NRC Form 748 National Source Tracking Transaction Report, Long Form

Submit by Email
U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0202

NRC FORM 748
(6-2010)
10 CFR 20.2207

NATIONAL SOURCE TRACKING TRANSACTION REPORT

EXPIRES: 12/31/2012

Estimated burden per response to comply with this mandatory information collection request: 9.5 minutes. NRC requires this information to
populate the National Source Tracking System for certain sealed sources. Send comments regarding burden estimate to the Records and
FOIA/Privacy Services Branch (T-5 F53), 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, (3150-0202), Office o f
Management and Budget, Washington, DC 20503. If a means used to impose an information 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.

1. LICENSEE INFORMATION
A. LICENSEE NAME

2. TRANSACTION DATE

C. LICENSEE STREET ADDRESS

B. LICENSE NO.

3B. TRANSACTION TYPE (Check all that apply)

3A. TRANSACTION INFORMATION

(Only transactions completed on the same
date may be reported together on this form)

NEW

CORRECTION

IF CORRECTION, PREVIOUS TRANSACTION DATE:

E. STATE F. ZIP CODE

D. CITY

REPORT SOURCE
INVENTORY
NEW SOURCE
MANUFACTURED

TRANSFER

IMPORT

RECEIPT

DISPOSAL

EXPORT

DISASSEMBLE

4. PREPARER INFORMATION
A. NAME OF PREPARER

B.DATE PREPARED

C. PREPARER PHONE

D. PREPARER E-MAIL (REQUIRED FOR CONFIRMATION)

5. SOURCE INVENTORY DATA (Note: Only use this section for reporting initial source inventory)
A1. SOURCE MAKE

B1. SOURCE MODEL

H1. SOURCE LOCATION ADDRESS

I1. CITY

A2. SOURCE MAKE

B2. SOURCE MODEL

H2. SOURCE LOCATION ADDRESS

I2. CITY

C1. SOURCE SERIAL
NUMBER

C2. SOURCE SERIAL
NUMBER

D1. ISOTOPE E1. ACTIVITY AND UNIT

F1. ACTIVITY DATE

J1. STATE

L1. SAME AS STREET
ADDRESS

K1. ZIP CODE

D2. ISOTOPE E2. ACTIVITY AND UNIT

F2. ACTIVITY DATE

J2. STATE

L2. SAME AS STREET
ADDRESS

K2. ZIP CODE

G1. COMMENTS

G2. COMMENTS

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 RESPECTS. 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 748 (6-2010)

U.S. NUCLEAR REGULATORY COMMISSION LICENSEE NAME

NRC FORM 748
(6-2010)
10 CFR 20.2207

LICENSE NO.

NATIONAL SOURCE TRACKING
TRANSACTION REPORT (continued)
5. SOURCE INVENTORY DATA (continued)

A3. SOURCE MAKE

B3. SOURCE MODEL

H3. SOURCE LOCATION ADDRESS

I3. CITY

A4. SOURCE MAKE

B4. SOURCE MODEL

H4. SOURCE LOCATION ADDRESS

I4. CITY

A5. SOURCE MAKE

B5. SOURCE MODEL

H5. SOURCE LOCATION ADDRESS

I5. CITY

A6. SOURCE MAKE

B6. SOURCE MODEL

H6. SOURCE LOCATION ADDRESS

I6. CITY

C3. SOURCE SERIAL
NUMBER

C4. SOURCE SERIAL
NUMBER

D3. ISOTOPE E3. ACTIVITY AND UNIT

F3. ACTIVITY DATE

J3. STATE

L3. SAME AS STREET
ADDRESS

D4. ISOTOPE E4. ACTIVITY AND UNIT

J4. STATE

C5. SOURCE SERIAL
NUMBER

C6. SOURCE SERIAL
NUMBER

K3. ZIP CODE

K4. ZIP CODE

F4. ACTIVITY DATE

F5. ACTIVITY DATE

J5. STATE

L5. SAME AS STREET
ADDRESS

D6. ISOTOPE E6. ACTIVITY AND UNIT

F6. ACTIVITY DATE

J6. STATE

L6. SAME AS STREET
ADDRESS

K6. ZIP CODE

G4. COMMENTS

L4. SAME AS STREET
ADDRESS

D5. ISOTOPE E5. ACTIVITY AND UNIT

K5. ZIP CODE

G3. COMMENTS

G5. COMMENTS

G6. COMMENTS

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 RESPECTS. 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 748 (6-2010)

NRC FORM 748
(6-2010)
10 CFR 20.2207

U.S. NUCLEAR REGULATORY COMMISSION

LICENSEE NAME

LICENSE NO.

NATIONAL SOURCE TRACKING
TRANSACTION REPORT (continued)
6. SOURCE TRANSFER DATA

A1. RECEIVING LICENSEE NAME

B1. RECEIVING LICENSEE
LICENSE NO.

C1. RECEIVING LICENSEE SHIPPING ADDRESS

D1. CITY

G1. SOURCE MAKE

H1. SOURCE MODEL

I1. SOURCE SERIAL J1. ISOTOPE
NUMBER

L1. ACTIVITY
DATE

O1. ESTIMATED ARRIVAL DATE

P1. COMMENTS

A2. RECEIVING LICENSEE NAME

B2. RECEIVING LICENSEE
LICENSE NO.

C2. RECEIVING LICENSEE SHIPPING ADDRESS

D2. CITY

G2. SOURCE MAKE

H2. SOURCE MODEL

I2. SOURCE SERIAL J2. ISOTOPE
NUMBER

L2. ACTIVITY
DATE

O2. ESTIMATED ARRIVAL DATE

P2. COMMENTS

K1. ACTIVITY AND
UNIT

K2. ACTIVITY AND
UNIT

E1. STATE

F1. ZIP CODE

M1. WASTE MANIFEST NO. N1. CONTAINER ID
(For waste shipments only) (For waste shipments only

E2. STATE F2. ZIP CODE

M2. WASTE MANIFEST NO. N2. CONTAINER ID
(For waste shipments only) (For waste shipments only

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 RESPECTS. 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 748 (6-2010)

NRC FORM 748
(6-2010)
10 CFR 20.2207

U.S. NUCLEAR REGULATORY COMMISSION

LICENSE NO.

LICENSEE NAME

NATIONAL SOURCE TRACKING
TRANSACTION REPORT (continued)
6. SOURCE TRANSFER DATA (continued)

A3. RECEIVING LICENSEE NAME

B3. RECEIVING LICENSEE
LICENSE NO.

C3. RECEIVING LICENSEE SHIPPING ADDRESS

D3. CITY

G3. SOURCE MAKE

H3. SOURCE MODEL

I3. SOURCE SERIAL
NUMBER

L3. ACTIVITY
DATE

O3. ESTIMATED ARRIVAL DATE

P3. COMMENTS

A4. RECEIVING LICENSEE NAME

B4. RECEIVING LICENSEE
LICENSE NO.

C4. RECEIVING LICENSEE SHIPPING ADDRESS

G4. SOURCE MAKE

H4. SOURCE MODEL

I4. SOURCE SERIAL
NUMBER

O4. ESTIMATED ARRIVAL DATE

P4. COMMENTS

J3. ISOTOPE

J4. ISOTOPE

K3. ACTIVITY AND
UNIT

D4. CITY

E3. STATE

F3. ZIP CODE

M3. WASTE MANIFEST NO. N3. CONTAINER ID
(For waste shipments only) (For waste shipments only)

E4. STATE

F4. ZIP CODE

K4 ACTIVITY AND UNIT L4. ACTIVITY M4. WASTE MANIFEST NO. N4. CONTAINER ID
DATE
(For waste shipments only) (For waste shipments only)

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 RESPECTS. 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 748 (6-2010)

NRC FORM 748
(6-2010)
10 CFR 20.2207

U.S. NUCLEAR REGULATORY COMMISSION

LICENSEE NAME

LICENSE NO.

NATIONAL SOURCE TRACKING
TRANSACTION REPORT (continued)
7. SOURCE RECEIPT DATA

A1. SENDING LICENSEE NAME

B1. SENDING LICENSEE
LICENSE NO.

C1. SENDING LICENSEE SHIPPING ADDRESS

G1. SOURCE MAKE

H1. SOURCE MODEL

I1. SOURCE SERIAL
NUMBER

O1. SOURCE LOCATION ADDRESS

P1. CITY

K1. ACTIVITY AND UNIT L1. ACTIVITY
DATE

Q1. STATE

R1. ZIP CODE

B2. SENDING LICENSEE
LICENSE NO.

C2. SENDING LICENSEE SHIPPING ADDRESS

G2. SOURCE MAKE

H2. SOURCE MODEL

I2. SOURCE SERIAL
NUMBER

P2. CITY

E1. STATE

J1. ISOTOPE

A2. SENDING LICENSEE NAME

O2. SOURCE LOCATION ADDRESS

D1. CITY

F1. ZIP CODE

M1. WASTE MANIFEST NO. N1. CONTAINER ID
(For waste shipments only) (For waste shipments only)

S1. SAME AS STREET
ADDRESS

T1. COMMENTS

E2. STATE F2. ZIP CODE

D2. CITY

J2. ISOTOPE

K2. ACTIVITY AND
UNIT

L2. ACTIVITY
DATE

M2. WASTE MANIFEST NO, N2. CONTAINER ID
(For waste shipments only) (For waste shipments only)

Q2. STATE

R2. ZIP CODE

S2. SAME AS STREET
ADDRESS

T2. COMMENTS

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 RESPECTS. 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 748 (6-2010)

NRC FORM 748
(6-2010)
10 CFR 20.2207

U.S. NUCLEAR REGULATORY COMMISSION

LICENSEE NAME

LICENSE NO.

NATIONAL SOURCE TRACKING
TRANSACTION REPORT (continued)
7. SOURCE RECEIPT DATA (continued)

A3. SENDING LICENSEE NAME

B3. SENDING LICENSEE
LICENSE NO.

C3. SENDING LICENSEE SHIPPING ADDRESS

G3. SOURCE MAKE

H3. SOURCE MODEL

I3. SOURCE SERIAL
NUMBER

O3. SOURCE LOCATION ADDRESS

P3. CITY

K3. ACTIVITY AND UNIT L3. ACTIVITY
DATE

Q3. STATE

R3. ZIP CODE

B4. SENDING LICENSEE
LICENSE NO.

C4. SENDING LICENSEE SHIPPING ADDRESS

G4. SOURCE MAKE

H4. SOURCE MODEL

I4. SOURCE SERIAL
NUMBER

P4. CITY

E3. STATE

J3. ISOTOPE

A4. SENDING LICENSEE NAME

O4. SOURCE LOCATION ADDRESS

D3. CITY

F3. ZIP CODE

M3. WASTE MANIFEST NO. N3. CONTAINER ID
(For waste shipments only) (For waste shipments only)

S3. SAME AS STREET
ADDRESS

D4. CITY

T3. COMMENTS

E4. STATE F4. ZIP CODE

J4. ISOTOPE

K4. ACTIVITY AND UNIT L4. ACTIVITY
DATE

Q4. STATE

R4. ZIP CODE

M4. WASTE MANIFEST NO. N4. CONTAINER ID
(For waste shipments only) (For waste shipments only)

S4. SAME AS STREET
ADDRESS

T4. COMMENTS

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 RESPECTS. 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 748 (6-2010)

NRC FORM 748
(6-2010)
10 CFR 20.2207

U.S. NUCLEAR REGULATORY COMMISSION

LICENSEE NAME

LICENSE NO.

NATIONAL SOURCE TRACKING
TRANSACTION REPORT (continued)
8. SOURCE DISPOSAL DATA

A1. WASTE MANIFEST NUMBER

C1. METHOD OF DISPOSAL

B1. CONTAINER ID

D1. SOURCE MAKE

E1. SOURCE MODEL

K1.SOURCE DISPOSAL ADDRESS

L1. CITY

A2. WASTE MANIFEST NUMBER

F1. SOURCE SERIAL G1. ISOTOPE H1. ACTIVITY AND UNIT I1. ACTIVITY DATE
NUMBER

M1. STATE

N1. ZIP CODE

E2. SOURCE MODEL

K2.SOURCE DISPOSAL ADDRESS

L2. CITY

O1. SAME AS STREET
ADDRESS

C2. METHOD OF DISPOSAL

B2. CONTAINER ID

D2. SOURCE MAKE

J1. COMMENTS

F2. SOURCE SERIAL G2. ISOTOPE H2. ACTIVITY AND UNIT I2. ACTIVITY DATE
NUMBER

M2. STATE

N2. ZIP CODE

J2. COMMENTS

O2. SAME AS STREET
ADDRESS

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 RESPECTS. 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 748 (6-2010)

NRC FORM 748
(6-2010)
10 CFR 20.2207

U.S. NUCLEAR REGULATORY COMMISSION

LICENSEE NAME

LICENSE NO.

NATIONAL SOURCE TRACKING
TRANSACTION REPORT (continued)
8. SOURCE DISPOSAL DATA (continued)

A3. WASTE MANIFEST NUMBER

C3. METHOD OF DISPOSAL

B3. CONTAINER ID

D3. SOURCE MAKE

E3. SOURCE MODEL

K3.SOURCE DISPOSAL ADDRESS

L3. CITY

A4. WASTE MANIFEST NUMBER

F3. SOURCE SERIAL G3. ISOTOPE H3. ACTIVITY AND UNIT I3. ACTIVITY DATE
NUMBER

M3. STATE

N3. ZIP CODE

E4. SOURCE MODEL

K4.SOURCE DISPOSAL ADDRESS

L4. CITY

O3. SAME AS STREET
ADDRESS

C4. METHOD OF DISPOSAL

B2. CONTAINER ID

D4. SOURCE MAKE

J3. COMMENTS

F4. SOURCE SERIAL G4. ISOTOPE H4. ACTIVITY AND UNIT I4. ACTIVITY DATE
NUMBER

M4. STATE

N4. ZIP CODE

J4. COMMENTS

O4. SAME AS STREET
ADDRESS

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 RESPECTS. 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 748 (6-2010)

NRC FORM 748
(6-2010)
10 CFR 20.2207

U.S. NUCLEAR REGULATORY COMMISSION

LICENSEE NAME

LICENSE NO.

NATIONAL SOURCE TRACKING
TRANSACTION REPORT (continued)
9. NEW MANUFACTURED SOURCE DATA

A1. SOURCE MAKE

G1 SOURCE LOCATION ADDRESS

A2. SOURCE MAKE

G2 SOURCE LOCATION ADDRESS

A3. SOURCE MAKE

G3 SOURCE LOCATION ADDRESS

A4. SOURCE MAKE

G4 SOURCE LOCATION ADDRESS

B1. SOURCE MODEL

H1. CITY

B2. SOURCE MODEL

H2. CITY

B3. SOURCE MODEL

H3. CITY

B4. SOURCE MODEL

H4. CITY

C1. SOURCE SERIAL D1. ISOTOPE
NUMBER

I1. STATE

E1. ACTIVITY AND UNIT

J1. ZIP CODE

C2. SOURCE SERIAL D2. ISOTOPE
NUMBER

I2. STATE

C3. SOURCE SERIAL D3. ISOTOPE
NUMBER

I3. STATE

J3. ZIP CODE

F3. COMMENTS

K3. SAME AS
STREET ADDRESS

E4. ACTIVITY AND UNIT

J4. ZIP CODE

F2. COMMENTS

K2 SAME AS
STREET ADDRESS

E3. ACTIVITY AND UNIT

C4. SOURCE SERIAL D4. ISOTOPE
NUMBER

I4. STATE

K1. SAME AS
STREET ADDRESS

E2. ACTIVITY AND UNIT

J2. ZIP CODE

F1. COMMENTS

F4. COMMENTS

K4. SAME AS
STREET ADDRESS

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 RESPECTS. 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 748 (6-2010)

NRC FORM 748
(6-2010)
10 CFR 20.2207

U.S. NUCLEAR REGULATORY COMMISSION

LICENSEE NAME

LICENSE NO.

NATIONAL SOURCE TRACKING
TRANSACTION REPORT (continued)
10. SOURCE IMPORT DATA

A1. FOREIGN COMPANY NAME

B1. IMPORT LICENSE

C1. FOREIGN COMPANY ADDRESS

F1. SOURCE MAKE

G1. SOURCE MODEL

H1. SOURCE SERIAL I1. ISOTOPE
NUMBER

M1. SOURCE LOCATION ADDRESS

N1. CITY

O1. STATE

A2. FOREIGN COMPANY NAME

B2. IMPORT LICENSE

C2. FOREIGN COMPANY ADDRESS

F2. SOURCE MAKE

G2. SOURCE MODEL

H2. SOURCE SERIAL I2. ISOTOPE
NUMBER

M2.SOURCE LOCATION ADDRESS

N2. CITY

O2. STATE

D1. CITY

J1. ACTIVITY AND UNIT K1. ACTIVITY DATE

P1. ZIP CODE

L1. COMMENTS

Q1. SAME AS STREET
ADDRESS

D2. CITY

J2. ACTIVITY AND UNIT K2. ACTIVITY DATE

P2. ZIP CODE

E1. COUNTRY

E2. COUNTRY

L2. COMMENTS

Q2. SAME AS STREET
ADDRESS

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 RESPECTS. 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 748 (6-2010)

NRC FORM 748
(6-2010)
10 CFR 20.2207

U.S. NUCLEAR REGULATORY COMMISSION

LICENSEE NAME

LICENSE NO.

NATIONAL SOURCE TRACKING
TRANSACTION REPORT (continued)
10. SOURCE IMPORT DATA (continued)

A3. FOREIGN COMPANY NAME

B3. IMPORT LICENSE

C3.FOREIGN COMPANY ADDRESS

F3. SOURCE MAKE

G3. SOURCE MODEL

H3. SOURCE SERIAL I3. ISOTOPE
NUMBER

M3. SOURCE LOCATION ADDRESS

N3. CITY

O3. STATE

A4. FOREIGN COMPANY NAME

B4. IMPORT LICENSE

C4.FOREIGN COMPANY ADDRESS

F4. SOURCE MAKE

G4. SOURCE MODEL

H4. SOURCE SERIAL I4. ISOTOPE
NUMBER

M4. SOURCE LOCATION ADDRESS

N4. CITY

O4. STATE

D3. CITY

J3. ACTIVITY AND UNIT K3. ACTIVITY DATE

P3. ZIP CODE

L3. COMMENTS

Q3. SAME AS STREET
ADDRESS

D4. CITY

J4. ACTIVITY AND UNIT K4. ACTIVITY DATE

P4. ZIP CODE

E3. COUNTRY

E4. COUNTRY

L4. COMMENTS

Q4. SAME AS STREET
ADDRESS

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 RESPECTS. 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 748 (6-2010)

NRC FORM 748
(6-2010)
10 CFR 20.2207

U.S. NUCLEAR REGULATORY COMMISSION

LICENSEE NAME

LICENSE NO.

NATIONAL SOURCE TRACKING
TRANSACTION REPORT (continued)
11. SOURCE EXPORT DATA

A1. FOREIGN COMPANY NAME

B1. EXPORT LICENSE NO.

C1. ULTIMATE CONSIGNEE ADDRESS

F1. SOURCE MAKE

G1. SOURCE MODEL

H1. SOURCE SERIAL I1. ISOTOPE
NUMBER

A2. FOREIGN COMPANY NAME

B2. EXPORT LICENSE NO.

C2.ULTIMATE CONSIGNEE ADDRESS

F2. SOURCE MAKE

G2. SOURCE MODEL

H2. SOURCE SERIAL I2. ISOTOPE
NUMBER

D1. CITY

J1. ACTIVITY AND UNIT K1. ACTIVITY DATE

E1. COUNTRY

L1. CONTAINER ID

M1.COMMENTS

D2. CITY

J2. ACTIVITY AND UNIT K2. ACTIVITY DATE

E2. COUNTRY

L2. CONTAINER ID

M2.COMMENTS

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 RESPECTS. 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 748 (6-2010)

NRC FORM 748
(6-2010)
10 CFR 20.2207

U.S. NUCLEAR REGULATORY COMMISSION

LICENSEE NAME

LICENSE NO.

NATIONAL SOURCE TRACKING
TRANSACTION REPORT (continued)
11. SOURCE EXPORT DATA (continued)

A3. FOREIGN COMPANY NAME

B3. EXPORT LICENSE NO.

C3. ULTIMATE CONSIGNEE ADDRESS

F3. SOURCE MAKE

G3. SOURCE MODEL

H3. SOURCE SERIAL I3. ISOTOPE
NUMBER

A4. FOREIGN COMPANY NAME

B4. EXPORT LICENSE NO.

C4.ULTIMATE CONSIGNEE ADDRESS

F4. SOURCE MAKE

G4. SOURCE MODEL

H4. SOURCE SERIAL I4. ISOTOPE
NUMBER

D3. CITY

J3. ACTIVITY AND UNIT K3. ACTIVITY DATE

E3. COUNTRY

L3. CONTAINER ID

M3.COMMENTS

D4. CITY

J4. ACTIVITY AND UNIT K4. ACTIVITY DATE

E4. COUNTRY

L4. CONTAINER ID

M4.COMMENTS

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 RESPECTS. 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 748 (6-2010)

NRC FORM 748
(6-2010)
10 CFR 20.2207

U.S. NUCLEAR REGULATORY COMMISSION

LICENSEE NAME

LICENSE NO.

NATIONAL SOURCE TRACKING
TRANSACTION REPORT (continued)
12. SOURCE DISASSEMBLE DATA

A1. SOURCE MAKE

I1 SOURCE LOCATION ADDRESS

A2. SOURCE MAKE

I2 SOURCE LOCATION ADDRESS

A3. SOURCE MAKE

I3 SOURCE LOCATION ADDRESS

A4. SOURCE MAKE

I4 SOURCE LOCATION ADDRESS

B1. SOURCE MODEL

J1. CITY

B2. SOURCE MODEL

J2. CITY

B3. SOURCE MODEL

J3. CITY

B4. SOURCE MODEL

J4. CITY

C1. SOURCE SERIAL D1. ISOTOPE E1. ACTIVITY
NUMBER
A ND UNIT

K1. STATE

K3. STATE

L4. ZIP CODE

H1. COMMENTS

G2. DISASSEMBLE
DATE

H2. COMMENTS

M2 SAME AS
STREET ADDRESS

F3. ACTIVITY
DATE

G3. DISASSEMBLE
DATE

H3. COMMENTS

M3. SAME AS
STREET ADDRESS

L3. ZIP CODE

C4. SOURCE SERIAL D4. ISOTOPE E4. ACTIVITY
NUMBER
AND UNIT

K4. STATE

F2. ACTIVITY
DATE

L2. ZIP CODE

C3. SOURCE SERIAL D3. ISOTOPE E3. ACTIVITY
NUMBER
AND UNIT

G1.DISASSEMBLE
DATE

M1. SAME AS
STREET ADDRESS

L1. ZIP CODE

C2. SOURCE SERIAL D2. ISOTOPE E2. ACTIVITY
NUMBER
AND UNIT

K2. STATE

F1. ACTIVITY
DATE

F4. ACTIVITY
DATE

G4. DISASSEMBLE
DATE

H4. COMMENTS

M4. SAME AS
STREET ADDRESS

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 RESPECTS. 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 748 (6-2010)

NRC FORM 748
(6-2010)
10 CFR 20.2207

U.S. NUCLEAR REGULATORY COMMISSION

LICENSEE NAME

LICENSE NO.

NATIONAL SOURCE TRACKING
TRANSACTION REPORT (continued)
12. SOURCE DISASSEMBLE DATA (continued)

A5. SOURCE MAKE

I5 SOURCE LOCATION ADDRESS

A6. SOURCE MAKE

I6 SOURCE LOCATION ADDRESS

A7. SOURCE MAKE

I7 SOURCE LOCATION ADDRESS

A8. SOURCE MAKE

I8 SOURCE LOCATION ADDRESS

B5. SOURCE MODEL

J5. CITY

B6. SOURCE MODEL

J6. CITY

B7. SOURCE MODEL

J7. CITY

B8. SOURCE MODEL

J8. CITY

C5. SOURCE SERIAL D5. ISOTOPE E5. A CTIVITY
NUMBER
AND UNIT

K5. STATE

A CTIVITY
A ND UNIT

K7. STATE

L7. ZIP CODE

C8. SOURCE SERIAL D8. ISOTOPE E8.
NUMBER

K8. STATE

F6. ACTIVITY
DATE

L6. ZIP CODE

C7. SOURCE SERIAL D7. ISOTOPE E7. ACTIVITY
NUMBER
AND UNIT

ACTIVITY
AND UNIT

L8. ZIP CODE

G5.DISASSEMBLE
DATE

H5. COMMENTS

M5. SAME AS
STREET ADDRESS

L5. ZIP CODE

C6. SOURCE SERIAL D6. ISOTOPE E6.
NUMBER

K6. STATE

F5. ACTIVITY
DATE

G6. DISASSEMBLE
DATE

H6. COMMENTS

M6 SAME AS
STREET ADDRESS

F7. ACTIVITY
DATE

G7. DISASSEMBLE
DATE

H7. COMMENTS

M7. SAME AS
STREETADDRESS

F8. ACTIVITY G8. DISASSEMBLE
DATE
DATE

H8. COMMENTS

M8. SAME AS
STREET ADDRESS

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 RESPECTS. 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 748 (6-2010)

INSTRUCTIONS TO NRC AND AGREEMENT STATE LICENSEES FOR REPORTING HIGH-RISK SEALED SOURCE TRANSACTIONS
The completed form is considered to be Official Use Only – Security Related Information; it is not considered to be Safeguards Information. Use an addendum sheet
for reporting additional sources.

Source Receipt Data – For Receipt transaction reports, all fields in Section 7 are
required EXCEPT M. Waste Manifest Number, N. Container ID, and T. Comments. If
the licensee is reporting multiple sources on the Receipt transaction at the same
Source Location Address, the location address information may be populated once,
and referenced in the Comments block for the additional sources.
8. Source Disposal Data – For Disposal transaction reports, all fields in Section 8 are
required EXCEPT J. Comments. If the licensee is reporting multiple sources on the
Disposal transaction at the same Source Disposal Address, the source disposal
address information may be populated once, and referenced in the Comments block
for the additional sources.
9. New Manufactured Source Data – For New Manufactured Source transaction
reports, all fields in Section 9 are required EXCEPT F. Comments. If the licensee is
reporting multiple sources on the Manufacturer transaction at the same Source
Location Address, the location address information may be populated once, and
referenced in the Comments block for the additional sources.
10. Source Import Data – For Import Source transaction reports, all fields are required
EXCEPT L. Comments. If the licensee is reporting multiple sources on the Import
transaction at the same Source Location Address, the location address information
may be populated once, and referenced in the Comments block for the additional
sources.
11. Source Export Data – For Export Source transaction reports, all fields are required
EXCEPT M. Comments. If the licensee is reporting multiple sources on the Export
transaction to the same Foreign Company/Foreign Address, the information in cells
A-E may be populated once, and referenced in the Comments block for the
additional sources.
12. Source Disassemble Data – For Disassemble Source transaction reports, all fields
are required EXCEPT H. Comments. If the licensee is reporting multiple sources on
the Disassemble transaction at the same Source Location Address, the location
address information may be populated once, and referenced in the Comments block
for the additional sources.
7.

1.
2.
3.

4.

5.

6.

Note to Licensees: This form may be used to report source transactions in lieu of
using the NSTS online application. Sections 1-4 on Page 1 of the form are required
for all source transaction types. Sections 5 – 12 should only be populated for the
associated Transaction Type (3B) selected. For example, when reporting a Source
Transfer and a Source Export, Sections 6 and 11 should be populated. Multiple
Transaction Types may be selected if they occur on the same Transaction Date, and
should be reported on NRC Form 748. Licensees reporting only one transaction type
may use the condensed form for the Transaction Type. For example, when reporting
a Source Receipt, NRC Form 748c should be used.
Licensee Information – Enter the name and license number, and street address of
the licensed facility
Transaction Date – Enter the date the transaction occurred, which would be the date
of the transfer, receipt, manufacture, etc.
Transaction Information and Transaction Type – Indicate if this is a new transaction
or a correction. For corrections, select the date of the previously submitted
transaction that the correction should be associated with. Select the Transaction
Type. Report Source should only be used for initial inventory submissions, or to
report a source excluded from the initial inventory submission. Dispose Source
should only be used by a Disposal Licensee. If you are sending your source back to
the manufacturer, or sending it to a disposal facility, the transaction should be
recorded as a Transfer. Multiple Transaction Types may be selected if they occur on
the same Transaction Date.
Preparer Information – An email address is required for a confirmation. For
regulatory purposes, your source transaction report is not considered complete
without a confirmation from the NSTS Help Desk that the transaction report has
been received.
Source Inventory Data – This section should only be used for initial inventory
submissions. The Make, Model and Serial Number refer to the Source, not the
Device. All fields are required in Section 5 EXCEPT G. Comments. If the licensee is
reporting multiple sources on the Source Inventory transaction at the same Source
Location Address, the location address information may be populated once, and
referenced in the Comments block for the additional sources.
Source Transfer Data – For Transfer transaction reports, all fields in Section 6 are
required EXCEPT M. Waste Manifest Number, N. Container ID, and P. Comments. If
the licensee is reporting multiple sources on the Transfer transaction to the same
Receiving Licensee, the receiving licensee information may be populated once, and
referenced in the Comments block for the additional sources.

DISTRIBUTION
Mail one copy to: Lockheed Martin, NSTS Help Desk, 30 West
Gude Drive, Suite 300, Rockville, MD, 20850
or FAX a copy to: (240) 403-4391
or Submit by email: [email protected] or by clicking the
“Submit by Email” button at the top of the form.