, and referenced in the Comments block for the additional sources.

6.

Source Transfer Data - For Transfer transaction reports, all fields in Section 6 are required EXCEPT M. Waste Manifest Number, N. Container ID, and P. Comments. If the licensee is reporting multiple sources on the Transfer transaction to the same Receiving Licensee, the receiving licensee information may be populated once, and referenced in the Comments block for the additional sources.

7.

Source Receipt Data - For Receipt transaction reports, all fields in Section 7 are required EXCEPT M. Waste Manifest Number, N. Container ID, and T. Comments. If the licensee is reporting multiple sources on the Receipt transaction at the same Source Location Address, the location address information may be populated once, and referenced in the Comments block for the additional sources.

8.

Source Disposal Data - For Disposal transaction reports, all fields in Section 8 are required EXCEPT J. Comments. If the licensee is reporting multiple sources on the Disposal transaction at the same Source Disposal Address, the source disposal address information may be populated once, and referenced in the Comments block for the additional sources.

9.

New Manufactured Source Data - For New Manufactured Source transaction reports, all fields in Section 9 are required EXCEPT F. Comments. If the licensee is reporting multiple sources on the Manufacturer transaction at the same Source Location Address, the location address information may be populated once, and referenced in the Comments block for the additional sources.

10. Source Import Data - For Import Source transaction reports, all fields are required EXCEPT L. Comments. If the licensee is reporting multiple sources on the Import transaction at the same Source Location Address, the location address information may be populated once, and referenced in the Comments block for the additional sources.
11. Source Export Data - For Export Source transaction reports, all fields are required EXCEPT M. Comments. If the licensee is reporting multiple sources on the Export transaction to the same Foreign Company/Foreign Address, the information in cells A-E may be populated once, and referenced in the Comments block for the additional sources.
12. Source Disassemble Data - For Disassemble Source transaction reports, all fields are required EXCEPT H. Comments. If the licensee is reporting multiple sources on the Disassemble transaction at the same Source Location Address, the location address information may be populated once, and referenced in the Comments block for the additional sources.

DISTRIBUTION For most timely processing, click the "Submit by E-mail" button on page 1.

You may also:

> manually submit this form by email to: NSTSFax.Resource@nrc.gov,

> FAX to: 1-888-821-2534, or

> mail to: NSTS Help Desk 9737 Washingtonian Blvd, Room #5145, Mail Stop #11 Gaithersburg, MD 20878

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