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U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0202
NRC FORM 748A
(MM-YYYY)
10 CFR 20.2207
REPORT SOURCE INVENTORY
NATIONAL SOURCE TRACKING TRANSACTION REPORT
EXPIRES: (MM/DD/YYYY)
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.
1. LICENSEE INFORMATION
B. LICENSE NO.
A. LICENSEE NAME
2. TRANSACTION DATE
C. LICENSEE STREET ADDRESS
3A. TRANSACTION INFORMATION
(Only transactions completed on the same
date may be reported together on this form)
NEW
CORRECTION
IF CORRECTION, PREVIOUS TRANSACTION DATE:
D. CITY
E. STATE F. ZIP CODE
3B. TRANSACTION TYPE (Check all that apply)
REPORT SOURCE
TRANSFER
RECEIPT
DISPOSAL
IMPORT
EXPORT
DISASSEMBLE
INVENTORY
NEW SOURCE
MANUFACTURED
4. PREPARER INFORMATION
A. NAME OF PREPARER
B. DATE PREPARED
D. PREPARER E-MAIL (REQUIRED FOR CONFIRMATION)
C. PREPARER PHONE
5. SOURCE INVENTORY DATA (Note: Only use this section for reporting initial source inventory)
A1. SOURCE MAKE
B1. SOURCE MODEL
H1. SOURCE LOCATION ADDRESS
I1. CITY
A2. SOURCE MAKE
B2. SOURCE MODEL
H2. SOURCE LOCATION ADDRESS
I2. CITY
C1. SOURCE SERIAL
NUMBER
C2. SOURCE SERIAL
NUMBER
D1. ISOTOPE
E1. ACTIVITY AND UNIT
F1. ACTIVITY DATE
J1. STATE
K1. ZIP CODE
L1. SAME AS STREET
ADDRESS
D2. ISOTOPE
E2. ACTIVITY AND UNIT
F2. ACTIVITY DATE
J2. STATE
K2. ZIP CODE
L2. SAME AS STREET
ADDRESS
G1. COMMENTS
G2. COMMENTS
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 748A (MM-YYYY)
Page 1
NRC FORM 748A
U.S. NUCLEAR REGULATORY COMMISSION LICENSEE NAME
(MM-YYYY)
10 CFR 20.2207
LICENSE NO.
REPORT SOURCE INVENTORY
NATIONAL SOURCE TRACKING TRANSACTION REPORT (continued)
5. SOURCE INVENTORY DATA (continued)
A3. SOURCE MAKE
B3. SOURCE MODEL
H3. SOURCE LOCATION ADDRESS
I3. CITY
A4. SOURCE MAKE
B4. SOURCE MODEL
H4. SOURCE LOCATION ADDRESS
I4. CITY
A5. SOURCE MAKE
B5. SOURCE MODEL
H5. SOURCE LOCATION ADDRESS
I5. CITY
A6. SOURCE MAKE
B6. SOURCE MODEL
H6. SOURCE LOCATION ADDRESS
I6. CITY
C3. SOURCE SERIAL
NUMBER
C4. SOURCE SERIAL
NUMBER
C5. SOURCE SERIAL
NUMBER
C6. SOURCE SERIAL
NUMBER
D3. ISOTOPE E3. ACTIVITY AND UNIT
F3. ACTIVITY DATE
J3. STATE
L3. SAME AS STREET
ADDRESS
K3. ZIP CODE
D4. ISOTOPE E4. ACTIVITY AND UNIT
F4. ACTIVITY DATE
J4. STATE
L4. SAME AS STREET
ADDRESS
K4. ZIP CODE
D5. ISOTOPE E5. ACTIVITY AND UNIT
F5. ACTIVITY DATE
J5. STATE
L5. SAME AS STREET
ADDRESS
K5. ZIP CODE
D6. ISOTOPE E6. ACTIVITY AND UNIT
F6. ACTIVITY DATE
J6. STATE
L6. SAME AS STREET
ADDRESS
K6. ZIP CODE
G3. COMMENTS
G4. COMMENTS
G5. COMMENTS
G6. COMMENTS
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 748A (MM-YYYY)
Page 2
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.
1.
2.
3.
4.
5.
6.
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.
Licensee Information – Enter the name, license number, and street address of
the licensed facility.
Transaction Date – Enter the date the transaction occurred, which would be the date
of the transfer, receipt, manufacture, etc.
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.
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.
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.
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.
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.
7.
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
File Type | application/pdf |
File Title | o:\informs\fixforms\n748_2a.wpf |
Author | CXC7 |
File Modified | 2015-04-03 |
File Created | 2015-04-03 |