Form DOE/NRC Form 741 DOE/NRC Form 741 Nuclear Material Transaction Report

DOE/NRC FORM 741

(MM-YYYY) Previous editions are obsolete
MANDATORY DATA COLLECTION
AUTHORIZED BY 10 CFR 30, 40, 50, 70,
72, 74, 75, 150
Public Laws 83-703, 93-438, 95-91

1. SHIPPER'S RIS

U. S. DEPARTMENT OF ENERGY
APPROVED BY OMB: NO. 3150-0003
EXPIRES: (MM/DD/YYYY)
AND
U. S. NUCLEAR REGULATORY COMMISSION Estimated burden per response to comply with this mandatory collection request: 1 hour and 15 minutes. This information is required for IAEA

NUCLEAR MATERIAL TRANSACTION REPORT

2. RECEIVER'S RIS

3. TRANSACTION NO.

4. CORRECTION NO.

5. PROCESSING CODE
a. SHIPPER

8.a. NAME AND ADDRESS
OF SHIPPER

accounting reports that show changes in inventory of nuclear materials. Send comments regarding burden estimate to the Information Services Branch
(T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to [email protected],and the OMB reviewer
at: OMB Office of Information and Regulatory Affairs, (3150-0003), Attn: Desk Officer for the Nuclear Regulatory Commission, 725 17th Street NW,
Washington, DC 20503; e-mail: [email protected]. The NRC may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless the document requesting or requiring the collection displays a currently valid OMB control number.

b. LICENSE
NO.

9.a. NAME AND ADDRESS
OF RECEIVER

b. LICENSE
NO.

7. DOCUMENTATION (Only if document is classified SECRET)

6. ACTION CODE

b. RECEIVER

a. SHIPPER

b. RECEIVER

10. NO OF DATA LINES

PAGE

OF

PAGES

COPY

OF

11. NATURE OF TRANSACTION

12.a. SHIPPED FOR ACCOUNT OF

NO.

13.a. SHIPPED TO ACCOUNT OF

b. RIS

COPIES

b. RIS

SERIES
DISTRIBUTION OF COPIES

1
2
3
4

c. ATTENTION:

c. ATTENTION:

d. TELEPHONE:

d. TELEPHONE:

5

14. TRANSFER AUTHORITY - CONTRACT, NM DRAFT, OR ORDER NUMBER

6

15. EXPORT OR IMPORT TRANSFERS: LICENSE NO.

7

16. MATERIAL TYPE AND DESCRIPTION

17.

18.

19.

20.

21.

LINE
NUMBER

COUNTRY OF
OBLIGATION

MATERIAL
TYPE

OBLIGATED
ELEMENT WEIGHT

OBLIGATED ISOTOPE
WEIGHT
For Enriched Uranium Only

8
9
MONTH DAY
(MM)
(DD)

22. ACTION DATE

YEAR
(YYYY)

a. SHIPMENT

23a. MISCELLANEOUS

b. SHIPPER'S CORRECTION

b. CONCISE NOTE ATTACHED
c. UK REPORTABLE?

YES

c. RECEIPT

NO

d. RECEIVER'S MEASUREMENT
e. RECEIVER'S CORRECTION

26. SHIPPER'S DATA

24. TOTAL GROSS WEIGHT
BACK
REFERENCE
NUMBER

LINE
NO.

TYPE
OF INV.
CHANGE

IDENTIFICATION
(ITEM/BATCH NAME)

NO. OF
ITEMS

PROJECT
NUMBER

MATERIAL
TYPE

a.

b.

c.

d.

e.

f.

g.

SIGNATURE OF AUTHORIZED OFFICIAL AND DATE SIGNED

h.

i.

KEY
MEAS.
POINT
j.

MEAS. IDENT.
k.
1
BASIS

2
OMP

3
METHOD

GROSS WEIGHT

NET WEIGHT

ELEMENT
WEIGHT

ELEMENT
LIMIT OF
ERROR

WEIGHT %
ISOTOPE

ISOTOPE
WEIGHT

ISOTOPE
LIMIT OF
ERROR

l.

m.

n.

o.

p.

q.

r.

27s. RECEIVER'S DATA

SIGNATURE OF AUTHORIZED OFFICIAL AND DATE SIGNED

27. RECEIVER'S DATA

26s. SHIPPER'S DATA

COMP/ OWNER
FACILITY CODE
CODE

25. TOTAL VOLUME (Waste Transfers Only)

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.
DOE/NRC FORM 741 (MM-YYYY)