ML23193B006

NRC 749 (OMB Copy)(07-06-2023) Fm

ML23193B006
Person / Time
Issue date:	07/12/2023
From:	NRC/NMSS/DMSST
To:
References
OMB 3150-0223
Download: ML23193B006 (1)

Text

OFFICIAL USE ONLY - SECURITY-RELATED INFORMATION

NRC FORM 749 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0223 EXPIRES: (MM/DD/YYYY)

(MM-DD-YYYY) Estimated burden per response to comply with this collection request: 6 minutes. This form is a voluntary means of fulfilling the 10 CFR 37.71 requirements in 10 CFR 37.71. The information provided will be used to perform a license verification prior to transfer. Send MANUAL LICENSE comments regarding burden estimate to the FOIA, Library, and Information Collections Branch (T-6 A10M), U.S. Nuclear VERIFICATION REPORT Regulatory Commission, Washington, DC 20555-0001, or by email to Infocollects.Resource@nrc.gov, and the OMB reviewer at:

OMB Office of Information and Regulatory Affairs, (3150-0223), Attn: Desk Officer for the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 20503; email: 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.

Sections A-B to be completed by LVS Help Desk (if applicable). Sections C-D to be completed by the licensee: Complete sections C and D below for NRC or Agreement State licensees needing to verify a license outside of the License Verification System. For issues with submitting this form, please contact the LVS Help Desk: 1-877-671-6787 or E-mail: lvshelp.resource@nrc.gov.

A. CONTACTED VIA PhoneEmailB. DATE (MM/DD/YYYY)

C. TRANSFERRING LICENSEE INFORMATION

C.1 Agency (issuing Agency for license)

C.2 Licensee Name

C.3 License Number

C.4 Contact Name and Title

C.5 Contact Telephone Number C.7 Contact Fax Telephone Number

C.6 Contact Email Address

D. RECEIVING LICENSEE INFORMATION

D.1 Agency (issuing Agency for license)

D.2 Licensee Name

D.3 License Number D.4 Amendment Number

D.5 Issue Date

D.6 Authorized Location

D.7 Material(s) of concern being requested D.8 Chemical/Physical Form D.9 Quantity/Activity/Unit (being requested)

1. 1. 1.

2. 2. 2.

3. 3. 3.

4. 4. 4.

Sections E-F instructions (Agency representative to provide): Verify the information in Section D above and make sure that all information provided is valid and the authorized location, materials and quantities being requested are authorized on the recipient's license. Record the verification outcome below. Return the completed form via e-mail to the LVS Help Desk (lvshelp.resource@nrc.gov).

E. VERIFIER'S INFORMATION

E.1 Verifier's Name

E.2 Verifier's Telephone Number E.3 Verifier's Fax Telephone Number

E.4 Verifier's E-mail Address

F. VERIFICATION OUTCOME

F.1 Verification Date

Requested materials, quantities, and Requested materials, quantities, and authorized location are authorized on authorized location are not authorized F.2 Verification Outcome the license on the license

Other

F.3 If other, please explain:

NRC FORM 749 (MM-DD-YYYY) OFFICIAL USE ONLY - SECURITY-RELATED INFORMATION