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pdfUNITED STATES
NUCLEAR REGULATORY COMMISSION
WASHINGTON, D.C. 20555-0001
November 30, 2009
TO:
All New, Current, or Previous Users of Devices Subject to General License Registration
PURPOSE:
To Track and Account for Certain Generally Licensed Devices for Public Protection
SUBJECT:
ANNUAL REGISTRATION OF GENERALLY LICENSED DEVICES
The U.S. Nuclear Regulatory Commission (NRC) requires annual registration of certain devices
that are 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
the radioactive material and activity listed in Table 1. You are receiving this notice because
NRC records indicate that you have one or more such devices. 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.
Mail the registration fee (check or money order payable to the USNRC) or credit card
authorization and a copy of completed SECTION 1, Page 1 of 2, in the small enclosed
envelope to:
U.S. Bank
Accounts Receivable Team - GL Registration
U.S. Nuclear Regulatory Commission
P. O. Box 979051
St Louis, MO 63197-9000
IMPORTANT
YOUR PAYMENT WILL NOT BE CREDITED TO YOUR ACCOUNT UNLESS YOU PUT
YOUR GENERAL LICENSE NUMBER (GL-XXXXX-X) ON THE CHECK OR OTHER
PAYMENT METHOD. THE GL NUMBER CAN BE FOUND ON SECTION 1, PAGE 1 of 2, IN
THE UPPER LEFT CORNER.
Note that under 10 CFR 31.5(c)(11), the attached General Licensee Registration Package
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 THE PACKAGE.
Mail the completed package in the large enclosed envelope to:
U.S. Nuclear Regulatory Commission
ATTN: Accounts Receivable Team
OCFO, Mail Stop T-9 E10
11555 Rockville Pike
Rockville, MD 20852-2738
Registration Fee: Commission regulations (10 CFR 170.31, Category 3Q) require that you
submit a registration fee with each registration on an annual basis. The registration fee is
subject to change yearly, and you are required to submit the fee that is in effect as of the date
of this letter. If you wish to pay by credit card, you need to complete NRC Form 629,
"Authorization for Payment by Credit Card." You can obtain NRC Form 629 by accessing the
NRC Public Website at http://www.nrc.gov/reading-rm/doc-collections/forms/nrc629.pdf. If you
are unable to access this information on our Website, or if you have any questions about the
fee or payment options, call 301-415-7554.
The REGISTRATION FEE is $310.00
NRC amended 10 CFR Parts 170.11 and 170.31 to provide that 10 CFR Part 170 fees be assessed to Federal agencies, where
applicable, in accordance with the Energy Policy Act of 2005. Therefore, those Federal facilities required to register certain
generally licensed devices in their possession will be required to pay the annual registration fee.
Enclosures:
1. NRC Form 664, "General Licensee Registration and Instructions"
2. Small envelope
3. Large envelope
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
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
Strontium-90
SR90
Cesium-137
CS137
Cobalt-60
CO60
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. Before starting copy this
section as needed for your additional devices. 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 3. Unit 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
gram
G
kilogram
KG
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 LARGE ENVELOPE WITH PROPER POSTAGE.
-
GL -
SECTION 1
PAGE 1 of 2
Date November 30, 2009
NRC FORM 664
(3-2007)
10 CFR 31.5
U.S. NUCLEAR REGULATORY COMMISSION
GENERAL LICENSEE REGISTRATION
APPROVED BY OMB: NO. 3150-0198
EXPIRES: 03/31/2010
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 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, (3150-0198), 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
SECTION 1 - GENERAL LICENSEE INFORMATION
-
GL -
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
>
>
GL -
-
SECTION 1
PAGE 2 of 2
Date November 30, 2009
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.
Department:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
>
-
>
GL -
-
SECTION 2
Date November 30, 2009
SECTION 2 - DEVICES SUBJECT TO REGISTRATION
PAGE 1 OF
Our records indicate that you have these devices. Please update the information as necessary.
(Internal Control Number)
NRC Device Key
Distributor/Distributed By:
Distributor License Number:
Manufacturer Name:
Device Model (Not Source Model):
Device Serial Number:
Not in possession of device (Also complete Section 4)
Transfer Date: MM/DD/YYYY
MM
DD
YYYY
Isotope (e.g., AM241)
Activity (e.g., 100)
Unit (e.g., mCi)
1.
2.
3.
4.
5.
6.
>
>
GL -
-
SECTION 2
Date November 30, 2009
SECTION 2 - DEVICES SUBJECT TO REGISTRATION
PAGE
OF
Our records indicate that you have these devices. Please update the information as necessary.
(Internal Control Number)
NRC Device Key
Distributor/Distributed By:
Distributor License Number:
Manufacturer Name:
Device Model (Not Source Model):
Device Serial Number:
Not in possession of device (Also complete Section 4)
Transfer Date: MM/DD/YYYY
MM
DD
YYYY
Isotope (e.g., AM241)
Activity (e.g., 100)
Unit (e.g., mCi)
1.
2.
3.
4.
5.
6.
>
>
GL -
-
SECTION 3
Date November 30, 2009
PAGE 1 OF
SECTION 3 - ADDITIONAL DEVICES SUBJECT TO REGISTRATION
Provide information about other devices you have that are subject to registration. Do not report specifically
licensed devices.
Manufacturer Name
Initial Transferor Name
Initial Transferor License Number (if known)
Device Model Number (Not Source Model)
Device Serial Number
How acquired and date
(e.g., from a distributor/
manufacturer, other
licensee, other source)?
Manufacturer/Initial Transferor listed above
Other General License
Other Source
Date
Transferred:
MM
DD
Isotope (e.g., AM241)
YYYY
Activity (e.g., 100)
Unit (e.g., mCi)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
>
>
GL -
SECTION 4
-
Date November 30, 2009
SECTION 4 - NOT IN POSSESSION OF DEVICE
PAGE 1 OF
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
Whereabouts Unknown
(Complete Part 1 only)
Transferred to another general licensee
(Complete Parts 2 and 3)
Never Possessed the Device
(Complete Part 1 only)
Transferred to a Specific Licensee (not the manufacturer)
(Complete Part 2)
Returned to Manufacturer
(Complete Part 1 only)
Part 2
License Number of Recipient (if transferred to a specific licensee)
Company Name:
Department:
Address Line 1:
Address Line 2:
City:
State:
Part 3
Zip Code:
-
Enter the name of the individual responsible for this device.
Last Name:
First Name:
Middle Initial:
Telephone Number:
Extension
-
-
Title
>
>
GL -
SECTION 5
PAGE 1 of 1
-
Date November 30, 2009
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.gov/reading-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.
>
>
GL -
SECTION 6
PAGE 1 OF
-
Date November 30, 2009
NRC Device Key:
SECTION 6 - DEVICES NOT SUBJECT TO REGISTRATION
Manufacturer License No.:
Manufacturer Name:
Model Number:
Serial No.:
Transfer Date:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
NRC Device Key:
Manufacturer License No.:
Manufacturer Name:
Model Number:
Serial No.:
Transfer Date:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
NRC Device Key:
Manufacturer License No.:
Manufacturer Name:
Model Number:
Serial No.:
Transfer Date:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
>
>
GL -
SECTION 6
PAGE
OF
-
Date November 30, 2009
NRC Device Key:
SECTION 6 - DEVICES NOT SUBJECT TO REGISTRATION
Manufacturer License No.:
Manufacturer Name:
Model Number:
Serial No.:
Transfer Date:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
NRC Device Key:
Manufacturer License No.:
Manufacturer Name:
Model Number:
Serial No.:
Transfer Date:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
NRC Device Key:
Manufacturer License No.:
Manufacturer Name:
Model Number:
Serial No.:
Transfer Date:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
Isotope:
Activity:
Unit:
>
>
| File Type | application/pdf |
| File Title | o:\informs\fixforms\nrc664_q.wpf |
| Author | cxc7 |
| File Modified | 2010-02-19 |
| File Created | 2007-04-17 |