Form 366 Licensee Event Report

NRC FORM 366

U.S. NUCLEAR REGULATORY COMMISSION

EXPIRES: MM/DD/YYYY

APPROVED BY OMB: NO. 3150-0104

(M-YYYY)

Estimated burden per response to comply with this mandatory collection
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information collection.

LICENSEE EVENT REPORT (LER)
(See reverse for required number of
digits/characters for each block)

2. DOCKET NUMBER

1. FACILITY NAME

3. PAGE

05000

1

OF

4. TITLE

5. EVENT DATE
MONTH

DAY

6. LER NUMBER

YEAR

YEAR

SEQUENTIAL
NUMBER

-

7. REPORT DATE
REV
NO.

MONTH

DAY

8. OTHER FACILITIES INVOLVED
FACILITY NAME

DOCKET NUMBER

FACILITY NAME

DOCKET NUMBER

YEAR

-

05000
05000

9. OPERATING MODE

11. THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR §: (Check all that apply)

10. POWER LEVEL

20.2201(b)
20.2201(d)
20.2203(a)(1)
20.2203(a)(2)(i)
20.2203(a)(2)(ii)
20.2203(a)(2)(iii)
20.2203(a)(2)(iv)
20.2203(a)(2)(v)
20.2203(a)(2)(vi)

20.2203(a)(3)(i)
20.2203(a)(3)(ii)
20.2203(a)(4)
50.36(c)(1)(i)(A)
50.36(c)(1)(ii)(A)
50.36(c)(2)
50.46(a)(3)(ii)
50.73(a)(2)(i)(A)
50.73(a)(2)(i)(B)

50.73(a)(2)(i)(C)
50.73(a)(2)(ii)(A)
50.73(a)(2)(ii)(B)
50.73(a)(2)(iii)
50.73(a)(2)(iv)(A)
50.73(a)(2)(v)(A)
50.73(a)(2)(v)(B)
50.73(a)(2)(v)(C)
50.73(a)(2)(v)(D)

50.73(a)(2)(vii)
50.73(a)(2)(viii)(A)
50.73(a)(2)(viii)(B)
50.73(a)(2)(ix)(A)
50.73(a)(2)(x)
73.71(a)(4)
73.71(a)(5)
OTHER
Specify in Abstract below
or in NRC Form 366A

12. LICENSEE CONTACT FOR THIS LER
FACILITY NAME

TELEPHONE NUMBER (Include Area Code)

13. COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT
CAUSE

SYSTEM

COMPONENT

MANUFACTURER

REPORTABLE
TO EPIX

CAUSE

14. SUPPLEMENTAL REPORT EXPECTED
YES (If yes, complete 15. EXPECTED SUBMISSION DATE)

NO

ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines)

NRC FORM 366 (M-YYYY)

SYSTEM

COMPONENT

15. EXPECTED
SUBMISSION
DATE

MANUFACTURER

MONTH

REPORTABLE
TO EPIX

DAY

YEAR

REQUIRED NUMBER OF DIGITS/CHARACTERS
FOR EACH BLOCK
BLOCK
NUMBER

NUMBER OF
DIGITS/CHARACTERS

TITLE

1

UP TO 46

FACILITY NAME

2

8 TOTAL
3 IN ADDITION TO 05000

DOCKET NUMBER

3

VARIES

PAGE NUMBER

4

UP TO 76

TITLE

5

8 TOTAL
2 FOR MONTH
2 FOR DAY
4 FOR YEAR

EVENT DATE

6

9 TOTAL
4 FOR YEAR
3 FOR SEQUENTIAL NUMBER
2 FOR REVISION NUMBER

LER NUMBER

7

8 TOTAL
2 FOR MONTH
2 FOR DAY
4 FOR YEAR

REPORT DATE

UP TO 18 -- FACILITY NAME
8

8 TOTAL -- DOCKET NUMBER
3 IN ADDITION TO 05000

OTHER FACILITIES INVOLVED

9

1

OPERATING MODE

10

3

POWER LEVEL

11

VARIES
CHECK ALL BOXES THAT APPLY

REQUIREMENTS OF 10 CFR

12

UP TO 50 FOR NAME
14 FOR TELEPHONE

LICENSEE CONTACT

13

CAUSE VARIES
2 FOR SYSTEM
4 FOR COMPONENT
4 FOR MANUFACTURER
EPIX VARIES

EACH COMPONENT FAILURE

14

1
CHECK BOX THAT APPLIES

SUPPLEMENTAL REPORT EXPECTED

15

8 TOTAL
2 FOR MONTH
2 FOR DAY
4 FOR YEAR

EXPECTED SUBMISSION DATE

16

1400

ABSTRACT