NRC Form 540

APPROVED BY OMB: NO. 3150-0164
EXPIRES: MM/DD/YYYY

NRC FORM 540

Estimated burden per response to comply with this information collection reques t: 45 minutes. This uniform manifest is required by NRC to meet reporting requ irements of Federal and State Agencies for the safe transportation and disposal of low-level waste. Send comments regarding burden
estimate to the Records and FOIA/Privacy Service 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 Regulat ory Affairs, NEOB-10202, (3150-0164), Office of
Management and Budget, Washington, DC 20503. If a means used to impose an inf ormation collection does not display a currently vaild OMB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.

U.S. NUCLEAR REGULATORY COMMISSION

SHIPPER I.D. NUMBER

5. SHIPPER - NAME AND FACILITY

(MM-YYYY)

UNIFORM LOW-LEVEL RADIOACTIVE
WASTE MANIFEST
USER PERMIT NUMBER

SHIPPING PAPER

SHIPMENT NUMBER

PAGE 1 OF

PAGE(S)

NRC FORM 541 AND 541A

PAGE(S)

COLLECTOR

NRC FORM 542 AND 542A

PAGE(S)

PROCESSOR

ADDITIONAL INFORMATION

PAGE(S)

GENERATOR TYPE
(Specify)

1. EMERGENCY TELEPHONE NUMBER (Include Area Code)

7. NRC FORM 540 AND 540A

CONTACT

TELEPHONE NUMBER
(Include Area Code)

6. CARRIER - Name and Address

EPA I.D. NUMBER

9. CONSIGNEE - Name and Facility Address

8. MANIFEST NUMBER
(Use this number on all continuation pages)

CONTACT

TELEPHONE NUMBER (Include Area Code)

ORGANIZATION

2. IS THIS AN "EXCLUSIVE USE" SHIPMENT?
YES

SHIPPING DATE

=====>

NO
4. DOES EPA REGULATED
WASTE REQUIRING A
MANIFEST ACCOMPANY
THIS SHIPMENT?
If "Yes," provide Manifest Number

3. TOTAL NUMBER OF
PACKAGES IDENTIFIED
ON THIS MANIFEST

YES

EPA MANIFEST NUMBER

CONTACT

TELEPHONE NUMBER
(Include Area Code)

SIGNATURE - Authorized carrier acknowledging waste receipt

DATE

NO

11. U.S. DEPARTMENT OF TRANSPORTATION DESCRIPTION
(Including proper shipping name, hazard class, UN ID number,
and any additional inforation)

12.
DOT LABEL
"RADIOACTIVE"

13.
TRANSPORT
INDEX

14.
PHYSICAL AND
CHEMICAL FORM

FOR CONSIGNEE USE ONLY

NRC FORM 540 (MM-YYYY)

PRINTED ON RECYCLED PAPER

15.
INDIVIDUAL
RADIONUCLIDES

SIGNATURE - Authorized consignee acknowledging waste receipt

DATE

10. CERTIFICATION
This is to certify that the herein-named materials are properly classified, des cribed, packaged, marked, and labeled and are
in proper condition for transportation according to the applicable regulations of the Department of Transprtation This also
certifies that the materials are classified, packaged, marked, and labeled and are in proper condition for transportation and
disposal as described in accordance with the applicable requirements of 10 CFR Parts 20 and 61, or equivalent state
regulations.
DATE
AUTHORIZED SIGNATURE
TITLE

16.
TOTAL PACKAGE
ACTIVITY IN SI UNITS

17.
LSA/SCO
CLASS

18. TOTAL WEIGHT
OR VOLUME
(Use appropriate units)

19. IDENTIFICATION
NUMBER OF
PACKAGE