Form NRC Form 664 NRC Form 664 General Licensee Registration

UNITED STATES

NUCLEAR REGULATORY COMMISSION
WASHINGTON, D.C. 20555-0001

TO:

All Organizations Who Have Devices Containing Radioactive Material

SUBJECT:

REGISTRATION OF GENERALLY LICENSED DEVICES

The U.S. Nuclear Regulatory Commission (NRC) is starting a registration program for certain
devices possessed under the general license issued in Section 31.5 of Title 10 U.S. Code of
Federal Regulations (10 CFR 31.5). Devices subject to registration include those containing at
least one of the following radionuclides in an amount equal to or greater than the indicated
quantity at the time of manufacture:
Table 1. Criteria for Registration
Radionuclide
Strontium-90
Cobalt-60, Curium-244, Americium-241, Californium-252,
Plutonium-238, and Plutonium-239

Activity greater than or equal to:
3.7 megabecquerel (0.1 millicurie)
37 megabecquerel (1 millicurie)

Cesium-137

370 megabecquerel (10 millicurie)

You are receiving this notice because NRC records indicate that you have one or more such
devices. Information about this program was sent to you and published in the Federal Register
on July 26, 1999, August 4, 1999, and December 18, 2000 (64 FR 40295, 64 FR 422 69, and 65
FR 79162).
Note that under 10 CFR 31.5(c)(11), the attached General Licensee Registration Form
must be completed, signed, and returned to the NRC within 30 days from the date of this
letter.
READ ALL OF THE INSTRUCTIONS PRIOR TO COMPLETING THIS FORM. Mail the
completed form to:
Director of Nuclear Material Safety and Safeguards
ATTN: GLTS
U S Nuclear Regulatory Commission
Washington, DC 20555-0001
NO REGISTRATION FEE IS REQUIRED AT THIS TIME. However, on your next annual
registration, you will be billed for the registration fee. Based on current budgeted costs and the
estimated number of registrants, the fee is expected to be $450.
Additional information about the general license registration program is available on the Internet
at http://www.nrc.gov/materials/miau/miau-reg-initiatives/gen-license.html. Questions may be
directed to the address above, or by telephone to 301-415-7138.

Attachment: NRC Form 664, "General Licensee Registration"

INSTRUCTIONS FOR COMPLETING NRC FORM 664
"GENERAL LICENSEE REGISTRATION"
Review all six sections of this registration form. If any information is incorrect or missing, make corrections in the
applicable boxes. If you have more devices than space provided in the form, copy the form before starting, as
needed. Use black ink and print using CAPITAL LETTERS. Start information in the first box provided. If the information
contains a number which contains a dash (-) or a decimal point (.), include the dash or decimal point as an individual
character. Use the "Ø" character to represent the number 0 (zero).
Verify information about the devices by reviewing the label on the outside of the device. For safety reasons, DO NOT
TRY TO TAKE APART any device to verify this information. If you are uncertain how to identify the device's label,
contact the device's manufacturer or an authorized service agent for this information. Also contact the manufacturer for
any additional information about NRC requirements. You may also review 10 CFR 31.5 and other applicable regulations
on the NRC web site at http://www.nrc.gov/reading-rm/doc-collections/cfr/, or review specific information about the
general licensee project at http://www.nrc.gov/materials/miau/miau-reg-initiatives/gen-license.html
Note to specific licensees: If you believe the device(s) listed on the registration form are possessed under your specific
license, then verify the device label does not state the device is subject to a general license. If the labels indicate the
device is subject to a general license, then complete the registraion form as instructed below. If not, complete the
registration form as instructed below; however, in Section 2, follow the instructions for "not in possession of device" and
complete one Section 4 page per device transferred to your specific license.
Section 1 - General Licensee Information. Provide the requested information about you, the general licensee.
On Page 1, provide the street address/location where your device(s) are used. For portable devices, provide the storage
location. P. O. Box addresses are not allowed.
Do not write in the box marked For NRC Use Only.
On Page 2, provide the name, telephone number, and title of the individual responsible for your device(s), and a mailing
address where correspondence about your device(s) can be sent. The mailing address should be specific tothe physical
location where the devices are used and/or stored (P.O. boxes may be used if this is the only available mailing address).
The individual indicated in this section as responsible for your device(s) must also verify and sign the form in Section 5.
Section 2 - Devices Subject to Registration. This section lists each device subject to registration and in your
possession, according to NRC records. Devices subject to registration include those containing at least one of the
radionuclides listed in Table 1, with the activity indicated, at the time of manufacture.
Table 1. Criteria for Registration
Radionuclide

Activity greater than or equal to:

Strontium-90
Cobalt-60, Curium-244, Americium-241, Californium-252,
Plutonium-238, and Plutonium-239

3.7 megabecquerel (0.1 millicurie)
37 megabecquerel (1 millicurie)

Cesium-137

370 megabecquerel (10 millicurie)

Use the codes from Table 2 when correcting isotope information for devices in this section. If you do not possess a
device on this list, blacken the "not in possession of device" circle, and provide the relevant information in Section 4. Note
that each device is assigned a unique six-digit number called the NRC Device Key.
Table 2. Isotope Codes for Sections 2 and 3
Radionuclide

Code for form

Radionuclide

Code for form

Americium-241

AM241

Curium-244

CM244

Californium-252

CF252

Plutonium-238

PU238

Cesium-137

CS137

Plutonium-239

PU239

Cobalt-60

CO60

Strontium-90

SR90

Section 3 - Additional Devices. If you have other generally licensed devices (not listed in Section 2) that meet the
conditions for registration listed in Table 1, provide information about each additional device. Also indicate how you
acquired each device by blackening the proper circle.
When entering isotope and unit information for your device(s), use the codes listed in Table 2 of Section 2 for isotope
information, and use the codes from Table 3 for unit information:
Table 2. Isotope Codes for Section 3
Unit

Code for form

Unit

Code for form

picocurie

PCI

becquerel

BQ

nanocurie

NCI

kilobecurel

KBQ

microcurie

UCI

megabecurel

MBQ

millicurie

MCI

gigabecurel

GBQ

curie

CI

terabecurel

TBQ

pound

LB

microgram

UG

milligram

MG

kilogram

KG

gram

G

Section 4 - Not in Possession of Device. Use this section to report any devices that are listed in Sections 2 or 6, but
that you no longer possess. Before starting, copy this section as needed for additional devices that are not in your
possession. Enter the NRC Device Key, as listed in Section 2 or 6. Blacken the circle (choose only one) that best
describes the disposition of the device and complete the rest of the section as appropriate.
Section 5 - Certification and Signature. The responsible individual must certify, sign, and date Section 5.
Section 6 - Devices Not Subject to Registration. This list contains information about devices that NRC records
indicate are in your possession, but are not subject to registration. If you no longer have one or more of the listed
devices, you are required to make a transfer report to NRC in accordance with 10 CFR 31.5(c)(8) or (9), as applicable.
You may use Section 4 for this purpose. This section does not list any static eliminators containing polonium-210
(Po-210), or luminous exit signs containing tritium (H-3). These devices are not subject to registration, and are not
included in this section in an effort to reduce the length of this form.
RETURN THE COMPLETED FORM IN THE ENCLOSED ENVELOPE WITH PROPER POSTAGE.

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SECTION 1
PAGE 1 of 2

Date
NRC FORM 664
(2 -2004)
10 CFR 31.5

U.S. NUCLEAR REGULATORY COMMISSION

GENERAL LICENSEE REGISTRATION
APPROVED BY OMB: NO. 3150-0198

EXPIRES: 02/28/2007

Estimated burden per response to comply with this mandatory collection request: 20 minutes. NRC will use this information to track general licensees and their devices to
ensure a higher level of device accountability. Send comments regarding burden estimate to the Records Management Branch (T-6 E6), U.S. Nuclear Regulatory
Commission, Washington, DC 20555-0001, or by internet e-mail to [email protected], and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202,
(3150-0198), 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.

Complete all six sections of this registration form. If any of the preprinted information is incorrect, provide the
changes in the applicable boxes. USE CAPITAL LETTERS.
General License
Registration Number
GL -

SECTION 1 - GENERAL LICENSEE INFORMATION
-

Enter the company name and street address for the physical location of use for the device(s). For portable
devices, specify the primary storage location. Do not use P. O. Boxes.
Company Name:

Department:

Address Line 1:

Address Line 2:

City:

State:

-

Zip Code:

For NRC Use Only
(Do not write here)

Category:
Packet Receipt Date (MMDDYYYY)

Accession Number

>

>

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SECTION 1
PAGE 2 of 2

Date

SECTION 1 - GENERAL LICENSEE INFORMATION (Continued)
Enter the name, telephone number, and title of the person who is the responsible individual for the device(s).
Last Name

First Name:

Middle Initial:

Telephone:

Extension:

-

-

Title:

Enter the mailing address where correspondence regarding your device(s) should be sent.
This address should be specific to the use or storage location of your device(s).
Department:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

>

-

>

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SECTION 2
PAGE 1 of 1

Date

SECTION 2 - DEVICES SUBJECT TO REGISTRATION
Our records indicate that you have these devices. Please update the information as necessary.
NRC Device Key

Manufacturer Name:

Manufacturer License Number:

Device Model:

Device Serial Number:

Isotope:

Receipt Date: MM/DD/YYYY (if known)
Not in possession of device
(Also complete Section 4)

MM

DD

YYYY

NRC Device Key

Manufacturer Name:

Manufacturer License Number:

Device Model:

Device Serial Number:

Isotope:

Receipt Date: MM/DD/YYYY (if known)
Not in possession of device
(Also complete Section 4)

MM

>

DD

YYYY

>

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SECTION 3
PAGE 1 of 1

Date

SECTION 3 - ADDITIONAL DEVICES SUBJECT TO REGISTRATION
Provide information about other devices you have that are subject to registration.
Manufacturer/Initial Transferor Name

Manufacturer/Initial Transferor License Number (if known)

Device Model Number

Device Serial Number

How acquired and date
(e.g., from a distributor/
manufacturer, other
licensee, other source)?

Manufacturer/Initial Transferor listed above
Date
Other General License
Received:
Other Source

MM

DD

YYYY

Isotope

Activity

Unit

Isotope

Activity

Unit

Isotope

Activity

Unit

Isotope

Activity

Unit

Isotope

Activity

Unit

Isotope

Activity

Unit

Isotope

Activity

Unit

Isotope

Activity

Unit

Isotope

Activity

Unit

Isotope

Activity

Unit

>

>

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SECTION 4
PAGE 1 of 1

-

Date

SECTION 4 - NOT IN POSSESSION OF DEVICE

Provide information about devices listed in Section 2 or 6, but no longer in your possession.
Transfer Date

Part 1
NRC Device Key
(from Section 2 or 6)

MM

Location of the Device:

DD

YYYY

Whearabouts Unknown
(Complete Part 1 only)

Transferred to another general licensee:
(Complete Parts 2 and 3)

Never Possessed the Device
(Complete Part 1 only)

Disposed of/Transferred to a Specific Licensee
(Complete Part 2)

Returned to Manufacturer
(Complete Part 1 only)
Part 2
License Number of Recipient (if applicable)

Company Name:

Department:

Address Line 1:

Address Line 2:

City:

Zip Code:

State:
Part 3

-

Enter the name of the individual responsible for this device.

Last Name:

First Name:

Middle Initial:

Telephone Number:

Extension

-

-

Title

>

>

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SECTION 5
PAGE 1 of 1

-

Date

SECTION 5 - CERTIFICATION

I hereby certify that:
A.

All information contained in this registration is true and complete to the best of my knowledge and belief.

B.

A physical inventory of the devices subject to registration has been completed, and the device information on this
form has been checked against the device labeling.

C.

I am aware of the requirements of the general license, provided in 10 CFR 31.5.
(Copies of applicable regulations may be viewed at the NRC web site at www.nrc.govreading-rm/doc-collections/cfr/

SIGNATURE - RESPONSIBLE INDIVIDUAL (Listed in Section 1)

DATE

WARNING: FALSE STATEMENTS MAY BE SUBJECT TO CIVIL AND/OR CRIMINAL PENALTIES. NRC
REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRC BE COMPLETE AND ACCURATE IN ALL
MATERIAL ASPECTS. 18 U.S.C. SECTION 1001 MAKES IT A CRIMINAL OFFENSE TO MAKE A
WILLFULLY WRONG STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE
UNITED STATES AS TO ANY MATTER IN ITS JURISDICTION.

>

>

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SECTION 6
PAGE 1 of 1

-

Date

SECTION 6 - DEVICES NOT SUBJECT TO REGISTRATION

NRC Device Key:

Manufacturer License No.:

Manufacturer Name:
Model Number:

Serial No.:

Transfer Date:

Isotope:

Activity:

Unit:

NRC Device Key:

Manufacturer License No.:

Manufacturer Name:
Model Number:

Serial No.:

Transfer Date:

Isotope:

Activity:

Unit:

NRC Device Key:

Manufacturer License No.:

Manufacturer Name:
Model Number:

Serial No.:

Transfer Date:

Isotope:

Activity:

Unit:

NRC Device Key:

Manufacturer License No.:

Manufacturer Name:
Model Number:

Serial No.:

Transfer Date:

Isotope:

Activity:

Unit:

NRC Device Key:

Manufacturer License No.:

Manufacturer Name:
Model Number:

Serial No.:

Transfer Date:

Isotope:

Activity:

Unit:

NRC Device Key:

Manufacturer License No.:

Manufacturer Name:
Model Number:

Serial No.:

Transfer Date:

Isotope:

Activity:

Unit:

>

>