Form NRC Form 830 NRC Form 830 Report of Import

10 CFR Part 110, Export and Import of Nuclear Equipment and Material

nrc830

10 CFR 110 Part 110, Export and Import of Nuclear Equipment and Material

OMB: 3150-0036

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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)


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