NRC Form 366 Licensee Event Report

NRC FORM 366

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

EXPIRES: (MM/DD/YYYY)

APPROVED BY OMB: NO. 3150-0104

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information collection.

LICENSEE EVENT REPORT (LER)
(See Page 2 for required number of
digits/characters for each block)

1. FACILITY NAME

2. DOCKET NUMBER

3. PAGE

05000

1 OF

4. TITLE

6. LER NUMBER

5. EVENT DATE
MONTH

DAY

YEAR

SEQUENTIAL
NUMBER

YEAR

9. OPERATING MODE

10. POWER LEVEL

7. REPORT DATE
REV
NO.

MONTH

DAY

YEAR

-

8. OTHER FACILITIES INVOLVED
DOCKET NUMBER

FACILITY NAME

05000
DOCKET NUMBER

FACILITY NAME

05000

11. THIS REPORT IS SUBMITTED PURSUANT TO THE REQUIREMENTS OF 10 CFR §: (Check all that apply)
20.2201(b)

20.2203(a)(3)(i)

50.73(a)(2)(ii)(A)

50.73(a)(2)(viii)(A)

20.2201(d)

20.2203(a)(3)(ii)

50.73(a)(2)(ii)(B)

50.73(a)(2)(viii)(B)

20.2203(a)(1)

20.2203(a)(4)

50.73(a)(2)(iii)

50.73(a)(2)(ix)(A)

20.2203(a)(2)(i)

50.36(c)(1)(i)(A)

50.73(a)(2)(iv)(A)

50.73(a)(2)(x)

20.2203(a)(2)(ii)

50.36(c)(1)(ii)(A)

50.73(a)(2)(v)(A)

73.71(a)(4)

20.2203(a)(2)(iii)

50.36(c)(2)

50.73(a)(2)(v)(B)

73.71(a)(5)

20.2203(a)(2)(iv)

50.46(a)(3)(ii)

50.73(a)(2)(v)(C)

73.77(a)(1)

20.2203(a)(2)(v)

50.73(a)(2)(i)(A)

50.73(a)(2)(v)(D)

73.77(a)(2)(i)

20.2203(a)(2)(vi)

50.73(a)(2)(i)(B)

50.73(a)(2)(vii)

73.77(a)(2)(ii)

50.73(a)(2)(i)(C)

OTHER

Specify in Abstract below or in NRC Form 366A

12. LICENSEE CONTACT FOR THIS LER
LICENSEE CONTACT

TELEPHONE NUMBER (Include Area Code)

13. COMPLETE ONE LINE FOR EACH COMPONENT FAILURE DESCRIBED IN THIS REPORT
CAUSE

SYSTEM

COMPONENT

MANUFACTURER

REPORTABLE
TO EPIX

CAUSE

14. SUPPLEMENTAL REPORT EXPECTED
YES (If yes, complete 15. EXPECTED SUBMISSION DATE)

NO

ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines)

NRC FORM 366 (MM-YYYY)

SYSTEM

COMPONENT

15. EXPECTED
SUBMISSION
DATE

MANUFACTURER

MONTH

REPORTABLE
TO EPIX

DAY

YEAR

REQUIRED NUMBER OF DIGITS/CHARACTERS
FOR EACH BLOCK
BLOCK
NUMBER

NUMBER OF
DIGITS/CHARACTERS

TITLE

1

UP TO 120 / 2 LINES

FACILITY NAME

2

8 TOTAL
3 IN ADDITION TO 05000

DOCKET NUMBER

3

VARIES

PAGE NUMBER

4

UP TO 230 / 2 LINES

TITLE

5

6

7

8 TOTAL
2 FOR MONTH
2 FOR DAY
4 FOR YEAR
9 TOTAL
4 FOR YEAR
3 FOR SEQUENTIAL NUMBER
2 FOR REVISIONS NUMBER
8 TOTAL
2 FOR MONTH
2 FOR DAY
4 FOR YEAR

EVENT DATE

LER NUMBER

REPORT DATE

UP TO 37 -- FACILITY NAME
8

8 TOTAL -- DOCKET NUMBER
3 IN ADDITION TO 05000

OTHER FACILITIES INVOLVED

9

1

OPERATING MODE

10

3

POWER LEVEL

11

VARIES
CHECK ALL BOXES THAT APPLY

REQUIREMENTS OF 10 CFR

12

UP TO 100 FOR NAME
10 FOR TELEPHONE

LICENSEE CONTACT

13

CAUSE VARIES (UP TO 10)
2 FOR SYSTEM (UP TO 10)
4 FOR COMPONENT (UP TO 10)
4 FOR MANUFACTURER (UP TO 10)
EPIX VARIES (UP TO 10)

EACH COMPONENT FAILURE

14

1
CHECK BOX THAT APPLIES

SUPPLEMENTAL REPORT EXPECTED

15

8 TOTAL
2 FOR MONTH
2 FOR DAY
4 FOR YEAR

EXPECTED SUBMISSION DATE

16

1400 OR 15 LINES OF TYPING

ABSTRACT