ML22186A233

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NRC 748A Report Source (OMB Copy)(07-01-2022) Fm
ML22186A233
Person / Time
Issue date: 07/01/2022
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ML21356A000 List:
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Download: ML22186A233 (3)
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NRC FORM 748A U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0202 EXPIRES: (MM/DD/YYYY)

(MM-DD-YYYY) 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 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 REPORT SOURCE INVENTORY Commission, 725 17th Street NW, Washington, DC 20503; e-mail: oira_submission@omb.eop.gov. The NRC may not conduct or sponsor, and a NATIONAL SOURCE TRACKING TRANSACTION REPORT 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.

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 748A (MM-DD-YYYY) Page 1 NRC FORM 748A U.S. NUCLEAR REGULATORY COMMISSION LICENSEE NAME LICENSE NO.

(MM-DD-YYYY) 10 CFR 20.2207 REPORT SOURCE INVENTORY 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 748A (MM-DD-YYYY) Page 2 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 E-mail" 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. 9737 Washingtonian Blvd, Room #5145, Mail Stop #11 Gaithersburg, MD 20878

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