NRC Form 830a Report of Import, Continuation Sheet

NRC FORM 830A
(MM-YYYY)
10 CFR 110.50(c)(3)(ii)

U.S. NUCLEAR REGULATORY COMMISSION

REPORT OF IMPORT
CONTINUATION SHEET

RADIOACTIVE SOURCES In accordance
with 10 CFR Part 110.50(c)(3)(ii) of the
U. S. NRC Regulations
Reference Number:

APPROVED BY OMB: NO. 3150-0036

EXPIRES: (MM/DD/YYYY)

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.

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)

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

ACTIVITY (TBq)

MAKE

MODEL

SERIAL NUMBER

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NRC Form 830A (MM-YYYY)

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