ML22202A526

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OMB 3150-0120, Screenshots of NRC Form 313 Online Form
ML22202A526
Person / Time
Issue date: 08/16/2022
From:
Office of Nuclear Material Safety and Safeguards
To:
Brenda Silk, NMSS/MSST/MSTB
References
OMB 3150-0120
Download: ML22202A526 (10)
v • d • e


Text

NRC Form 313 Licensee: Kim Lukes (ismpkkl002)

Agency: U.S. Nuclear Regulatory Commission Create an Application for Materials license (Form 31JI Action View Status of Applications Notifications

Create New License Request ID:

NRC FORM 313 (01/2020)

U.S. NUCLEAR REGULATORY COMMISSION APPLICATION FOR MATERIALS LICENSE

[1] This is an application for:

@ Newlicense 0 Amendment to License Number: I Select License.. v I 0 Renewal of License Number:

I Select License... v I APPROVED BY 0MB: NO. 3150-0120 INSTRUCTIONS: SEE THE CURRENT VOLUMES OF THE NUREG-1556 TECHNICAL REPORT SERIES ("CONSOLIDATED GUIDANCE ABOUT MATERIALS LICENSES") FOR DETAILED INSTRUCTIONS FOR COMPLETING THIS FORM: bnp:J(www.nrc.gID'lre..a.dlng~

col lections/n uregslstaff/sr1 5561 PERSONS LOCATED IN AGREEMENT STATES SEND APPLICATIONS TO THE U.S. NUCLEAR REGULATORY COMMISSION ONLY IF THEY WISH TO POSSESS AND USE LICENSED MATERIAL IN STATES SUBJECT TO U.S. NUCLEAR REGULATORY COMMISSION JURISDICTIONS.

EXPIRES: 01/31 /2023 Estimated burden per response to comply with this mandatory collection request: 4.3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br />. Submittal of the application is necessary to determine that the applicant is qualified and that adequate procedures exist to protect the public health and safety. 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 lnfocollects.Resource@nrc.gov, and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0120), Office of Management and Budget, Washington, DC 20503. If a means used to impose an information collection does not display a currently valid 0MB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.

[2,4] Applicant

[2] NAME AND MAILING ADDRESS OF APPLICANT

  • Applicant Name:
  • Address Line 1:

Address Line 2:

' State:

Select State...

  • Zip:~

Province:

  • country:

[4] NAME OF PERSON TO BE CONTACTED ABOUT THIS APPLICATION Prefix:

' First Name:

Middle Name:

' Last Name:

Suffix:

Job

Title:

  • Business Telephone No:

Business Cellular No:

  • Business Email Address:

Save Cancel

Create New License Request ID: 8 NRC FORM 313 (01/2020)

U.S. NUCLEAR REGULATORY COMMISSION APPLICATION FOR MATERIALS LICENSE

[1 ] This is an application for:

New License Amendment to License Number: Select License... v Renewal of License Number:

Select License... v INSTRUCTIONS: SEE THE CURRENT VOLUMES OF THE NUREG-1556 TECHNICAL REPORT SERIES ("CONSOLIDATED GUIDANCE ABOUT MATERIALS LICENSES") FOR DETAILED INSTRUCTIONS FOR COMPLETING THIS FORM: bnp:J(www.nrc.gID'lre..a.dlng~

col lections/n uregslstaff/sr1 5561 PERSONS LOCATED IN AGREEMENT STATES SEND APPLICATIONS TO THE U.S. NUCLEAR REGULATORY COMMISSION ONLY IF THEY WISH TO POSSESS AND USE LICENSED MATERIAL IN STATES SUBJECT TO U.S. NUCLEAR REGULATORY COMMISSION JURISDICTIONS.

<< PREV NEXT >>

[2,4] Applicant

[3] l ocations

[5,6] Materials

[7,8] Individuals

[9, 10, 11] Other Info.

Attachments Review

[3] Address(es) where Licensed Materials will be Used or Possessed

+ Add location SEQ Address line 1 Address line 2 Address line 3 City State Zip Province Country Edit Remove I}?~ Frlit X RPmovf' NEXT >>

Create New License Request ID: 8 NRC FORM 313 (01/2020)

U.S. NUCLEAR REGULATORY COMMISSION APPLICATION FOR MATERIALS LICENSE

[1 ] This is an application for:

New License Amendment to License Number: Select License... v Renewal of License Number:

Select License... v INSTRUCTIONS: SEE THE CURRENT VOLUMES OF THE NUREG-1556 TECHNICAL REPORT SERIES ("CONSOLIDATED GUIDANCE ABOUT MATERIALS LICENSES") FOR DETAILED INSTRUCTIONS FOR COMPLETING THIS FORM: bnp:J(www.nrc.gID'lre..a.dlng~

col lections/n uregslstaff/sr1 5561 PERSONS LOCATED IN AGREEMENT STATES SEND APPLICATIONS TO THE U.S. NUCLEAR REGULATORY COMMISSION ONLY IF THEY WISH TO POSSESS AND USE LICENSED MATERIAL IN STATES SUBJECT TO U.S. NUCLEAR REGULATORY COMMISSION JURISDICTIONS.

<< PREV NEXT >>

[2,4] Applicant

[3] locations

[5,6] Materials

[7,8] Individuals

[9, 10, 11] Other Info.

Attachments Review

[5] Radioactive Material and [6] Purpose(s) for which Licensed Material will be Used

+ Add Material Sequence Element &

Mass No.

CS-137 Chemical and/ or Physical Form Sealed Sources Any Amount No Maximum Amount 27.000 Material Unit mCi Purpose(s) of Use Edit Remove

" E dit X Remove 1 - 1 of 1 items NEXT >>

Create New License Request ID: 8 NRC FORM 313 (01/2020)

U.S. NUCLEAR REGULATORY COMMISSION APPLICATION FOR MATERIALS LICENSE

[1 ] This is an application for:

New License Amendment to License Number: Select License... v Renewal of License Number:

Select License... v INSTRUCTIONS: SEE THE CURRENT VOLUMES OF THE NUREG-1556 TECHNICAL REPORT SERIES ("CONSOLIDATED GUIDANCE ABOUT MATERIALS LICENSES") FOR DETAILED INSTRUCTIONS FOR COMPLETING THIS FORM: bnp:J(www.nrc.gID'lre..a.dlng~

col lections/n uregslstaff/sr1 5561 PERSONS LOCATED IN AGREEMENT STATES SEND APPLICATIONS TO THE U.S. NUCLEAR REGULATORY COMMISSION ONLY IF THEY WISH TO POSSESS AND USE LICENSED MATERIAL IN STATES SUBJECT TO U.S. NUCLEAR REGULATORY COMMISSION JURISDICTIONS.

<< PREV NEXT >>

[2,4] Applicant

[3] Locations

[5,6] Materials

[7,8] Individuals

[9, 10, 11] Other Info.

Attachments Review

[7] lndividual{s) Responsible for Radiation Safety Program and their Training and Experience

+ Add Individual Role Individual Radiation Safety Officer Kim Lukes Authorized User Kim Lukes I

[8] Training for Individuals Working in or Frequenting Restricted Areas Use the Attachments Tab to upload training information.

Training and Experience Attended all required courses and attained needed certifications.

Attended all required courses and attained needed certifications.

Edit it* Edit it* Edit Remove X Remove X Remove 1 - 2 of 2 items NEXT >>

Create New License Request ID: 8 NRC FORM 313 (01/2020)

U.S. NUCLEAR REGULATORY COMMISSION APPLICATION FOR MATIERIALS LICENSE

[1] This is an application for:

New License Amendment to License Number: Select License... v Renewal of License Number:

Select License... v INSTRUCTIONS: SEE THE CURRENT VOLUMES OF THE NUREG-1556 TIECHNICAL REPORT SERIES ("CONSOLIDATIED GUIDANCE ABOUT MATIERIALS LICENSES") FOR DETAILED INSTRUCTIONS FOR COMPLETING THIS FORM: hnR:Jlwww.nrc.gov(reading~

col lections/n uregs{staff/sr1 556/

PERSONS LOCATIED IN AGREEMENT STATIES SEND APPLICATIONS TO THE U.S. NUCLEAR REGULATORY COMMISSION ONLY IF THEY WISH TO POSSESS AND USE LICENSED MATIERIAL IN STATIES SUBJECT TO U.S. NUCLEAR REGULATORY COMMISSION JURISDICTIONS.

(( PREV j NEXT )) I

[2,4] Applicant

[3] Locations

[5,6] Materials

[7,8] Individuals

[9, 10, 11] Other Info.

Attachments Review

[9] Facilities and Equipment Use the Attachments Tab to upload Facilities and Equipment information.

[10] Radiation Safety Program Use the Attachments Tab to upload Radiation Safety Program information.

[11] Waste Management Use the Attachments Tab to upload Waste Management information.

NEXT >>

Create New License Request ID: 8 NRC FORM 313 (01/2020)

U.S. NUCLEAR REGULATORY COMMISSION APPLICATION FOR MATIERIALS LICENSE

[1] This is an application for:

New License Amendment to License Number: Select License... v Renewal of License Number:

Select License... v INSTRUCTIONS: SEE THE CURRENT VOLUMES OF THE NUREG-1556 TIECHNICAL REPORT SERIES ("CONSOLIDATIED GUIDANCE ABOUT MATIERIALS LICENSES") FOR DETAILED INSTRUCTIONS FOR COMPLETING THIS FORM: hnR:Jlwww.nrc.gov(reading~

col lections/n uregs{staff/sr1 556/

PERSONS LOCATIED IN AGREEMENT STATIES SEND APPLICATIONS TO THE U.S. NUCLEAR REGULATORY COMMISSION ONLY IF THEY WISH TO POSSESS AND USE LICENSED MATIERIAL IN STATIES SUBJECT TO U.S. NUCLEAR REGULATORY COMMISSION JURISDICTIONS.

(( PREV j NEXT )) I

[2,4] Applicant

[3] Locations

[5,6] Materials

[7,8] Individuals

[9, 10, 11] Other Info.

Attachments Review

+ Add Attachment File Name Description Attached By Attached Timestamp Edit Remove No items to display NEXT >>

Create New License Request ID: 8 NRC FORM 313 (01/2020)

U.S. NUCLEAR REGULATORY COMMISSION APPLICATION FOR MATIERIALS LICENSE

[1] This is an application for:

INSTRUCTIONS: SEE THE CURRENT VOLUMES OF THE NUREG-1556 TIECHNICAL REPORT SERIES ("CONSOLIDATIED GUIDANCE ABOUT MATIERIALS LICENSES") FOR DETAILED INSTRUCTIONS FOR COMPLETING THIS FORM: hnR:Jlwww.nrc.gov(reading~

[2,4] Applicant New License Amendment to License Number: Select License... v Renewal of License Number:

Select License... v

[3] locations

[5,6] Materials

[7,8] Individuals col lections/n uregs{staff/sr1 556/

PERSONS LOCATIED IN AGREEMENT STATIES SEND APPLICATIONS TO THE U.S. NUCLEAR REGULATORY COMMISSION ONLY IF THEY WISH TO POSSESS AND USE LICENSED MATIERIAL IN STATIES SUBJECT TO U.S. NUCLEAR REGULATORY COMMISSION JURISDICTIONS.

[9, 10, 11 ] Other Info.

Attachments Review Generate Draft I have reviewed the application form and am ready to submit

<< PREV

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Use the Attachments Tab to upload a list of additional fee categories.

Amount Enclosed ($)

I I Please click on fiY~92ll to make a payment.

  • Amendments/Renewals that increase the scope of the existing license to a new or higher fee category will require a fee.

(13] CERTIFICATION (Must be completed by applicant) THE APPLICANT UNDERSTANDS THAT ALL STATEMENTS AND REPRESENTATIONS MADE IN THIS APPLICATION ARE BINDING UPON THE APPLICANT THE APPLICANT AND ANY OFFICIAL EXECUTING THIS CERTIFICATION ON BEHALF OF THE APPLICANT. NAMED IN ITEM 2, CERTIFY THAT THIS APPLICATION IS PREPARED IN CONFORMITY WITH TITLE 10, CODE OF FEDERAL REGULATIONS, PARTS 30, 32, 33, 34, 35, 36, 37, 39, AND 40, AND THAT ALL INFORMATION CONTAINED HEREIN IS TRUE AND CORRECT TO THE BEST OF THEIR KNOWLEDGE ANO BELIEF. WARNING: 18 U.S.C. SECTION 1001 ACT OF JUNE 2 5, 1948 62 STAT. 749 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.

Certifying Officer Prefix:

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  • First Name:

IK;m I

Middle Name:

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  • Last Name:

I Lukes I

Suffix:

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  • Job

Title:

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Save Cancel Sign and Submit Submit Date:

I Digitally Sign & Submit APPLICATION ANO PAYMENT CAN BE SUBMITTED ONLINE ABOVE OR CAN BE PRINTED ANO MAILED TO THE NRC OFFICE SPECIFIED BELOW.

APPLICATION FOR DISTRIBUTION OF EXEMPT PRODUCTS FILE IF YOU ARE LOCATED IN:

APPLICATIONS WITH:

ILLINOIS, INOIANA, IOWA, MICHIGAN, MINNESOTA, MISSOURI, OHIO, MATERIALS SAFETY LICENSING BRANCH OR WISCONSIN, DIVISION OF MATERIAL SAFETY. STATE. TRIBAL AND RULEMAKING PROGRAMS SEND APPLICATIONS TO:

OFFICE OF NUCLEAR MATERIALS SAFETY AND SAFEGUARDS U.S. NUCLEAR REGULATORY COMMISSION MATERIALS LICENSING BRANCH WASHINGTON, DC 20SS5-0001 U.S. NUCLEAR REGULATORY COMMISSION, REGION Ill 2443 WARRENVILLE ROAD, SUITE 210 All OTHER PERSONS FILE APPLICATIONS AS FOLLOWS:

LISLE, ll 60532-4352 IF YOU ARE LOCATED IN:

IF YOU ARE LOCATED IN:

ALABAMA.CONNECTICUT, DELAWARE, DISTRICT OF COLUMBIA, FLORIDA, GEORGIA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, COLORADO, HAWAII, KENTUCKY, MAINE, MARYLAND, MASSACHUSETTS, NEW HAMPSHIRE, NEW JERSEY, IDAHO, KANSAS, LOUISIANA, MISSISSIPPI, MONTANA, NEBRASKA, NEW YORK, NORTH CAROLINA, PENNSYLVANIA, PUERTO RICO, RHODE ISLAND, NEVADA, NEW MEXICO, NORTH DAKOTA, OKLAHOMA, OREGON, SOUTH CAROLINA, TENNESSEE, VERMONT, VIRGINIA, VIRGIN ISLANDS, OR WEST PACIFIC TRUST TERRITORIES, SOUTH DAKOTA, TEXAS, UTAH,

VIRGINIA, WASHINGTON, OR WYOMING, SEND APPLICATIONS TO:

SEND APPLICATIONS TO:

LICENSING ASSISTANCE TEAM NUCLEAR MATERIALS LICENSING BRANCH DIVISION OF NUCLEAR MATERIALS SAFETY U.S. NUCLEAR REGULATORY COMMISSION REGION IV U.S. NUCLEAR REGULATORY COMMISSION, REGION I 1600 E. LAMAR BOULEVARD 475 Al l[NDAL[ ROAD, SUIT[ 102 ARLINGTON, TX 76011 -4511 KING OF PRUSSIA, PA 19406-1415 PERSONS LOCATED IN AGREEMENT STATES SEND APPLICATIONS TO THE U.S. NUCLEAR REGULATORY COMMISSION ONLY IF THEY WISH TO POSSESS AND USE LICENSED MATERIAL IN STATES SUBJECT TO U.S. NUCLEAR REGULATORY COMMISSION JURISDICTIONS.

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Whats Happening... 0 Sign In

~ NRC Intranet

  • Last Name:

I Lukes Suffix:

Before submitting this application, please return to the Review tab and click Generate Draft so that the entered fee information is included in the application to be signed.

  • Job

Title:

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Sign and Submit Submit Date:

17/ 15/2022 D1g1tally Sign & Submit APPLICATION AND PAYMENT CAN BE SUBMITTED ONLINE ABOVE OR CAN BE PRINTED AND MAILED TO THE NRC OFFICE SPECIFIED BELOW.

APPLICATION FOR DISTRIBUTION OF EXEMPT PRODUCTS FILE APPLICATIONS WITH:

MATERIALS SAFETY LICENSING BRANCH DIVISION OF MATERIAL SAFETY. STATE. TRIBAL AND RULEMAKING PROGRAMS OFFICE OF NUCLEAR MATERIALS SAFETY AND SAFEGUARDS U.S. NUCLEAR REGULATORY COMMIS'.::ION WASHINGTON, DC 20555-0001 ALL OTHER PERSONS FILE APPLICATIONS AS FOLLOWS:

IF YOU ARE LOCATED IN:

ALABAMA.CONNECTICUT, DELAWARE, DISTRICT OF COLUMBIA, FLORIDA, GEORGIA, el Create New License - NRC Form X

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IF YOU ARE LOCATED IN:

ILLINOIS, INDIANA, IOWA, MICHIGAN, MINNESOTA, MISSOURI, OHIO, OR WISCONSIN, SEND APPLICATIONS TO:

MATERIALS LICENSING BRANCH U.S. NUCLEAR REGULATORY COMMISSION, REGION Ill 2443 WARRENVILLE ROAD, SUITE 210 LISLE, IL 60532-4352 IF YOU ARE LOCATED IN:

ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, COLORADO, HAWAII, LJ

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~ NRC Intranet Once the application is successfully submitted, you will receive an email request from Adobe with instructions for signing your application.

Please check your spam folder if you do not receive this email.

Sign and Submit Are you ready to submit the application?

Submit Date:

17/ 15/2022

  • ++I Cancel
E SPECIFIED BELOW.

APPLICATION AND PAYMENT CAN BE SUBMITTEI APPLICATION FOR DISTRIBUTION OF EXEMPT PRODUCTS: FILE APPLICATIONS WITH:

.,--'IF-YOU Al{E"l OCA1"ED IN:-'

MATERIALS SAFETY LICENSING BRANCH DIVISION OF MATERIAL SAFETY. STATE. TRIBAL AND RULEMAKING PROGRAMS OFFICE OF NUCLEAR MATERIALS SAFETY AND SAFEGUARDS U.S. NUCLEAR REGULATORY COMMIS'.::ION WASHINGTON, DC 20555-0001 ALL OTHER PERSONS FILE APPLICATIONS AS FOLLOWS:

IF YOU ARE LOCATED IN:

ALABAMA.CONNECTICUT, DELAWARE, DISTRICT OF COLUMBIA, FLORIDA, GEORGIA, KENTUCKY, MAINE, MARYLAND, MASSACHUSETTS, NEW HAMPSHIRE, NEW JERSEY, NEW YORK, NORTH CAROLINA, PENNSYLVANIA, PUERTO RICO, RHODE ISLAND, SOUTH CAROLINA, TENNESSEE, VERMONT, VIRGINIA, VIRGIN ISLANDS, OR WEST

VIRGINIA, ILLINOIS, INDIANA, IOWA, MICHIGAN, MINNESOTA, MISSOURI, OHIO, OR WISCONSIN, SEND APPLICATIONS TO:

MATERIALS LICENSING BRANCH U.S. NUCLEAR REGULATORY COMMISSION, REGION Ill 2443 WARRENVILLE ROAD, SUITE 210 LISLE, IL 60532-4352 IF YOU ARE LOCATED IN:

ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, COLORADO, HAWAII, IDAHO, KANSAS, LOUISIANA, MISSISSIPPI, MONTANA, NEBRASKA, NEVADA, NEW MEXICO, NORTH DAKOTA, OKLAHOMA, OREGON, PACIFIC TRUST TERRITORIES, SOUTH DAKOTA, TEXAS, UTAH, WASHINGTON, OR WYOMING, X

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