Form NRC Form 653, NRC NRC Form 653, NRC Transfers of Industrial Devices Report (To General Licen

10 CFR Part 32, Specific Domestic Licenses to Manufacture or Transfer Certain Items Containing Byproduct Material

NRC Form 653, 653A and 653B

10 CFR Part 32, Specific Domestic Licenses to Manufacture or Transfer Certain Items Containing Byproduct Material

OMB: 3150-0001

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3150-0001 can be found here:
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NRC FORM 653

U. S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0001

(MM-YYYY)
10 CFR 32

TRANSFERS OF INDUSTRIAL
DEVICES REPORT
(TO GENERAL LICENSEES)
(Continue on NRC Form 653, 653A or 653B, as appropriate)

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory collection request: 36 minutes. NRC
requests quarterly reports to keep apprised of device movements. Send comments regarding the
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, (3150-0001), 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.

For each "licensee" to whom a device(s) has been transferred during the reporting period, supply the following:
REPORTING PERIOD

NAME OF VENDOR

TO

FROM
LICENSE NUMBER

INTERMEDIATE PERSON(S) (if any)
NAME OF INTERMEDIATE PERSON(S)

NAME OF RESPONSIBLE INDIVIDUAL

TITLE OF RESPONSIBLE INDIVIDUAL

TELEPHONE

NAME OF INTERMEDIATE PERSON(S)

NAME OF RESPONSIBLE INDIVIDUAL

TITLE OF RESPONSIBLE INDIVIDUAL

TELEPHONE

GENERAL LICENSEE INFORMATION
NAME OF GENERAL LICENSEE

MAILING ADDRESS AT THE LOCATION OF USE (No P.O. Boxes, include Zip Code)

TELEPHONE

NAME OF RESPONSIBLE INDIVIDUAL

TITLE OF RESPONSIBLE INDIVIDUAL

INFORMATION ON DEVICE(S) TRANSFERRED
DATE OF
TRANSFER

TYPE OF DEVICE

MODEL NUMBER

SERIAL NUMBER

ISOTOPE

ACTIVITY AND UNITS

INTERMEDIATE PERSON(S) (if any)
NAME OF INTERMEDIATE PERSON

NAME OF RESPONSIBLE INDIVIDUAL

TITLE OF RESPONSIBLE INDIVIDUAL

TELEPHONE

NAME OF INTERMEDIATE PERSON

NAME OF RESPONSIBLE INDIVIDUAL

TITLE OF RESPONSIBLE INDIVIDUAL

TELEPHONE

GENERAL LICENSEE INFORMATION
NAME OF GENERAL LICENSEE

MAILING ADDRESS AT THE LOCATION OF USE(No., P.O. Boxes, include Zip Code)

NAME OF RESPONSIBLE INDIVIDUAL

TELEPHONE

TITLE OF RESPONSIBLE INDIVIDUAL

INFORMATION ON DEVICE(S) TRANSFERRED
DATE OF
TRANSFER

NRC FORM 653 (MM-YYYY)

TYPE OF DEVICE

MODEL NUMBER

SERIAL NUMBER

ISOTOPE

ACTIVITY AND UNITS

Page

of

NRC FORM 653 (Continued)
(MM-YYYY)
10 CFR 32

U. S. NUCLEAR REGULATORY COMMISSION

TRANSFERS OF INDUSTRIAL DEVICES REPORT
(TO GENERAL LICENSEES) (continued)
INTERMEDIATE PERSON(S) (if any)

NAME OF INTERMEDIATE PERSON(S)

NAME OF RESPONSIBLE INDIVIDUAL

TITLE OF RESPONSIBLE INDIVIDUAL

TELEPHONE

NAME OF INTERMEDIATE PERSON(S)

NAME OF RESPONSIBLE INDIVIDUAL

TITLE OF RESPONSIBLE INDIVIDUAL

TELEPHONE

GENERAL LICENSEE INFORMATION
MAILING ADDRESS AT THE LOCATION OF USE (No P.O. Boxes, include Zip Code)

NAME OF GENERAL LICENSEE

TELEPHONE

NAME OF RESPONSIBLE INDIVIDUAL

TITLE OF RESPONSIBLE INDIVIDUAL

INFORMATION ON DEVICE(S) TRANSFERRED
DATE OF
TRANSFER

TYPE OF DEVICE

MODEL NUMBER

SERIAL NUMBER

ISOTOPE

ACTIVITY AND UNITS

INTERMEDIATE PERSON(S) (if any)
NAME OF INTERMEDIATE PERSON(S)

NAME OF RESPONSIBLE INDIVIDUAL

TITLE OF RESPONSIBLE INDIVIDUAL

TELEPHONE

NAME OF INTERMEDIATE PERSON(S)

NAME OF RESPONSIBLE INDIVIDUAL

TITLE OF RESPONSIBLE INDIVIDUAL

TELEPHONE

GENERAL LICENSEE INFORMATION
NAME OF GENERAL LICENSEE

NAME OF RESPONSIBLE INDIVIDUAL

MAILING ADDRESS AT THE LOCATION OF USE(No P.O. Boxes, include Zip Code)

TELEPHONE

TITLE OF RESPONSIBLE INDIVIDUAL

INFORMATION ON DEVICE(S) TRANSFERRED
DATE OF
TRANSFER

NRC FORM 653 (MM-YYYY)

TYPE OF DEVICE

MODEL NUMBER

SERIAL NUMBER

ISOTOPE

ACTIVITY AND UNITS

Page

of

NRC FORM 653 (Continued)
(MM-YYYY)
10 CFR 32

U. S. NUCLEAR REGULATORY COMMISSION

TRANSFERS OF INDUSTRIAL DEVICES REPORT
(TO GENERAL LICENSEES) (continued)
INTERMEDIATE PERSON(S) (if any)

NAME OF INTERMEDIATE PERSON(S)

NAME OF RESPONSIBLE INDIVIDUAL

TITLE OF RESPONSIBLE INDIVIDUAL

TELEPHONE

NAME OF INTERMEDIATE PERSON(S)

NAME OF RESPONSIBLE INDIVIDUAL

TITLE OF RESPONSIBLE INDIVIDUAL

TELEPHONE

GENERAL LICENSEE INFORMATION
MAILING ADDRESS AT THE LOCATION OF USE (No P.O. Boxes, include Zip Code)

NAME OF GENERAL LICENSEE

NAME OF RESPONSIBLE INDIVIDUAL

TELEPHONE

TITLE OF RESPONSIBLE INDIVIDUAL

INFORMATION ON DEVICE(S) TRANSFERRED
DATE OF
TRANSFER

TYPE OF DEVICE

MODEL NUMBER

SERIAL NUMBER

ISOTOPE

ACTIVITY AND UNITS

INTERMEDIATE PERSON(S) (if any)
NAME OF INTERMEDIATE PERSON(S)

NAME OF RESPONSIBLE INDIVIDUAL

TITLE OF RESPONSIBLE INDIVIDUAL

TELEPHONE

NAME OF INTERMEDIATE PERSON(S)

NAME OF RESPONSIBLE INDIVIDUAL

TITLE OF RESPONSIBLE INDIVIDUAL

TELEPHONE

GENERAL LICENSEE INFORMATION
NAME OF GENERAL LICENSEE

NAME OF RESPONSIBLE INDIVIDUAL

MAILING ADDRESS AT THE LOCATION OF USE(No P.O. Boxes, include Zip Code)

TELEPHONE

TITLE OF RESPONSIBLE INDIVIDUAL

INFORMATION ON DEVICE(S) TRANSFERRED
DATE OF
TRANSFER

NRC FORM 653 (MM-YYYY)

TYPE OF DEVICE

MODEL NUMBER

SERIAL NUMBER

ISOTOPE

ACTIVITY AND UNITS

Page

of

NRC FORM 653A
(MM-YYYY)
10 CFR 32

U. S. NUCLEAR REGULATORY COMMISSION

TRANSFERS OF INDUSTRIAL DEVICES REPORT (FROM GENERAL LICENSEES)

For each "licensee" from whom a device(s) has been received during the reporting period, supply the following:
GENERAL LICENSEE INFORMATION
MAILING ADDRESS AT THE LOCATION OF USE (No P.O. Boxes, include Zip Code)

NAME OF GENERAL LICENSEE

INFORMATION ON DEVICE(S) RECEIVED
DATE OF
RECEIPT

TYPE OF
DEVICE

MODEL NUMBER

SERIAL NUMBER

MANUFACTURER OR INITIAL TRANSFEROR
(IF NOT REPORTING PARTY)

GENERAL LICENSEE INFORMATION
MAILING ADDRESS AT THE LOCATION OF USE (No P.O. Boxes, include Zip Code)

NAME OF GENERAL LICENSEE

INFORMATION ON DEVICE(S) RECEIVED
DATE OF
RECEIPT

TYPE OF
DEVICE

MODEL NUMBER

SERIAL NUMBER

MANUFACTURER OR INITIAL TRANSFEROR
(IF NOT REPORTING PARTY)

GENERAL LICENSEE INFORMATION
MAILING ADDRESS AT THE LOCATION OF USE (No P.O. Boxes, include Zip Code)

NAME OF GENERAL LICENSEE

INFORMATION ON DEVICE(S) RECEIVED
DATE OF
RECEIPT

TYPE OF
DEVICE

MODEL NUMBER

SERIAL NUMBER

MANUFACTURER OR INITIAL TRANSFEROR
(IF NOT REPORTING PARTY)

GENERAL LICENSEE INFORMATION
NAME OF GENERAL LICENSEE

MAILING ADDRESS AT THE LOCATION OF USE (No P.O. Boxes, include Zip Code)

INFORMATION ON DEVICE(S) RECEIVED
DATE OF
RECEIPT

TYPE OF
DEVICE

NRC FORM 653A (MM-YYYY)

MODEL NUMBER

SERIAL NUMBER

MANUFACTURER OR INITIAL TRANSFEROR
(IF NOT REPORTING PARTY)

Page

of

NRC FORM 653A (Continued)
(MM-YYYY)
10 CFR 32

U. S. NUCLEAR REGULATORY COMMISSION

TRANSFERS OF INDUSTRIAL DEVICES REPORT (FROM GENERAL LICENSEES)(continued)

For each "licensee" from whom a device(s) has been received during the reporting period, supply the following:
GENERAL LICENSEE INFORMATION
MAILING ADDRESS AT THE LOCATION OF USE (No P.O. Boxes, include Zip Code)

NAME OF GENERAL LICENSEE

INFORMATION ON DEVICE(S) RECEIVED
DATE OF
RECEIPT

TYPE OF
DEVICE

MODEL NUMBER

SERIAL NUMBER

MANUFACTURER OR INITIAL TRANSFEROR
(IF NOT REPORTING PARTY)

GENERAL LICENSEE INFORMATION
NAME OF GENERAL LICENSEE

MAILING ADDRESS AT THE LOCATION OF USE (No P.O. Boxes, include Zip Code)

INFORMATION ON DEVICE(S) RECEIVED
DATE OF
RECEIPT

TYPE OF
DEVICE

MODEL NUMBER

SERIAL NUMBER

MANUFACTURER OR INITIAL TRANSFEROR
(IF NOT REPORTING PARTY)

GENERAL LICENSEE INFORMATION
MAILING ADDRESS AT THE LOCATION OF USE (No P.O. Boxes, include Zip Code)

NAME OF GENERAL LICENSEE

INFORMATION ON DEVICE(S) RECEIVED
DATE OF
RECEIPT

TYPE OF
DEVICE

MODEL NUMBER

SERIAL NUMBER

MANUFACTURER OR INITIAL TRANSFEROR
(IF NOT REPORTING PARTY)

GENERAL LICENSEE INFORMATION
NAME OF GENERAL LICENSEE

MAILING ADDRESS AT THE LOCATION OF USE (No P.O. Boxes, include Zip Code)

INFORMATION ON DEVICE(S) RECEIVED
DATE OF
RECEIPT

TYPE OF
DEVICE

NRC FORM 653A (MM-YYYY)

MODEL NUMBER

SERIAL NUMBER

MANUFACTURER OR INITIAL TRANSFEROR
(IF NOT REPORTING PARTY)

Page

of

NRC FORM 653B

(MM-YYYY)
10 CFR 32

U. S. NUCLEAR REGULATORY COMMISSION

TRANSFERS OF INDUSTRIAL DEVICES REPORT (LABEL CHANGES)

For each device for which required label information has been changed, supply the following:
GENERAL LICENSEE USER INFORMATION
NAME OF GENERAL LICENSEE USER

MAILING ADDRESS AT THE LOCATION OF USE (No P.O. Boxes, include Zip Code)

INFORMATION ON DEVICE(S) RECEIVED
TYPE OF
DEVICE

MODEL
NUMBER

PREVIOUS
SERIAL
NUMBER

NEW SERIAL
NUMBER

PREVIOUS
ISOTOPE

NEW ISOTOPE

PREVIOUS LABEL
ACTIVITY
AND UNITS

LABEL ACTIVITY
AND UNITS

GENERAL LICENSEE USER INFORMATION
NAME OF GENERAL LICENSEE USER

MAILING ADDRESS AT THE LOCATION OF USE (No P.O. Boxes, include Zip Code)

INFORMATION ON DEVICE(S) RECEIVED
TYPE OF
DEVICE

MODEL
NUMBER

PREVIOUS
SERIAL
NUMBER

NEW SERIAL
NUMBER

PREVIOUS
ISOTOPE

NEW ISOTOPE

PREVIOUS LABEL
ACTIVITY
AND UNITS

LABEL ACTIVITY
AND UNITS

GENERAL LICENSEE USER INFORMATION
MAILING ADDRESS AT THE LOCATION OF USE (No P.O. Boxes, include Zip Code)

NAME OF GENERAL LICENSEE USER

INFORMATION ON DEVICE(S) RECEIVED
TYPE OF
DEVICE

MODEL
NUMBER

PREVIOUS
SERIAL
NUMBER

NEW SERIAL
NUMBER

PREVIOUS
ISOTOPE

NEW ISOTOPE

PREVIOUS LABEL
ACTIVITY
AND UNITS

LABEL ACTIVITY
AND UNITS

GENERAL LICENSEE USER INFORMATION
MAILING ADDRESS AT THE LOCATION OF USE (No P.O. Boxes, include Zip Code)

NAME OF GENERAL LICENSEE USER

INFORMATION ON DEVICE(S) RECEIVED
TYPE OF
DEVICE

NRC FORM 653B (MM-YYYY)

MODEL
NUMBER

PREVIOUS
SERIAL
NUMBER

NEW SERIAL
NUMBER

PREVIOUS
ISOTOPE

NEW ISOTOPE

PREVIOUS LABEL
ACTIVITY
AND UNITS

Page

LABEL ACTIVITY
AND UNITS

of

NRC FORM 653B (Continued)
(MM-YYYY)
10 CFR 32

U. S. NUCLEAR REGULATORY COMMISSION

TRANSFERS OF INDUSTRIAL DEVICES REPORT (LABEL CHANGES)(continued)
For each device for which required label information has been changed, supply the following:
GENERAL LICENSEE USER INFORMATION

NAME OF GENERAL LICENSEE USER

MAILING ADDRESS AT THE LOCATION OF USE (No P.O. Boxes, include Zip Code)

INFORMATION ON DEVICE(S) RECEIVED
TYPE OF
DEVICE

MODEL
NUMBER

PREVIOUS
SERIAL
NUMBER

NEW SERIAL
NUMBER

PREVIOUS
ISOTOPE

NEW ISOTOPE

PREVIOUS LABEL
ACTIVITY
AND UNITS

LABEL ACTIVITY
AND UNITS

GENERAL LICENSEE USER INFORMATION
MAILING ADDRESS AT THE LOCATION OF USE (No P.O. Boxes, include Zip Code)

NAME OF GENERAL LICENSEE USER

INFORMATION ON DEVICE(S) RECEIVED
TYPE OF
DEVICE

MODEL
NUMBER

PREVIOUS
SERIAL
NUMBER

NEW SERIAL
NUMBER

PREVIOUS
ISOTOPE

NEW ISOTOPE

PREVIOUS LABEL
ACTIVITY
AND UNITS

LABEL ACTIVITY
AND UNITS

GENERAL LICENSEE USER INFORMATION
MAILING ADDRESS AT THE LOCATION OF USE (No P.O. Boxes, include Zip Code)

NAME OF GENERAL LICENSEE USER

INFORMATION ON DEVICE(S) RECEIVED
TYPE OF
DEVICE

MODEL
NUMBER

PREVIOUS
SERIAL
NUMBER

NEW SERIAL
NUMBER

PREVIOUS
ISOTOPE

NEW ISOTOPE

PREVIOUS LABEL
ACTIVITY
AND UNITS

LABEL ACTIVITY
AND UNITS

GENERAL LICENSEE USER INFORMATION
MAILING ADDRESS AT THE LOCATION OF USE (No P.O. Boxes, include Zip Code)

NAME OF GENERAL LICENSEE USER

INFORMATION ON DEVICE(S) RECEIVED
TYPE OF
DEVICE

NRC FORM 653B (MM-YYYY)

MODEL
NUMBER

PREVIOUS
SERIAL
NUMBER

NEW SERIAL
NUMBER

PREVIOUS
ISOTOPE

NEW ISOTOPE

PREVIOUS LABEL
ACTIVITY
AND UNITS

Page

LABEL ACTIVITY
AND UNITS

of
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File Title	c:\temp\ffdah1.wpf
Author	dah1
File Modified	2015-05-20
File Created	2015-05-20