Form NRC Form 830 NRC Form 830 Report of Import

NRC FORM 830

(MM-YYYY)
10 CFR 110.50(c)(3)(ii)

EXPIRES: (MM/DD/YYYY)
U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0036
Estimated burden per response to comply with this mandatory collection request: 12
minutes. This form allows the NRC to request additional information from licensees to
determine whether a license should be revoked, suspended, or modified. Send comments
regarding burden estimate to the Information Services Branch (T-5 F53), U.S. Nuclear
Regulatory [email protected], and to the Desk Officer, Office of Information
and Regulatory Affairs, NEOB-10202, 3150-0036, 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.

REPORT OF IMPORT

PRIOR NOTIFICATION OF
SHIPMENT OF CATEGORY 1 AND/OR 2
RADIOACTIVE SOURCES

In accordance with 10 CFR Part 110.50(c)(3)(ii)
of the U.S. NRC Regulations

Reference Number:

A

Name of Individual and licensee making the
notification; address and telephone number:

B

Recipient name, location, and address
(if different than above):

C

Name, location, address, contact name and
telephone number for exporting facility:

D

Radionuclide(s) and activity level in TBq, both
for single and aggregate shipments:
Total Activity Level (TBq):

E

Make, Model and Serial Number, for any
Category 1 or 2 Sealed Sources, if available:

F

End-use in the U.S.:

G

H

Shipment Date from the Exporting Facility:
(MM/DD/YYYY)
Estimated Arrival Date at the end use location:
(MM/DD/YYYY)
NRC or Agreement State License number to
possess the import in the U.S.:
Expiration Date of License: (MM/DD/YYYY)

Comments:
NRC Form 830 (MM-YYYY)

SEND COMPLETED FORM TO:

U.S. Nuclear Regulatory Commission
ATTN: Headquarters Operation Center
Email: [email protected] (Preferred Reporting Method)
Fax: (301) 816-5151 (Alternative Reporting Method)