DOE/NRC Form 742C DOE/NRC Form 742C, Physical Inventory Listing, REVISED V

NRC FORM 742C

(MM-YYYY)
MANDATORY DATA COLLECTION
AUTHORIZED BY 10 CFR 30,
40, 50, 70,72, 74, 75, 150,
Public Laws 83-703,
93-438, 95-91

U.S. DEPARTMENT OF ENERGY
AND
U.S. NUCLEAR REGULATORY COMMISSION

PHYSICAL INVENTORY LISTING

APPROVED BY OMB: NO. 3150-0058

EXPIRES: MM/DD/YYYY

Estimated burden per response to comply with this mandatory collection request: 6 hours. This information is required by NRC to fulfill its safeguards
responsibilities, bilateral agreements, and responsibilities as a participant in the US/IAEA Safeguards Agreement. Send comments regarding burden estimate to
the Records and FOIA/Privacy Services Branch (T-5 F52), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by internet e-mail to
infocollects@nrc.gov, and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0058), 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.

1. NAME AND ADDRESS

2. REPORTING IDENTIFICATION SYMBOL (RIS)

STREET ADDRESS

CITY

STATE

ZIP CODE

3. INVENTORY DATE

4. LICENSE NUMBER(S)

5. BATCH DATA
a.
b.
MATERIAL COMP/FAC
TYPE
CODE

c.
ELEMENT WEIGHT

d.
ISOTOPE WEIGHT

e.
DOE PROJECT NO.

f.
SCRAP
PROGRAM

g.
WEIGHT PERCENT ISOTOPE

h.
i.
OWNER SEQUENCE
CODE
NUMBER

j.
BATCH NAME

k.
NO. OF
ITEMS

l.
KEY
MEASURE
POINT

m. MEASUREMENT I.D.
MEAS.
BASIS

OTHER MEAS.
POINT

MEAS.
METHOD

n.
ENTRY
STATUS

o.
MBA

p.
SITE
IDC

q.
PROCESS
CODE

6. TOTALS
To the best of my knowledge and belief, the information given above and in any attached schedules is true, complete, and correct.
7. SIGNATURE

8. TITLE

9. DATE

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.