ML19037A053

OMB 3150-0001, NRC Form 653, 653A, 653B, Transfers of Industrial Devices Report (to General Licensees)

ML19037A053
Person / Time
Issue date:	03/21/2019
From:	Office of Nuclear Material Safety and Safeguards
To:
References
OMB 3150-0001
Download: ML19037A053 (7)

Text

NRC FORM 653 (MM-YYYY) 10 CFR 32 U. S. NUCLEAR REGULATORY COMMISSION TRANSFERS OF INDUSTRIAL DEVICES REPORT (TO GENERAL LICENSEES)

(Continue on NRC Form 653, 653A or 653B, as appropriate)

APPROVED BY OMB: NO. 3150-0001 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 Information Services Branch (O-1 F21), U.S.

Nuclear Regulatory Commission, Washington, DC 20555-0001, or by 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:

Name of Vendor License Number Reporting Period From To Intermediate Person(s) (if any)

Name of Intermediate Persons(s)

Name of Responsible Individual Title of Responsible Individual Business Telephone Number Name of Intermediate Persons(s)

Name of Responsible Individual Title of Responsible Individual Business Telephone Number General Licensee Information Name of General Licensee Name of Responsible Individual Business Telephone Number Title of Responsible Individual Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

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 Persons(s)

Name of Responsible Individual Title of Responsible Individual Business Telephone Number Name of Intermediate Persons(s)

Name of Responsible Individual Title of Responsible Individual Business Telephone Number General Licensee Information Name of General Licensee Name of Responsible Individual Business Telephone Number Title of Responsible Individual Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Transferred Date of Transfer Type of Device Model Number Serial Number Isotope Activity and Units NRC FORM 653 (MM-YYYY)

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

NRC FORM 653 (Continued)

(MM-YYYY) 10 CFR 32 U. S. NUCLEAR REGULATORY COMMISSION Intermediate Person(s) (if any)

Name of Intermediate Persons(s)

Name of Responsible Individual Title of Responsible Individual Business Telephone Number Name of Intermediate Persons(s)

Name of Responsible Individual Title of Responsible Individual Business Telephone Number General Licensee Information Name of General Licensee Name of Responsible Individual Business Telephone Number Title of Responsible Individual Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

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 Persons(s)

Name of Responsible Individual Title of Responsible Individual Business Telephone Number Name of Intermediate Persons(s)

Name of Responsible Individual Title of Responsible Individual Business Telephone Number General Licensee Information Name of General Licensee Name of Responsible Individual Business Telephone Number Title of Responsible Individual Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Transferred Date of Transfer Type of Device Model Number Serial Number Isotope Activity and Units NRC FORM 653 (MM-YYYY)

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

NRC FORM 653 (Continued)

(MM-YYYY) 10 CFR 32 U. S. NUCLEAR REGULATORY COMMISSION Intermediate Person(s) (if any)

Name of Intermediate Persons(s)

Name of Responsible Individual Title of Responsible Individual Business Telephone Number Name of Intermediate Persons(s)

Name of Responsible Individual Title of Responsible Individual Business Telephone Number General Licensee Information Name of General Licensee Name of Responsible Individual Business Telephone Number Title of Responsible Individual Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

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 Persons(s)

Name of Responsible Individual Title of Responsible Individual Business Telephone Number Name of Intermediate Persons(s)

Name of Responsible Individual Title of Responsible Individual Business Telephone Number General Licensee Information Name of General Licensee Name of Responsible Individual Business Telephone Number Title of Responsible Individual Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Transferred Date of Transfer Type of Device Model Number Serial Number Isotope Activity and Units NRC FORM 653 (MM-YYYY)

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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:

NRC FORM 653A (MM-YYYY) 10 CFR 32 U. S. NUCLEAR REGULATORY COMMISSION 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 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 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 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)

NRC FORM 653A (MM-YYYY)

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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:

NRC FORM 653A (Continued)

(MM-YYYY) 10 CFR 32 U. S. NUCLEAR REGULATORY COMMISSION 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 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 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 Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)

Information on Device(s) Received NRC FORM 653A (MM-YYYY)

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TRANSFERS OF INDUSTRIAL DEVICES REPORT (LABEL CHANGES)

For each device for which required label information has been changed, supply the following:

NRC FORM 653B (MM-YYYY) 10 CFR 32 U. S. NUCLEAR REGULATORY COMMISSION 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 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 NRC FORM 653B (MM-YYYY)

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TRANSFERS OF INDUSTRIAL DEVICES REPORT (LABEL CHANGES) (continued)

For each device for which required label information has been changed, supply the following:

NRC FORM 653B (Continued)

(MM-YYYY) 10 CFR 32 U. S. NUCLEAR REGULATORY COMMISSION 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 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 NRC FORM 653B (MM-YYYY)

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