Form NRC Form 314 NRC Form 314 Certificate of Disposition Materials

CERTIFICATE OF DISPOSITION OF MATERIALS
PLEASE READ THESE INSTRUCTIONS BEFORE COMPLETING NRC FORM 314.
Subpart E of 10 CFR Part 20 establishes the radiological criteria for license terminations/decommissioning of
facilities licensed under 10 CFR Parts 30, 40, 50, 60, 61, 70, and 72, as well as other facilities subject to the
Commission's jurisdiction under the Atomic Energy Act of 1954, as amended, and the Energy Reorganization
Act of 1974, as amended.

INSTRUCTIONS
Section B, Item 2.
Licensees should describe the specific radioactive material transfer actions. If radioactive wastes were
generated in terminating this license, the licensee should describe the disposa l actions taken, including the
disposition of low-level radioactive waste, mixed waste, greater-than-Class-C waste, and sealed sources.
Section B, Item 2.a.
The information provided concerning the transfer of radioactive material to ano ther licensee should specify the
date of the transfer, the name of the licensee recipient, an individual contact name and telephone number for
the licensee recipient, and the recipient's NRC or Agreement State license numb er.
Section B, Item 2.b.
For disposal of radioactive materials, licensees should describe the specific d isposal method or procedure
(e.g., decay-in-storage). For those cases when radioactive materials are disposed of by a licensed disposal
site or by a waste contractor, the licensee should specify the name, address, and telephone number of the
licensed disposal site operator or waste contractor.
Section B, Item 2.c.
"Residual radioactivity," as defined in 10 CFR 20.1003, means radioactivity in ‘areas' (structures, materials,
soils, etc.) remaining as a result of activities (licensed and unlicensed) under the licensee's control from
sources used by the licensee, excluding background radiation. ALARA is defined in 10 CFR 20.1003.

FILE CERTIFICATES AS FOLLOWS:
IF YOU ARE LOCATED IN:

IF YOU ARE LOCATED IN:

CONNECTICUT, DELAWARE, DISTRICT OF COLUMBIA,
MAINE, MARYLAND, MASSACHUSETTS, NEW HAMPSHIRE,
NEW JERSEY, NEW YORK, PENNSYLVANIA, RHODE
ISLAND, OR VERMONT, SEND CERTIFICATES TO:

ILLINOIS, INDIANA, IOWA, MICHIGAN, MINNESOTA,
MISSOURI, OHIO, OR WISCONSIN, SEND CERTIFICATES
TO:

LICENSING ASSISTANT SECTION
NUCLEAR MATERIALS SAFETY BRANCH
U.S. NUCLEAR REGULATORY COMMISSION, REGION I
475 ALLENDALE ROAD
KING OF PRUSSIA, PA 19406-1415

ALABAMA, FLORIDA, GEORGIA, KENTUCKY, MISSISSIPPI,
NORTH CAROLINA, PUERTO RICO, SOUTH CAROLINA,
TENNESSEE, VIRGINIA, VIRGIN ISLANDS, OR WEST
VIRGINIA, SEND CERTIFICATES TO:
NUCLEAR MATERIALS SAFETY SECTION
U. S. NUCLEAR REGULATORY COMMISSION, REGION II
SAM NUNN ATLANTA FEDERAL CENTER
61 FORSYTH STREET, S.W., SUITE 23T85
ATLANTA, GEORGIA 30303-8931

MATERIALS LICENSING SECTION
U.S. NUCLEAR REGULATORY COMMISSION, REGION III
801 WARRENVILLE RD.
LISLE, IL 60532-4351

ALASKA, ARIZONA, ARKANSAS, CALIFORNIA,
COLORADO, HAWAII, IDAHO, KANSAS, LOUISIANA,
MONTANA, NEBRASKA, NEVADA, NEW MEXICO, NORTH
DAKOTA, OKLAHOMA, OREGON, PACIFIC TRUST
TERRITORIES, SOUTH DAKOTA, TEXAS, UTAH,
WASHINGTON, OR WYOMING, SEND CERTIFICATES TO:
MATERIAL RADIATION PROTECTION SECTION
U. S. NUCLEAR REGULATORY COMMISSION, REGION IV
611 RYAN PLAZA DRIVE, SUITE 400
ARLINGTON, TX 76011-8064

NRC FORM 314

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)
10 CFR 30.36(j)(1); 40.42(j)(1);
70.38(j)(1); and 72.54(j)(1)

CERTIFICATE OF DISPOSITION OF MATERIALS

LICENSEE NAME AND ADDRESS

APPROVED BY OMB: NO. 3150-0028

EXPIRES: MM/DD/YYYY

Estimated burden per response to comply with this mandatory collection request: 30 minutes.
This submittal is used by NRC as part of the basis for its determination that the facility is released
for unrestricted use. Send comments regarding burden estimate to the Records and FOIA/Privacy
Services Branch (T-5 F52), 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, (3150-0028), 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.
LICENSE NUMBER

DOCKET NUMBER

LICENSE EXPIRATION DATE

A. LICENSE STATUS (Check the appropriate box)
This license has not yet expired; please terminate it.

This license has expired.

B. DISPOSAL OF RADIOACTIVE MATERIAL
(Check the appropriate boxes and complete as necessary. If additional space is needed, provide attachments)

The licensee, or any individual executing this certificate on behalf of the lic ensee, certifies that:
1. No radioactive materials have ever been procured or possessed by the licensee u nder this license.
2. All activities authorized by this license have ceased, and all radioactive mate rials procured and/or possessed by the licensee
under this license number cited above have been disposed of in the following ma nner.
a. Transfer of radioactive materials to the licensee listed below:
b. Disposal of radioactive materials:
1. Directly by the licensee:

2. By licensed disposal site:

3. By waste contractor:

c. All radioactive materials have been removed such that any remaining residua l radioactivity is within the limits of 10 CFR
Part 20, Subpart E, and is ALARA.
C. SURVEYS PERFORMED AND REPORTED
1. A radiation survey was conducted by the licensee. The survey confirms:
a. the absence of licensed radioactive materials
b. that any remaining residual radioactivity is within the limits of 10 CFR 20 , Subpart E, and is ALARA.
2. A copy of the radiation survey results:
a. is attached; or

b. is not attached (Provide explanation); or

c. was forwarded to NRC on:
Date

3. A radiation survey is not required as only sealed sources were ever possess ed under this license, and
a. The results of the latest leak test are attached; and/or

b. No leaking sources have ever been identified.

The person to be contacted regarding the information provided on this form:
NAME

TITLE

TELEPHONE (Include Area Code)

E-MAIL ADDRESS

Mail all future correspondence regarding this license to:

C. CERTIFYING OFFICIAL
I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT
PRINTED NAME AND TITLE

SIGNATURE

DATE

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 RESPECT. 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 314 (MM-YYYY)

PRINTED ON RECYCLED PAPER