Form NRC Form 540 NRC Form 540 Uniform Low-Level Radioactive Waste Manifest (Shipping P

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

NRC FORM 540
(MM-YYYY)

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 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

SHIPPER I.D. NUMBER

UNIFORM LOW-LEVEL RADIOACTIVE WASTE MANIFEST
SHIPPING PAPER

Instructions: See NUREG/BR-0204 for detailed instructions for completing this form:
http://www.nrc.gov/reading-rm/doc-collections/nuregs/brochures/br0204/
1. EMERGENCY TELEPHONE NUMBER (Include Area Code)

NO

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

FOR CONSIGNEE USE ONLY

NRC FORM 540 (MM-YYYY)

PAGE(S)

NRC FORM 542 AND 542A

PAGE(S)

PROCESSOR

ADDITIONAL INFORMATION

PAGE(S)

GENERATOR TYPE
(Specify)

12.

DOT LABEL
"RADIOACTIVE"

9. CONSIGNEE - Name and Facility Address

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

CONTACT

TELEPHONE NUMBER (Include Area Code)

SIGNATURE - Authorized consignee acknowledging waste receipt

DATE

CONTACT

TELEPHONE NUMBER
(Include Area Code)

10. CERTIFICATION
This is to certify that the herein-named materials 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.
This also certifies that the materials are classified, packaged, marked, and labeled and are in proper condition for
transportation and disposal as described in accordance with the applicable requirements of 10 CFR Parts 20 and 61, or
equivalent state regulations.

SIGNATURE - Authorized carrier acknowledging waste receipt

DATE

AUTHORIZED SIGNATURE

YES

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

PAGE(S)

NRC FORM 541 AND 541A

EPA I.D. NUMBER

EPA MANIFEST NUMBER

NO

PAGE 1 OF

COLLECTOR

SHIPPING DATE

3. TOTAL NUMBER OF
PACKAGES IDENTIFIED
ON THIS MANIFEST

7. NRC FORM 540 AND 540A

TELEPHONE NUMBER
(Include Area Code)

6. CARRIER - Name and Address

2. IS THIS AN "EXCLUSIVE USE" SHIPMENT?
YES

SHIPMENT NUMBER

USER PERMIT NUMBER

CONTACT

ORGANIZATION

11.

5. SHIPPER - NAME AND FACILITY

13.
TRANSPORT
INDEX

14.

PHYSICAL AND
CHEMICAL FORM

15.

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