NRC Form 831 Report of Export

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

NRC 831 (OMB Copy)

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

OMB: 3150-0036

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NRC FORM 831

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

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

REPORT OF EXPORT

ADVANCED NOTIFICATION OF
SHIPMENT OF CATEGORY 1 AND/OR 2
RADIOACTIVE SOURCES
In accordance with 10 CFR Part 110.50(c)(3)(i)
of the U.S. NRC Regulations

Reference Number:
A

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 Information
Services Branch, (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-001, or by
e-mail to [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)

Part 110 license number:
Expiration date:
Name of the individual and licensee making the
notification: (address, city, state, zip code and
telephone number)

B

C

D

U. S. exporting facility:
(company name, address, city, state, zip
code and telephone number)

Foreign recipient name, address and end use
location(s) if different than recipient's address:

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 importing country, if known:

G

Shipment date: (MM/DD/YYYY)

H

This notification should be accompanied by a copy of the foreign recipient's authorization or confirmation
of that authorization from the government of the importing country, as required by 110.32(g).

Comments:

NRC Form 831 (MM-YYYY)


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