NRC Form 748 National Source Tracking Transaction Report, Short 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 ADDRESS1

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

TRANSFER

IMPORT

RECEIPT

NEW SOURCE
MANUFACTURED

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)

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.