Form NRC Form 241 NRC Form 241 Report of Proposed Activities in Non-Agreement States, A

NRC FORM 241

U.S. NUCLEAR REGULATORY COMMISSION

(4-2008)

REPORT OF PROPOSED ACTIVITIES IN
NON-AGREEMENT STATES, AREAS OF EXCLUSIVE
FEDERAL JURISDICTION, OR OFFSHORE WATERS
(Please read the instructions before completing this form)

APPROVED BY OMB: NO. 3150-0013
EXPIRES: 08/31/2008
Estimated burden per response to comply with this mandatory collection
request: 15 minutes. This notification is required so that NRC may
schedule inspection of the activities to ensure that they are conducted in
accordance with requirements for protection of the public health and
safety. Send comments regarding burden estimate to the Records and
FOIA/Privacy Services Branch (T-5 F53), 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, (3150-0013), 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 OF LICENSEE (Person or firm proposing to conduct the activities described below)

2. TYPE OF REPORT
INITIAL

3. ADDRESS OF LICENSEE (Mailing address or other location where licensee may be located)

CHANGE

4. LICENSEE CONTACT AND TITLE

5. TELEPHONE NUMBER
(Include Area Code)

6. FACSIMILE NUMBER
(Include Area Code)

7. ACTIVITIES TO BE CONDUCTED UNDER THE GENERAL LICENSE GIVEN IN 10 CFR 150.20
WELL LOGGING

LEAK TESTING AND/OR CALIBRATIONS

PORTABLE GAUGES

OTHER (Specify)

RADIOGRAPHY

A

TELETHERAPY/IRRADIATOR SERVICE

A

REGISTERED AS USER OF PACKAGING (CERTIFICATES OF COMPLIANCE NUMBERS)

8. CLIENT NAME, ADDRESS, CITY/COUNTY, STATE, ZIP CODE

9. ACTUAL PHYSICAL ADDRESS OF WORK LOCATION
(Street and Number or other location. Give as complete an address or directi ons as possible.)

10. CLIENT TELEPHONE NUMBER
(Include Area Code)

13. NUMBER OF
WORK DAYS

12. DATES SCHEDULED
FROM

14.
ADD

11. WORK LOCATION TELEPHONE NUMBER
(Include Area Code)

15.
DELETE

TO

16. LOCATION
REFERENCE NUMBER
NUMBER TO BE
ASSIGNED BY NRC

LIST ADDITIONAL WORK SITES ON SEPARATE SHEET(S) TO INCLUDE ALL INFORMATION CONTAINED IN ITEMS 9-16 ABOVE.
17. LIST RADIOACTIVE MATERIAL, WHICH WILL BE POSSESSED, USED, INSTALLED, SERVICED, OR TESTED
(Include description of type and quantity of radioactive material, sealed sources, or devices to be used.)

18. AGREEMENT STATE SPECIFIC LICENSE WHICH AUTHORIZES THE UNDERSIGNED TO CONDUCT
ACTIVITIES WHICH ARE THE SAME, EXCEPT FOR LOCATION OF USE, AS SPECIFIED IN ITEM 9.
ABOVE. (One copy of the specific license must accompany the initial NRC Form 241.)

LICENSE NUMBER

STATE

EXPIRATION DATE

19. CERTIFICATION (MUST BE COMPLETED BY APPLICANT)
I, THE UNDERSIGNED, HEREBY CERTIFY THAT:
a.

All information in this report is true and complete.

b.

I have read and understand the provision of the general license 10 CFR 150.20 reprinted on the instructions of this form; and I understand that I am
required to comply with these provisions as to all byproduct, source, or special nuclear material which I possess and use in non-Agreement States or
offshore waters under the general license for which this report is filed with t he U.S. Nuclear Regulatory Commission.

c.

I understand that activities, including storage, conducted in non-Agreement States under general license 10 CFR 150.20 are limited to a total of 180 days
in calendar year. With the exception of work conducted in off-shore waters, whi ch is authorized for an unlimited period of time in the calendar year.

d.

I understand that I may be inspected by NRC at the above listed work site locations and at the Licensee home office address for activities performed in
non-Agreement States or offshore waters.

e.

I understand that conduct of any activities not described above, including conduct of activities on dates or locations different from those described
above or without NRC authorization, may subject me to enforcement action, including civil or criminal penalties.

CERTIFYING OFFICER - RSO or Management Representative (Name and Title)

SIGNATURE

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.

FOR NRC
USE ONLY

REVIEWING OFFICIAL (Typed/Printed Name and Title)

NRC FORM 241 (4-2008)

SIGNATURE

DATE

TOTAL USAGE -- DAYS TO DATE

PRINTED ON RECYCLED PAPER

APPROVED BY OMB: NO. 3150-0013
EXPIRES: 08/31/2008

NRC FORM 241
(4-2008)
U.S. NUCLEAR REGULATORY COMMISSION

REPORT OF PROPOSED ACTIVITIES IN NON-AGREEMENT STATES, AREAS OF
EXCLUSIVE FEDERAL JURISDICTION, OR OFFSHORE WATERS
PLEASE READ THIS INFORMATION AND THESE INSTRUCTIONS BEFORE COMPLETING NRC FORM 241
Section 150.20 of 10 CFR 150 establishes a general license authorizing any person who holds a specific license from an "Agreement
State" (a State with which the U.S. Nuclear Regulatory Commission has entered into an effective agreement under subsection 274b of
the Atomic Energy Act of 1954) where the licensee maintains an office for directing the licensed activity and at which radiation safety
records are normally maintained, to conduct the same activity in Non-Agreement States, areas of exclusive Federal jurisdiction, or in
offshore waters if the specific license issued by the Agreement State does not limit the authorized activity to specified locations or
installations.

INSTRUCTIONS
Licensees cannot perform work in areas of exclusive Federal jurisdiction without either (a) filing NRC Form 241 for reciprocity in
accordance with 10 CFR 150.20(b) or (b) applying for a specific NRC license. An area of exclusive Federal jurisdiction is an area over
which the Federal government exercises legal control without interference from the jurisdiction and administration of State law. For
example: If the work is to be performed on Federal property in an Agreement State, the licensee must first determine the jurisdictional
status of the area where the licensee plans to work. If the jurisdictional status of the work site is unknown to the licensee, the
Agreement State licensee should contact the Federal agency that controls the facility where the work is to be performed. A written
statement concerning the jurisdictional status is not required in order to file for reciprocity; however, it is recommended that the
Agreement State licensee obtain such a statement for the file for future reference and inspection purposes.
For licensees seeking to conduct activities under reciprocity for the first time in a calendar year, submit this Form, one copy of the
Agreement State specific license and the fee specified in fee Category 16, 10 CFR 170.31. NRC must receive this filing at least 3
days before the licensee engages in activities permitted under the General License established by Section 150.20 of 10 CFR 150.
In general, the preferred method of filing is through the facsimile transmission of NRC Form 241, a copy of the Agreement State
license, and evidence that the appropriate fee requirements will be met within 3 days. This evidence can be a copy of the check or a
copy of NRC Form 629, if paying by credit card, that will be mailed to the NRC. The licensee should receive confirmation (by
telephone, e-mail, or facsimile) that NRC has received the facsimile. Alternatively, the licensee may file the required information
through the mail or other means as long as NRC receives the information at least 3 days before the licensee engages in the activity.
In completing NRC Form 241, it is important that the information submitted on NRC Form 241 be specific regarding the location and
date of use as well as the activity requested. If it is not possible to provide complete information, such as addresses for the locations
of work, the licensee should provide as much information as possible. The licensee is responsible for providing additional information
as revisions or clarifications as soon as such information becomes available.
Item 2.
For licensees seeking to conduct activities under reciprocity for the first time in a calendar year, submit this Form, one copy of the
Agreement State specific license and the fee specified in fee Category 16, 10 CFR 170.31. NRC must receive this filing at least 3
days before the licensee engages in activities permitted under the General License established by Section 150.20 of 10 CFR 150. The
licensee should check the "initial" box if this is the first submission of Form 241 for the year.
For modifications such to the information submitted on the initial NRC Form 241, such as additional work locations, changes to
radioactive material, work activities, information that clarifies or deletes specific locations or work sites, modifies work site contacts, or
adds or deletes dates of work, licensees should file by NRC Form 241 or letter, so that NRC receives the filing at least 3 days prior to
engage in such activity. Licensees should check the "change" box to indicate changes to the information provided on the initial NRC
Form 241. It is not necessary to resubmit the Agreement State license unless the license has been amended since the filing of the
initial NRC Form 241. No fee is required for changes.
NRC Form 241 may be used for submitting multiple work locations and clients for initial filings of NRC Form 241, as well as for
submitting revisions and clarifications to previous filings. Separate sheets may be used provided it includes all of the requested
information in Items 9-16 of NRC Form 241.
Under the general license, reciprocity activities are authorized only as long as the licensee holds a valid radioactive material license. If
the license expires during the year, an extension letter or a renewed license issued by the regulating agency must be subjitted to NRC
before performing any additional work under reciprocity.
Items 12. - 16.
Under the general license, reciprocity activities, including storage (usage), conducted in non-Agreement States and areas of exclusive
Federal jurisdiction, are limited to a total of 180 days in any calendar year except for work conducted in off-shore waters, which is
authorized for an unlimited period of time in a calendar year. NRC tracks reciprocity usage on the basis of approved usage days. NRC
will not approve any activity under the general license which causes the total usage days to exceed 180 days, except for work
conducted in off-shore waters. NRC may note and notify the licensee that a filing proposes reciprocity activities which approach or
would exceed the 180-day limit. It is important that licensees track the days of use and clarify or delete dates of work when applicable.
Item 12. should reference the proposed beginning and ending dates of work for each work location with the total number of days
worked recorded in Item 13. Item 14. should be completed to show additional work dates different from those provided on the initial
NRC Form 241 and Item 15. should indicate dates when work was not performed, as initially requested, that need to be deleted from
the total work days. The Location Reference Number in Item 16. is generated by the NRC for use in tracking reciprocity activities and
is specific for each work location. The Location Reference Number should be referenced for any revisions or clarifications to work
location information.

Item 18 Licensees should identify the specific make and model numbers of sealed sources and devices.
NOTE: Inspections by NRC of activities performed in non-Agreement States, areas of exclusive Federal jurisdiction, or offshore
waters by Agreement State licensees operating under the general license in 10 CFR 150.20 will be conducted at the listed
work site location(s). Failure to file an NRC Form 241 may result in the issuance of a notice of violation, the proposed
imposition of a civil penalty, or an order suspending, modifying, or revoking the license as specified in the "General Statement
of Policy and Procedures for NRC Enforcement Actions."
Agreement State licensees seeking to conduct activities under Reciprocity should file this Form, one copy of the Agreement State
license, and the appropriate fee with the U.S. Nuclear Regulatory Commission Regional Administrator listed below for the region in
which the Agreement State that issued the specific license is located:
IF THE AGREEMENT STATE LICENSE IS ISSUED BY:

IF THE AGREEMENT STATE LICENSE IS ISSUED BY:

Alabama, Florida, Georgia, Kentucky, Maine, Maryland,
Massachusetts, Mississippi, New Hampshire, New York,
North Carolina, Rhode Island, South Carolina, or
Tennessee,

Illinois, Iowa, Ohio, or Wisconsin,

SEND APPLICATION AND FEE PAYMENT TO:
Regional Administrator
Division of Nuclear Material Safety
ATTN: Reciprocity Request
Nuclear Materials Safety Branch
U.S. Nuclear Regulatory Commission, Region I
475 Allendale Road
King of Prussia, PA 19406-1415
Telephone Number (800) 432-1156
Facsimile Number (610) 337-5393

SEND APPLICATION AND FEE PAYMENT TO:
Regional Administrator
Division of Nuclear Material Safety
ATTN: Reciprocity Request
U.S. Nuclear Regulatory Commission, Region III
2443 Warrenville Road, Suite 210
Lisle, IL 60532-4352
Telephone Number (630) 829-9887
Facsimile Number (630) 515-1259

IF THE AGREEMENT STATE LICENSE IS ISSUED BY:
Arizona, Arkansas, California, Colorado, Idaho, Kansas,
Louisiana, Nebraska, Nevada, New Mexico, North Dakota,
Oregon, Texas, Utah, or Washington,
SEND APPLICATION AND FEE PAYMENT TO:
Regional Administrator
Division of Nuclear Material Safety
ATTN: Reciprocity Request
U.S. Nuclear Regulatory Commission, Region IV
612 E. Lamar Boulevard, Suite 400
Arlington, TX 76011-4125
Telephone Number (817) 860-8100
Facsimile Number (817) 860-8263

150.20 Recognition of Agreement State Licensees
(a)(1) Provided that the provisions of paragraph (b) of this section have been met, any person who holds a specific license from an
Agreement State, where the licensee maintains an office for directing the licensed activity and retaining radiation safety records, is
granted a general license to conduct the same activity in (i) Non-Agreement States; (ii) Areas of exclusive Federal jurisdiction within
Agreement States; and (iii) Offshore waters.
(2) The provisions of paragraph (a)(1) of this section do not apply if the specific Agreement State license limits the authorized activity
to a specific installation or location.
(b) Notwithstanding any provision to the contrary in any specific license issued by an Agreement State to a person engaging in
activities in a non-Agreement State, in an area of exclusive Federal jurisdiction within an Agreement State, or in offshore waters under
the general licenses provided in this section, the general licenses provided in this section are subject to all the provisions of the Act,
now or hereafter in effect, and to all applicable rules, regulations, and orders of the Commission including the provisions of §§ 30.7 (a)
through (f), 30.9, 30.10, 30.14(d), 30.34, 30.41, and 30.51 to 30.63, inclusive, of part 30 of this chapter; §§ 40.7 (a) through (f), 40.9,
40.10, 40.41, 40.51, 40.61, 40.63 inclusive, 40.71 and 40.81 of part 40 of this chapter; §§ 70.7 (a) through (f), 70.9, 70.10, 70.32,
70.42, 70.52, 70.55, 70.56, 70.60 to 70.62 of part 70 of this chapter; §§ 74.11, 74.15, and 74.19 of part 74 of this chapter; and to the
provisions of 10 CFR parts 19, 20 and 71 and subparts C through H of part 34, §§ 39.15 and 39.31 through 39.77, inclusive, of part 39
of this chapter. In addition, any person engaging in activities in non-Agreement States, in areas of exclusive Federal jurisdiction within
Agreement States, or in offshore waters under the general licenses provided in this section:

(1) Shall, at least 3 days before engaging in each activity for the first time in a calendar year, file a submittal containing an NRC Form
241, "Report of Proposed Activities in Non-Agreement States"' a copy of its Agreement State specific license, and the appropriate fee
as prescribed in § 170.31 of this chapter with the Regional Administrator of the U.S. Nuclear Regulatory Commission Regional Office
listed on the NRC Form 241 and in appendix D to part 20 of this chapter for the Region in which the Agreement State that issued the
license is located. If a submittal cannot be filed 3 days before engaging in activities under reciprocity, because of an emergency or
other reason, the Regional Administrator may waive the 3-day time requirement provided the licensee:
i) Informs the Region by telephone, facsimile, an NRC Form 241, or a letter of initial activities or revisions to the information submitted
on the initial NRC Form 241;
(ii) Receives oral or written authorization for the activity from the Region; and
(iii) Within 3 days after the notification, files an NRC Form 241, a copy of the Agreement State license, and the fee payment.
(2) Shall file an amended NRC Form 241 or letter with the Regional Administrator to request approval for changes in work locations,
radioactive material, or work activities different from the information contained on the initial NRC Form 241.
(3) Shall not, in any non-Agreement State, in an area of exclusive Federal jurisdiction within an Agreement State, or in offshore waters,
transfer or dispose of radioactive material possessed or used under the general licenses provided in this section, except by transfer to
a person who is-(i) Specifically licensed by the Commission to receive this material; or
(ii) Exempt from the requirements for a license for material under § 30.14 of this chapter.
(4) Shall not, under the general license concerning activities in non-Agreement States or in areas of exclusive Federal jurisdiction
within Agreement States, possess or use radioactive materials, or engage in the activities authorized in paragraph (a) of this section,
for more than 180 days in any calendar year, except that the general license in paragraph (a) of this section concerning activities in
offshore waters authorizes that person to possess or use radioactive materials, or engage in the activities authorized, for an unlimited
period of time.
(5) Shall comply with all terms and conditions of the specific license issued by an Agreement State except such terms or conditions as
are contrary to the requirements of this section.
[35 FR 7725, May 20, 1970, as amended at 38 FR 1273, Jan. 11, 1973; 46 FR 44152, Sept. 3, 1981; 46 FR 50781, Oct. 15, 1981; 52
FR 41700, Oct. 30, 1987; 55 FR 10406, Mar. 21, 1990; 56 FR 54779, Oct. 23, 1991; 58 FR 52414, Oct. 8, 1993; 62 FR 1665, Jan. 13,
1997; 62 FR 28973, May 28, 1997; 66 FR 5443, Jan. 19, 2001; 66 FR 32469, June 14, 2001; 67 FR 78149, Dec. 23, 2002; 68 FR
58825, Oct. 10, 2003]