ML13083A308
| ML13083A308 | |
| Person / Time | |
|---|---|
| Issue date: | 01/31/2016 |
| From: | NRC/OCIO/GEMSD/IMSB |
| To: | |
| References | |
| Download: ML13083A308 (4) | |
Text
1. LICENSEE INFORMATION NRC FORM 748F (01-2016)10 CFR 20.2207 IMPORT SOURCE NATIONAL SOURCE TRACKING TRANSACTION REPORT U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748F (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 10. SOURCE IMPORT DATA F1. SOURCE MAKE G1. SOURCE MODEL H1. SOURCE SERIAL NUMBER I1. ISOTOPE J1. ACTIVITY AND UNIT K1. ACTIVITY DATE L1. COMMENTS C1. FOREIGN COMPANY ADDRESS B1. IMPORT LICENSE NO.
A1. FOREIGN COMPANY NAME M1. SOURCE LOCATION ADDRESS E1. COUNTRY D1. CITY P1. ZIP CODE N1. CITY O1. STATE Q1. SAME AS STREET ADDRESS 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, and 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 748F (01-2016)10 CFR 20.2207 U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748F (01-2016)
LICENSE NO.
LICENSEE NAME
- 10. SOURCE IMPORT DATA F2. SOURCE MAKE G2. SOURCE MODEL H2. SOURCE SERIAL NUMBER I2. ISOTOPE J2. ACTIVITY AND UNIT K2. ACTIVITY DATE L2. COMMENTS C2. FOREIGN COMPANY ADDRESS B2. IMPORT LICENSE NO.
A2. FOREIGN COMPANY NAME M2. SOURCE LOCATION ADDRESS E2. COUNTRY D2. CITY P2. ZIP CODE N2. CITY O2. STATE Q2. SAME AS STREET ADDRESS F3. SOURCE MAKE G3. SOURCE MODEL H3. SOURCE SERIAL NUMBER I3. ISOTOPE J3. ACTIVITY AND UNIT K3. ACTIVITY DATE L3. COMMENTS C3. FOREIGN COMPANY ADDRESS B3. IMPORT LICENSE NO.
A3. FOREIGN COMPANY NAME M3. SOURCE LOCATION ADDRESS E3. COUNTRY D3. CITY P3. ZIP CODE N3. CITY O3. STATE Q3. SAME AS STREET ADDRESS IMPORT SOURCE NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)
Page 2 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 748F (01-2016)10 CFR 20.2207 U.S. NUCLEAR REGULATORY COMMISSION NRC FORM 748F (01-2016)
LICENSE NO.
LICENSEE NAME
- 10. SOURCE IMPORT DATA (continued)
F4. SOURCE MAKE G4. SOURCE MODEL H4. SOURCE SERIAL NUMBER I4. ISOTOPE J4. ACTIVITY AND UNIT K4. ACTIVITY DATE L4. COMMENTS C4. FOREIGN COMPANY ADDRESS B4. IMPORT LICENSE NO.
A4. FOREIGN COMPANY NAME M4. SOURCE LOCATION ADDRESS E4. COUNTRY D4. CITY P4. ZIP CODE N4. CITY O4. STATE Q4. SAME AS STREET ADDRESS F5. SOURCE MAKE G5. SOURCE MODEL H5. SOURCE SERIAL NUMBER I5. ISOTOPE J5. ACTIVITY AND UNIT K5. ACTIVITY DATE L5. COMMENTS C5. FOREIGN COMPANY ADDRESS B5. IMPORT LICENSE NO.
A5. FOREIGN COMPANY NAME M5. SOURCE LOCATION ADDRESS E5. COUNTRY D5. CITY P5. ZIP CODE N5. CITY O5. STATE Q5. SAME AS STREET 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.
Page 3 IMPORT SOURCE NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)
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