Form NRC Form 748 NRC Form 748 National Source Tracking Transaction Report - PREVIOUS V

U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 748
(M-YYYY)
10 CFR 20.2207

NATIONAL SOURCE TRACKING TRANSACTION REPORT
1. LICENSEE
A. LICENSEE NAME AND ADDRESS

APPROVED BY OMB: NO. 3150-0202

2. TYPE OF TRANSACTION

B. LICENSE NO.

EXPIRES: MM/DD/YYYY

Estimated burden per response to comply with this mandatory information collection request: 15 minutes. NRC requires this information to
populate the National Source Tracking System for certain sealed sources. 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, (3150-0202), Office of Management
and Budget, Washington, DC 20503. If a means used to impose an information collection does not display a currently vaild OMB control
number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.

C. DOCKET NO.

NEW

CORRECTION

NEW SOURCE MANUFACTURED

DISASSEMBLE

RECEIPT

DISPOSAL

TRANSFER

REPORT SOURCE

3. DATE OF
TRANSACTION

4. PREPARER
A. NAME OF PREPARER

B. DATE PREPARED

C. TELEPHONE NO. OF PREPARER

5. SOURCE DATA
A. MANUFACTURER

B. MODEL NO.

C. SERIAL NO.

D. RADIOACTIVE
MATERIAL

E. ACTIVITY
AND UNIT

F. ACTIVITY
DATE

G. WASTE
MANIFEST NO.

H. CONTAINER
ID

I. COMMENT

6. TRANSFER DATA
6A. NAME AND ADDRESS OF RECIPIENT

B. LICENSE NO.

C. DOCKET NO.

D. ESTIMATED E. COMMENT
ARRIVAL DATE

7A. NAME AND ADDRESS OF SHIPPING LICENSEE

B. LICENSE NO.

C. DOCKET NO.

D. COMMENT

7. RECEIPT DATA

8. DISPOSAL DATA
A. WASTE MANIFEST NO.

B. CONTAINER ID

C. METHOD OF DISPOSAL

D. COMMENT

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 748 (M-YYYY)

PRINTED ON RECYCLED PAPER

INSTRUCTIONS TO NRC AND AGREEMENT STATE LICENSEES
FOR REPORTING HIGH-RISK SEALED SOURCE TRANSACTIONS
The numbered instructions which follow correspond to the numbered blocks. 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.
1. Licensee
A. Enter the name and address of the company making the report – the address where the
source is physically used/stored.
B. Enter the license number of the company making the report. Include NRC or the Agreement
State that issued the license (e.g., NRC-L0005 or CA-L0005)
C. NRC licensees only -- Enter the docket number of the company making the report.
Agreement State licensees -- Do not complete this block.
2. Type of Transaction
Check the box for a new report or a corrected report. Check the box for the type of transaction
being reported on the form. Report Source may be used to report initial inventory or a source
that was missed in the initial inventory.

6. Transfer Data
Complete this section for all transfers. Also complete Section 5 with the information on the
sources being transferred by the licensee.
A. Enter the name and address for the facility to which the source is being transferred (i.e. the
recipient).
B. Enter the license number for the facility to which the source is being transferred (i.e., the
recipient). If the source is being exported, enter the export license number.
C. Optional. NRC licensees only -- Enter the docket number of the facility to which the source
is being transferred. Agreement State licensees -- Do not complete this block.
D. Enter the estimated arrival date of the shipment.
E. Optional. Enter any additional information that may be pertinent to the transfer.

3. Date of Transaction
7. Receipt Data
Enter the date that the transaction occurred, which would be the date the source was
manufactured or the date of the transfer, receipt, or disposal.

Complete this section for all receipts. Also complete Section 5 with the information on the
sources being received by the licensee.

4. Preparer
A. Enter the name and address of the facility from which you received the source.
A. Enter the name of the person who prepared the report.
B. Enter the date the report was prepared.
C. Enter the telephone number of the person who prepared the report.
5. Source Data
Complete this section for all manufacture, transfer, receipt, and disassemble t ransactions. Do
not complete for disposal transactions. Also complete this section for any sources discovered in
the licensee's inventory that were not reported as part of the initial inventory.
A. Enter the manufacturer of the source (i.e. the name of the company that made the source).
B. Enter the model number of the source.
C. Enter the serial number of the source.
D. Enter the radioactive material in the source (i.e. Am-241, Am/Be -241, etc.).

B. Enter the License number of the facility from which you received the source. If the source
was imported, enter the import license number.
C. Optional. NRC licensees only -- Enter the docket number of the facility from which you
received the source. Agreement State licensees -- Do not complete this block.
D. Optional. Enter any additional information that may be pertinent to the receipt.
8. Disposal Data
Complete this section for all disposals of high-risk sealed sources.
A

Enter the waste manifest number.

B. Enter the ID of the container that holds the source.
C. Indicate the method of disposal (i.e. burial, incineration, etc).
D. Optional. Enter any additional information that may be pertinent to the disposal.

E. Enter the activity or source strength of the source in either curies or Becquerels.
F. Enter the date for which the source strength is reported. For example, if the reported source
strength was calculated, enter the date of the calculation.

9. DISTRIBUTION:
Mail one copy to:

Lockheed Martin
NSTS Help Desk
30 West Gude Drive, Suite 300
Rockville, MD 20850

or Fax a copy to:

240-403-4391

NSTS Help Desk:

1-877-671-6787 or email: NSTSHELP@nrc.gov

G. Enter the waste manifest number for any source that is part of a waste shipment to a waste
broker or disposal facility; otherwise leave blank.
H. Enter the ID of the container that holds the source that is part of a waste shipment to a
waste broker or disposal facility; otherwise leave blank.
I.

Optional. If the source does not have a serial number, provide other identifying information
in this block. Enter any information that may be pertinent to the source. The device number
may be provided in this block.