NRC Form 748 Disassemble Source National Source Tracking Transaction

Submit by Email
U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0202

NRC FORM 748G
(MM-YYYY)
10 CFR 20.2207

EXPORT SOURCE
NATIONAL SOURCE TRACKING TRANSACTION REPORT

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory information collection request: 9.5 minutes. NRC requires this information
to populate the National Source Tracking System for certain sealed sources. Send comments regarding burden estimate to the FOIA,
Privacy, Information Collections Branch (T-5 F53), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by internet email to [email protected], and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0202),
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.

1. LICENSEE INFORMATION
B. LICENSE NO.

A. LICENSEE NAME

2. TRANSACTION DATE

3A. TRANSACTION INFORMATION

(Only transactions completed on the same
date may be reported together on this form)

D. CITY

C. LICENSEE STREET ADDRESS

NEW

E. STATE F. ZIP CODE

3B. TRANSACTION TYPE (Check all that apply)

CORRECTION

REPORT SOURCE

TRANSFER

RECEIPT

DISPOSAL

IMPORT

EXPORT

DISASSEMBLE

INVENTORY

IF CORRECTION, PREVIOUS TRANSACTION DATE:

NEW SOURCE
MANUFACTURED

4. PREPARER INFORMATION
A. NAME OF PREPARER

B. DATE PREPARED

C. PREPARER PHONE

D. PREPARER E-MAIL (REQUIRED FOR CONFIRMATION)

11. SOURCE EXPORT DATA
A1. FOREIGN COMPANY NAME

B1. EXPORT LICENSE NO.

C1. ULTIMATE CONSIGNEE ADDRESS

F1. SOURCE MAKE

G1. SOURCE MODEL

H1. SOURCE SERIAL I1. ISOTOPE
NUMBER

D1. CITY

J1. ACTIVITY AND UNIT K1. ACTIVITY DATE

E1. COUNTRY

L1. CONTAINER ID

M1. COMMENTS

WARNING: FALSE STATEMENTS IN THIS CERTIFICATE MAY BE SUBJECT TO CIVIL AND/OR CRIMINAL PENALTIES. NRC REGULATIONS REQUIRE THAT SUBMISSIONS
TO THE NRC BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECTS. 18 U.S.C. SECTION 1001 MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE
STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTER WITHIN ITS JURISDICTION.
NRC FORM 748G (MM-YYYY)

Page 1

NRC FORM 748G
(MM-YYYY)
10 CFR 20.2207

U.S. NUCLEAR REGULATORY COMMISSION

LICENSEE NAME

LICENSE NO.

EXPORT SOURCE
NATIONAL SOURCE TRACKING TRANSACTION REPORT
(continued)
11. SOURCE EXPORT DATA (continued)

A2. FOREIGN COMPANY NAME

B2. EXPORT LICENSE NO.

C2. ULTIMATE CONSIGNEE ADDRESS

F2. SOURCE MAKE

G2. SOURCE MODEL

H2. SOURCE SERIAL I2. ISOTOPE
NUMBER

A3. FOREIGN COMPANY NAME

B3. EXPORT LICENSE NO.

C3. ULTIMATE CONSIGNEE ADDRESS

F3. SOURCE MAKE

G3. SOURCE MODEL

H3. SOURCE SERIAL I3. ISOTOPE
NUMBER

D2. CITY

J2. ACTIVITY AND UNIT K2. ACTIVITY DATE

E2. COUNTRY

L2. CONTAINER ID

M2. COMMENTS

D3. CITY

J3. ACTIVITY AND UNIT K3. ACTIVITY DATE

E3. COUNTRY

L3. CONTAINER ID

M3. COMMENTS

WARNING: FALSE STATEMENTS IN THIS CERTIFICATE MAY BE SUBJECT TO CIVIL AND/OR CRIMINAL PENALTIES. NRC REGULATIONS REQUIRE THAT SUBMISSIONS
TO THE NRC BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECTS. 18 U.S.C. SECTION 1001 MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE
STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTER WITHIN ITS JURISDICTION.
NRC FORM 748G (MM-YYYY)

Page 2

NRC FORM 748G
(MM-YYYY)
10 CFR 20.2207

U.S. NUCLEAR REGULATORY COMMISSION

LICENSEE NAME

LICENSE NO.

EXPORT SOURCE
NATIONAL SOURCE TRACKING TRANSACTION REPORT
(continued)
11. SOURCE EXPORT DATA (continued)

A4. FOREIGN COMPANY NAME

B4. EXPORT LICENSE NO.

C4. ULTIMATE CONSIGNEE ADDRESS

F4. SOURCE MAKE

G4. SOURCE MODEL

H4. SOURCE SERIAL I4. ISOTOPE
NUMBER

A5. FOREIGN COMPANY NAME

B5. EXPORT LICENSE NO.

C5. ULTIMATE CONSIGNEE ADDRESS

F5. SOURCE MAKE

G5. SOURCE MODEL

H5. SOURCE SERIAL I5. ISOTOPE
NUMBER

D4. CITY

J4. ACTIVITY AND UNIT K4. ACTIVITY DATE

E4. COUNTRY

L4. CONTAINER ID

M4. COMMENTS

D5. CITY

J5. ACTIVITY AND UNIT K5. ACTIVITY DATE

E5. COUNTRY

L5. CONTAINER ID

M5. COMMENTS

WARNING: FALSE STATEMENTS IN THIS CERTIFICATE MAY BE SUBJECT TO CIVIL AND/OR CRIMINAL PENALTIES. NRC REGULATIONS REQUIRE THAT SUBMISSIONS
TO THE NRC BE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECTS. 18 U.S.C. SECTION 1001 MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE
STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTER WITHIN ITS JURISDICTION.
NRC FORM 748G (MM-YYYY)

Page 3

INSTRUCTIONS TO NRC AND AGREEMENT STATE LICENSEES FOR REPORTING HIGH-RISK SEALED SOURCE TRANSACTIONS
The completed form is considered to be Official Use Only – Security Related Information; it is not considered to be Safeguards Information.
Use an addendum sheet for reporting additional sources.

1.
2.
3.

4.

5.

6.

Note to Licensees: This form may be used to report source transactions in lieu of
using the NSTS online application. Sections 1-4 on Page 1 of the form are required
for all source transaction types. Sections 5-12 should only be populated for the
associated Transaction Type (3B) selected. For example, when reporting a Source
Transfer and a Source Export, Sections 6 and 11 should be populated. Multiple
Transaction Types may be selected if they occur on the same Transaction Date, and
should be reported on NRC Form 748. Licensees reporting only one transaction type
may use the condensed form for the Transaction Type. For example, when reporting
a Source Receipt, NRC Form 748c should be used.
Licensee Information – Enter the name, license number, and street address of
the licensed facility.
Transaction Date – Enter the date the transaction occurred, which would be the date
of the transfer, receipt, manufacture, etc.
Transaction Information and Transaction Type – Indicate if this is a new transaction
or a correction. For corrections, select the date of the previously submitted
transaction that the correction should be associated with. Select the Transaction
Type. Report Source should only be used for initial inventory submissions, or to
report a source excluded from the initial inventory submission. Dispose Source
should only be used by a Disposal Licensee. If you are sending your source back to
the manufacturer, or sending it to a disposal facility, the transaction should be
recorded as a Transfer. Multiple Transaction Types may be selected if they occur on
the same Transaction Date.
Preparer Information – An email address is required for a confirmation. For
regulatory purposes, your source transaction report is not considered complete
without a confirmation from the NSTS Help Desk that the transaction report has
been received.
Source Inventory Data – This section should only be used for initial inventory
submissions. The Make, Model, and Serial Number refer to the Source, not the
Device. All fields are required in Section 5 EXCEPT G. Comments. If the licensee is
reporting multiple sources on the Source Inventory transaction at the same Source
Location Address, the location address information may be populated once, and
referenced in the Comments block for the additional sources.
Source Transfer Data – For Transfer transaction reports, all fields in Section 6 are
required EXCEPT M. Waste Manifest Number, N. Container ID, and P. Comments. If
the licensee is reporting multiple sources on the Transfer transaction to the same
Receiving Licensee, the receiving licensee information may be populated once, and
referenced in the Comments block for the additional sources.

Source Receipt Data – For Receipt transaction reports, all fields in Section 7 are
required EXCEPT M. Waste Manifest Number, N. Container ID, and T. Comments. If
the licensee is reporting multiple sources on the Receipt transaction at the same
Source Location Address, the location address information may be populated once,
and referenced in the Comments block for the additional sources.
8. Source Disposal Data – For Disposal transaction reports, all fields in Section 8 are
required EXCEPT J. Comments. If the licensee is reporting multiple sources on the
Disposal transaction at the same Source Disposal Address, the source disposal
address information may be populated once, and referenced in the Comments block
for the additional sources.
9. New Manufactured Source Data – For New Manufactured Source transaction
reports, all fields in Section 9 are required EXCEPT F. Comments. If the licensee is
reporting multiple sources on the Manufacturer transaction at the same Source
Location Address, the location address information may be populated once, and
referenced in the Comments block for the additional sources.
10. Source Import Data – For Import Source transaction reports, all fields are required
EXCEPT L. Comments. If the licensee is reporting multiple sources on the Import
transaction at the same Source Location Address, the location address information
may be populated once, and referenced in the Comments block for the additional
sources.
11. Source Export Data – For Export Source transaction reports, all fields are required
EXCEPT M. Comments. If the licensee is reporting multiple sources on the Export
transaction to the same Foreign Company/Foreign Address, the information in cells
A-E may be populated once, and referenced in the Comments block for the
additional sources.
12. Source Disassemble Data – For Disassemble Source transaction reports, all fields
are required EXCEPT H. Comments. If the licensee is reporting multiple sources on
the Disassemble transaction at the same Source Location Address, the location
address information may be populated once, and referenced in the Comments block
for the additional sources.
7.

DISTRIBUTION
For most timely processing, click the "Submit by Email" button on page 1.
You may also:
> manually submit this form by email to: [email protected],
> FAX to: 1-888-821-2534, or
> mail to: NSTS Help Desk
30 West Gude Drive, Suite 300
Rockville, MD 20850