ML22186A236

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NRC 748d Dispose Source (OMB Copy)(07-01-2022) Fm
ML22186A236
Person / Time
Issue date: 07/01/2022
From:
NRC/OCIO
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ML21356A000 List:
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Download: ML22186A236 (4)
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1. LICENSEE INFORMATION NRC FORM 748D (MM-DD-YYYY) 10 CFR 20.2207 DISPOSE SOURCE NATIONAL SOURCE TRACKING TRANSACTION REPORT U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748D (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) 3A. TRANSACTION INFORMATION

2. TRANSACTION DATE F. ZIP CODE E. STATE D. CITY INVENTORY
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 Page 1 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 748D (MM-DD-YYYY) 10 CFR 20.2207 U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748D (MM-DD-YYYY)

LICENSE NO.

LICENSEE NAME

8. SOURCE DISPOSAL DATA (continued)

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 O2. SAME AS STREET ADDRESS 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 ADDRESS O3. SAME AS STREET DISPOSE SOURCE NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)

Page 2 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) 10 CFR 20.2207 U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748D (MM-DD-YYYY)

LICENSE NO.

LICENSEE NAME

8. SOURCE DISPOSAL DATA (continued)

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 O4. SAME AS STREET ADDRESS D5. SOURCE MAKE E5. SOURCE MODEL F5. SOURCE SERIAL NUMBER G5. ISOTOPE H5. ACTIVITY AND UNIT I5. ACTIVITY DATE J5. COMMENTS B5. CONTAINER ID A5. WASTE MANIFEST NUMBER K5. SOURCE DISPOSAL ADDRESS C5. METHOD OF DISPOSAL N5. ZIP CODE L5. CITY M5. STATE ADDRESS O5. SAME AS STREET Page 3 DISPOSE SOURCE NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)

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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