NRC Form 830A Report of Import Continuation Sheet

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

NRC 830A (PS)

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

OMB: 3150-0036

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

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

REPORT OF IMPORT
CONTINUATION SHEET

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:

EXPIRES: (MM/YY/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)

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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