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

Submit by Email NRC FORM 748C U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0202 EXPIRES: 01/31/2019 (01-2016) Estimated burden per response to comply with this mandatory information collection request: 9.5 minutes. NRC requires this information 10 CFR 20.2207 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-RECEIVE SOURCE 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 NATIONAL SOURCE TRACKING TRANSACTION REPORT currently valid OMB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.

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)

7. SOURCE RECEIPT DATA A1. SENDING LICENSEE NAME B1. SENDING LICENSEE C1. SENDING LICENSEE SHIPPING ADDRESS D1. CITY E1. STATE F1. ZIP CODE LICENSE NO.

G1. SOURCE MAKE H1. SOURCE MODEL I1. SOURCE SERIAL J1. ISOTOPE K1. ACTIVITY AND UNIT L1. ACTIVITY M1. WASTE MANIFEST NO. N1. CONTAINER ID NUMBER DATE (For waste shipments only) (For waste shipments only)

O1. SOURCE LOCATION ADDRESS P1. CITY Q1. STATE R1. ZIP CODE S1. SAME AS STREET T1. COMMENTS ADDRESS 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) Page 1

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

(01-2016) 10 CFR 20.2207 RECEIVE SOURCE NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)

7. SOURCE RECEIPT DATA (continued)

A2. SENDING LICENSEE NAME B2. SENDING LICENSEE C2. SENDING LICENSEE SHIPPING ADDRESS D2. CITY E2. STATE F2. ZIP CODE LICENSE NO.

G2. SOURCE MAKE H2. SOURCE MODEL I2. SOURCE SERIAL J2. ISOTOPE K2. ACTIVITY AND UNIT L2. ACTIVITY M2. WASTE MANIFEST NO. N2. CONTAINER ID NUMBER DATE (For waste shipments only) (For waste shipments only)

O2. SOURCE LOCATION ADDRESS P2. CITY Q2. STATE R2. ZIP CODE S2. SAME AS STREET T2. COMMENTS ADDRESS A3. SENDING LICENSEE NAME B3. SENDING LICENSEE C3. SENDING LICENSEE SHIPPING ADDRESS D3. CITY E3. STATE F3. ZIP CODE LICENSE NO.

G3. SOURCE MAKE H3. SOURCE MODEL I3. SOURCE SERIAL J3. ISOTOPE K3. ACTIVITY AND UNIT L3. ACTIVITY M3. WASTE MANIFEST NO. N3. CONTAINER ID NUMBER DATE (For waste shipments only) (For waste shipments only)

O3. SOURCE LOCATION ADDRESS P3. CITY Q3. STATE R3. ZIP CODE S3. SAME AS STREET T3. COMMENTS ADDRESS 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) Page 2

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

(01-2016) 10 CFR 20.2207 RECEIVE SOURCE NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)

7. SOURCE RECEIPT DATA (continued)

A4. SENDING LICENSEE NAME B4. SENDING LICENSEE C4. SENDING LICENSEE SHIPPING ADDRESS D4. CITY E4. STATE F4. ZIP CODE LICENSE NO.

G4. SOURCE MAKE H4. SOURCE MODEL I4. SOURCE SERIAL J4. ISOTOPE K4. ACTIVITY AND UNIT L4. ACTIVITY M4. WASTE MANIFEST NO. N4. CONTAINER ID NUMBER DATE (For waste shipments only) (For waste shipments only)

O4. SOURCE LOCATION ADDRESS P4. CITY Q4. STATE R4. ZIP CODE S4. SAME AS STREET T4. COMMENTS ADDRESS A5. SENDING LICENSEE NAME B5. SENDING LICENSEE C5. SENDING LICENSEE SHIPPING ADDRESS D5. CITY E5. STATE F5. ZIP CODE LICENSE NO.

G5. SOURCE MAKE H5. SOURCE MODEL I5. SOURCE SERIAL J5. ISOTOPE K5. ACTIVITY AND UNIT L5. ACTIVITY M5. WASTE MANIFEST NO. N5. CONTAINER ID NUMBER DATE (For waste shipments only) (For waste shipments only)

O5. SOURCE LOCATION ADDRESS P5. CITY Q5. STATE R5. ZIP CODE S5. SAME AS STREET T5. COMMENTS ADDRESS 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) 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 Email" 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 30 West Gude Drive, Suite 300 referenced in the Comments block for the additional sources. Rockville, MD 20850