ML22186A236

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NRC 748d Dispose Source (OMB Copy)(07-01-2022) Fm
ML22186A236
Person / Time
Issue date: 07/01/2022
From:
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ML21356A000 List:
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Download: ML22186A236 (4)
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Submit by Email NRC FORM 748D U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0202 EXPIRES: (MM/DD/YYYY)

(MM-DD-YYYY) Estimated burden per response to comply with this mandatory information collection request: 9.5 minutes. NRC requires this information to populate 10 CFR 20.2207 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, DISPOSE SOURCE 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 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 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)
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 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 748D (MM-DD-YYYY) Page 1

NRC FORM 748D U.S. NUCLEAR REGULATORY COMMISSION LICENSEE NAME LICENSE NO.

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

8. SOURCE DISPOSAL DATA (continued)

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 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 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 748D (MM-DD-YYYY) Page 2

NRC FORM 748D U.S. NUCLEAR REGULATORY COMMISSION LICENSEE NAME LICENSE NO.

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

8. SOURCE DISPOSAL DATA (continued)

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 A5. WASTE MANIFEST NUMBER B5. CONTAINER ID C5. METHOD OF DISPOSAL D5. SOURCE MAKE E5. SOURCE MODEL F5. SOURCE SERIAL G5. ISOTOPE H5. ACTIVITY AND UNIT I5. ACTIVITY DATE J5. COMMENTS NUMBER K5. SOURCE DISPOSAL ADDRESS L5. CITY M5. STATE N5. ZIP CODE O5. 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 748D (MM-DD-YYYY) Page 3

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 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 9737 Washingtonian Blvd, Room #5145, Mail Stop #11 referenced in the Comments block for the additional sources.

Gaithersburg, MD 20878

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