ML13083A305

NRC Form 748C - Receive Source National Source Tracking Transaction Report

ML13083A305
Person / Time
Issue date:	01/31/2016
From:	NRC/OCIO/GEMSD/IMSB
To:
References
Download: ML13083A305 (4)

Text

1. LICENSEE INFORMATION NRC FORM 748C (01-2016)10 CFR 20.2207 U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748C (01-2016)

A PPROVED BY OMB: NO. 3150-0202 EXPIRES: 01/31/2019 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 7. SOURCE RECEIPT DATA G1. SOURCE MAKE H1. SOURCE MODEL I1. SOURCE SERIAL NUMBER J1. ISOTOPE K1. ACTIVITY AND UNIT L1. ACTIVITY DATE T1. COMMENTS M1. WASTE MANIFEST NO.

C1. SENDING LICENSEE SHIPPING ADDRESS B1. SENDING LICENSEE LICENSE NO.

A1. SENDING LICENSEE NAME N1. CONTAINER ID O1. SOURCE LOCATION ADDRESS F1. ZIP CODE E1. STATE D1. CITY R1. ZIP CODE P1. CITY Q1. STATE S1. SAME AS STREET ADDRESS (For waste shipments only)(For waste shipments only)

RECEIVE SOURCE NATIONAL SOURCE TRACKING TRANSACTION REPORT 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, Privacy, Information Collections Branch (T-5 F53), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by internet 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.

NRC FORM 748C (01-2016)10 CFR 20.2207 U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748C (01-2016)

LICENSE NO.

LICENSEE NAME G2. SOURCE MAKE H2. SOURCE MODEL I2. SOURCE SERIAL NUMBER J2. ISOTOPE K2. ACTIVITY AND UNIT L2. ACTIVITY DATE T2. COMMENTS M2. WASTE MANIFEST NO.

C2. SENDING LICENSEE SHIPPING ADDRESS B2. SENDING LICENSEE LICENSE NO.

A2. SENDING LICENSEE NAME N2. CONTAINER ID O2. SOURCE LOCATION ADDRESS F2. ZIP CODE E2. STATE D2. CITY R2. ZIP CODE P2. CITY Q2. STATE S2. SAME AS STREET ADDRESS G3. SOURCE MAKE H3. SOURCE MODEL I3. SOURCE SERIAL NUMBER J3. ISOTOPE K3. ACTIVITY AND UNIT L3. ACTIVITY DATE T3. COMMENTS M3. WASTE MANIFEST NO.

C3. SENDING LICENSEE SHIPPING ADDRESS B3. SENDING LICENSEE LICENSE NO.

A3. SENDING LICENSEE NAME N3. CONTAINER ID O3. SOURCE LOCATION ADDRESS F3. ZIP CODE E3. STATE D3. CITY R3. ZIP CODE P3. CITY Q3. STATE S3. SAME AS STREET ADDRESS (For waste shipments only)(For waste shipments only)(For waste shipments only)(For waste shipments only)

7. SOURCE RECEIPT DATA (continued)

Page 2 RECEIVE 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.

NRC FORM 748C (01-2016)10 CFR 20.2207 U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748C (01-2016)

LICENSE NO.

LICENSEE NAME

7. SOURCE RECEIPT DATA (continued)

G4. SOURCE MAKE H4. SOURCE MODEL I4. SOURCE SERIAL NUMBER J4. ISOTOPE K4. ACTIVITY AND UNIT L4. ACTIVITY DATE T4. COMMENTS M4. WASTE MANIFEST NO.

C4. SENDING LICENSEE SHIPPING ADDRESS B4. SENDING LICENSEE LICENSE NO.

A4. SENDING LICENSEE NAME N4. CONTAINER ID O4. SOURCE LOCATION ADDRESS F4. ZIP CODE E4. STATE D4. CITY R4. ZIP CODE P4. CITY Q4. STATE S4. SAME AS STREET ADDRESS G5. SOURCE MAKE H5. SOURCE MODEL I5. SOURCE SERIAL NUMBER J5. ISOTOPE K5. ACTIVITY AND UNIT L5. ACTIVITY DATE T5. COMMENTS M5. WASTE MANIFEST NO.

C5. SENDING LICENSEE SHIPPING ADDRESS B5. SENDING LICENSEE LICENSE NO.

A5. SENDING LICENSEE NAME N5. CONTAINER ID O5. SOURCE LOCATION ADDRESS F5. ZIP CODE E5. STATE D5. CITY R5. ZIP CODE P5. CITY Q5. STATE S5. SAME AS STREET ADDRESS (For waste shipments only)(For waste shipments only)(For waste shipments only)(For waste shipments only)

RECEIVE SOURCE NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)

Page 3 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 Email" 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

30 West Gude Drive, Suite 300

Rockville, MD 20850