Form NRC Form 830 NRC Form 830 Report of Import

NRC FORM 830

(MM-YYYY)
10 CFR 110.50(c)(3)(ii)

U.S. NUCLEAR REGULATORY COMMISSION

REPORT OF IMPORT

ADVANCED NOTIFICATION OF
SHIPMENT OF CATEGORY 1 AND/OR 2
RADIOACTIVE SOURCES

In accordance with 10 CFR Part 110.50(c)(3)(ii)
of the U.S. NRC Regulations

Reference Number:

A

Name of individual and licensee making the
notification; address and telephone number:

B

Recipient name, location, and address
(if different than above):

C

Name, location, address, contact name and
telephone number for exporting facility:

D

Radionuclide(s) and activity level in TBq, both
for single and aggregate shipments:
Total Activity Level (TBq):

E

Make, model and serial number, for any
Category 1 and 2 sealed sources, if available:

F

End-use in the U.S.:

G

H

Shipment date from the exporting facility:
(MM/DD/YYYY)
Estimated arrival date at the end use location:
(MM/DD/YYYY)
NRC or agreement state license number to
possess the import in the U.S.:
Expiration date of license: (MM/DD/YYYY)

Comments:
NRC Form 830 (MM-YYYY)

APPROVED BY OMB: NO. 3150-0036

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory collection request: 30 minutes. This form allows
the NRC to request additional information from licensees to determine whether a license should be revoked,
suspended, or modified. Send comments regarding burden estimate to the FOIA, Library, and Information
Collections Branch, (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-001, or by
e-mail to Infocollects.Resource@nrc.gov, and the OMB reviewer at: OMB Office of Information and Regulatory
Affairs, (3150-0036), Attn: Desk Officer for the Nuclear Regulatory Commission, 725 17th Street NW,
Washington, DC 20503; e-mail: oira_submission@omb.eop.gov. The NRC may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless the document requesting or requiring the
collection displays a currently valid OMB control number.

SEND COMPLETED FORM TO:

U.S. Nuclear Regulatory Commission
ATTN: Headquarters Operation Center
Email: hoo.hoc@nrc.gov (Preferred Reporting Method)
Fax: (301) 816-5151 (Alternative Reporting Method)