ML22186A237

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NRC 748e Manufacture Source (OMB Copy)(07-01-2022) Fm
ML22186A237
Person / Time
Issue date: 07/01/2022
From:
NRC/OCIO
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ML21356A000 List:
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Download: ML22186A237 (3)
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1. LICENSEE INFORMATION NRC FORM 748E (MM-DD-YYYY) 10 CFR 20.2207 NEW SOURCE MANUFACTURED NATIONAL SOURCE TRACKING TRANSACTION REPORT U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748E (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
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 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 Information Services Branch (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.

Resource@nrc.gov, and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0202), Office of Management and Budget, Washington, DC 20503. If a means used to impose an information collection does not display a currently valid OMB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.

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.

Submit by Email

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

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

LICENSE NO.

LICENSEE NAME

9. NEW MANUFACTURED SOURCE DATA 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 A5. SOURCE MAKE B5. SOURCE MODEL C5. SOURCE SERIAL NUMBER D5. ISOTOPE E5. ACTIVITY AND UNIT G5. SOURCE LOCATION ADDRESS K5. SAME AS STREET ADDRESS F5. COMMENTS J5. ZIP CODE I5. STATE H5. CITY 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.

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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