NRC Form 830A Report of Import and Continuation Sheet

NRC FORM 830A
(MM-YYYY)
10 CFR 110.50(c)(3)(ii)

U.S. NUCLEAR REGULATORY COMMISSION

REPORT OF IMPORT
CONTINUATION SHEET

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:

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)

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

ACTIVITY (TBq)

MAKE

MODEL

SERIAL NUMBER

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NRC Form 830A (MM-YYYY)

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