Form NRC Form 830 NRC Form 830 Report of Import

NRC FORM 830

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

U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0036

REPORT OF IMPORT

ADVANCED 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 and 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)

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory collection request: 30 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 FOIA, Privacy, and Information Collections 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)