ML22186A239

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NRC 748G Export Source (OMB Copy)(07-01-2022) Fm
ML22186A239
Person / Time
Issue date: 07/01/2022
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ML21356A000 List:
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Download: ML22186A239 (4)
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Submit by Email NRC FORM 748G 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, EXPORT 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)
11. SOURCE EXPORT DATA A1. FOREIGN COMPANY NAME B1. EXPORT LICENSE NO. C1. ULTIMATE CONSIGNEE ADDRESS D1. CITY E1. COUNTRY F1. SOURCE MAKE G1. SOURCE MODEL H1. SOURCE SERIAL I1. ISOTOPE J1. ACTIVITY AND UNIT K1. ACTIVITY DATE L1. CONTAINER ID NUMBER M1. COMMENTS 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 748G (MM-DD-YYYY) Page 1

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

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

11. SOURCE EXPORT DATA (continued)

A2. FOREIGN COMPANY NAME B2. EXPORT LICENSE NO. C2. ULTIMATE CONSIGNEE ADDRESS D2. CITY E2. COUNTRY F2. SOURCE MAKE G2. SOURCE MODEL H2. SOURCE SERIAL I2. ISOTOPE J2. ACTIVITY AND UNIT K2. ACTIVITY DATE L2. CONTAINER ID NUMBER M2. COMMENTS A3. FOREIGN COMPANY NAME B3. EXPORT LICENSE NO. C3. ULTIMATE CONSIGNEE ADDRESS D3. CITY E3. COUNTRY F3. SOURCE MAKE G3. SOURCE MODEL H3. SOURCE SERIAL I3. ISOTOPE J3. ACTIVITY AND UNIT K3. ACTIVITY DATE L3. CONTAINER ID NUMBER M3. COMMENTS 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 748G (MM-DD-YYYY) Page 2

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

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

11. SOURCE EXPORT DATA (continued)

A4. FOREIGN COMPANY NAME B4. EXPORT LICENSE NO. C4. ULTIMATE CONSIGNEE ADDRESS D4. CITY E4. COUNTRY F4. SOURCE MAKE G4. SOURCE MODEL H4. SOURCE SERIAL I4. ISOTOPE J4. ACTIVITY AND UNIT K4. ACTIVITY DATE L4. CONTAINER ID NUMBER M4. COMMENTS A5. FOREIGN COMPANY NAME B5. EXPORT LICENSE NO. C5. ULTIMATE CONSIGNEE ADDRESS D5. CITY E5. COUNTRY F5. SOURCE MAKE G5. SOURCE MODEL H5. SOURCE SERIAL I5. ISOTOPE J5. ACTIVITY AND UNIT K5. ACTIVITY DATE L5. CONTAINER ID NUMBER M5. COMMENTS 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 748G (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

> mail to: NSTS Help Desk Receiving Licensee, the receiving licensee information may be populated once, and 9737 Washingtonian Blvd, Room #5145, Mail Stop #11 referenced in the Comments block for the additional sources. Gaithersburg, MD 20878

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