Form 540 Form 540 Uniform Low-Level Radioactive Waste Manifest Shipping Pa

APPROVED BY OMB: NO. 3150-0164
EXPIRES: (MM/DD/YYYY)

NRC FORM 540

Estimated burden per response to comply with this information collection request: 45 minutes. This uniform manifest is required by NRC to meet reporting requirements of Federal and State Agencies for the safe transportation and disposal of low-level waste. Send comments regarding burden
estimate to the FOIA, Privacy and Information Collections 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, (3150-0164),
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.

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

SHIPPER I.D. NUMBER

5. SHIPPER - NAME AND FACILITY

UNIFORM LOW-LEVEL
RADIOACTIVEWASTE MANIFEST

COLLECTOR

SHIPPING PAPER

PROCESSOR
SHIPMENT NUMBER

USER PERMIT NUMBER

1. EMERGENCY TELEPHONE NUMBER (Include Area Code)

CONTACT

6. CARRIER - Name and Address

YES

NO

4. DOES EPA REGULATED
WASTE REQUIRING A
MANIFEST ACCOMPANY
THIS SHIPMENT?
If "Yes," provide Manifest Number
11.

FOR CONSIGNEE USE ONLY

NRC FORM 540 (MM-YYYY)

PAGE(S)

NRC FORM 541 AND 541A

PAGE(S)

NRC FORM 542 AND 542A

PAGE(S)

ADDITIONAL INFORMATION

PAGE(S)

8. MANIFEST NUMBER
(Use this number on all continuation pages)

CONTACT

9. CONSIGNEE - Name and Facility Address

TELEPHONE NUMBER (Include Area Code)

EPA I.D. NUMBER
SIGNATURE - Authorized consignee acknowledging waste receipt

3. TOTAL NUMBER OF
PACKAGES IDENTIFIED
ON THIS MANIFEST

DATE

SHIPPING DATE

=====>

10. CERTIFICATION

EPA MANIFEST NUMBER

CONTACT

TELEPHONE NUMBER
(Include Area Code)

SIGNATURE - Authorized carrier acknowledging waste receipt

DATE

YES
NO

U. S. DEPARTMENT OF TRANSPORTATION DESCRIPTION
(Including proper shipping name, hazard class, UN ID number,
and any additional information)

PAGE 1 OF

TELEPHONE NUMBER
(Include Area Code)

ORGANIZATION

2. IS THIS AN "EXCLUSIVE USE" SHIPMENT?

GENERATOR TYPE
(Specify)

7. NRC FORM 540 AND 540A

12.

DOT LABEL
"RADIOACTIVE"

13.
TRANSPORT
INDEX

14.

PHYSICAL AND
CHEMICAL FORM

15.

This is to certify that the herein-named materials are acceptable for disposal, are properly classified,
described, packaged, marked, and labeled, and are in proper condition for transportation according to
the applicable regulations of the Department of Transportation and the Commission.
AUTHORIZED SIGNATURE

INDIVIDUAL RADIONUCLIDES

TITLE

16.

TOTAL PACKAGE
ACTIVITY IN SI UNITS

17.

LSA/SCO
CLASS

DATE

18. TOTAL WEIGHT
OR VOLUME
(Use appropriate units)

19. IDENTIFICATION
NUMBER OF
PACKAGE