Form NRC Form 653, NRC NRC Form 653, NRC Transfers of Industrial Devices Report (To General Licen

NRC FORM 653
(MM-YYYY)
10 CFR 32

U. S. NUCLEAR REGULATORY COMMISSION

TRANSFERS OF INDUSTRIAL
DEVICES REPORT
(TO GENERAL LICENSEES)
(Continue on NRC Form 653, 653A or 653B, as appropriate)

APPROVED BY OMB: NO. 3150-0001

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory collection request: 36
minutes. NRC requests quarterly reports to keep apprised of device movements. Send
comments regarding the 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 to the Desk Officer, Office of Information and
Regulatory Affairs, NEOB-10202, (3150-0001), 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.

For each "licensee" to whom a device(s) has been transferred during the reporting period, supply the following:
Name of Vendor

Reporting Period
From

To

License Number

Intermediate Person(s) (if any)
Name of Intermediate Persons(s)

Name of Responsible Individual

Title of Responsible Individual

Business Telephone Number

Name of Intermediate Persons(s)

Name of Responsible Individual

Title of Responsible Individual

Business Telephone Number

General Licensee Information
Name of General Licensee

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Name of Responsible Individual

Business Telephone Number

Title of Responsible Individual

Information on Device(s) Transferred
Date of Transfer

Type of Device

Model Number

Serial Number

Isotope

Activity and Units

Intermediate Person(s) (if any)
Name of Intermediate Persons(s)

Name of Responsible Individual

Title of Responsible Individual

Business Telephone Number

Name of Intermediate Persons(s)

Name of Responsible Individual

Title of Responsible Individual

Business Telephone Number

General Licensee Information
Name of General Licensee

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Name of Responsible Individual

Business Telephone Number

Title of Responsible Individual

Information on Device(s) Transferred
Date of Transfer

NRC FORM 653 (MM-YYYY)

Type of Device

Model Number

Serial Number

Isotope

Activity and Units

Page

of

NRC FORM 653 (Continued)

(MM-YYYY)
10 CFR 32

U. S. NUCLEAR REGULATORY COMMISSION

TRANSFERS OF INDUSTRIAL DEVICES REPORT
(TO GENERAL LICENSEES) (continued)
Intermediate Person(s) (if any)

Name of Intermediate Persons(s)

Name of Responsible Individual

Title of Responsible Individual

Business Telephone Number

Name of Intermediate Persons(s)

Name of Responsible Individual

Title of Responsible Individual

Business Telephone Number

General Licensee Information
Name of General Licensee

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Name of Responsible Individual

Business Telephone Number

Title of Responsible Individual

Information on Device(s) Transferred
Date of Transfer

Type of Device

Model Number

Serial Number

Isotope

Activity and Units

Intermediate Person(s) (if any)
Name of Intermediate Persons(s)

Name of Responsible Individual

Title of Responsible Individual

Business Telephone Number

Name of Intermediate Persons(s)

Name of Responsible Individual

Title of Responsible Individual

Business Telephone Number

General Licensee Information
Name of General Licensee

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Name of Responsible Individual

Business Telephone Number

Title of Responsible Individual

Information on Device(s) Transferred
Date of Transfer

NRC FORM 653 (MM-YYYY)

Type of Device

Model Number

Serial Number

Isotope

Activity and Units

Page

of

NRC FORM 653 (Continued)
(MM-YYYY)
10 CFR 32

U. S. NUCLEAR REGULATORY COMMISSION

TRANSFERS OF INDUSTRIAL DEVICES REPORT
(TO GENERAL LICENSEES) (continued)
Intermediate Person(s) (if any)

Name of Intermediate Persons(s)

Name of Responsible Individual

Title of Responsible Individual

Business Telephone Number

Name of Intermediate Persons(s)

Name of Responsible Individual

Title of Responsible Individual

Business Telephone Number

General Licensee Information
Name of General Licensee

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Name of Responsible Individual

Business Telephone Number

Title of Responsible Individual

Information on Device(s) Transferred
Date of Transfer

Type of Device

Model Number

Serial Number

Isotope

Activity and Units

Intermediate Person(s) (if any)
Name of Intermediate Persons(s)

Name of Responsible Individual

Title of Responsible Individual

Business Telephone Number

Name of Intermediate Persons(s)

Name of Responsible Individual

Title of Responsible Individual

Business Telephone Number

General Licensee Information
Name of General Licensee

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Name of Responsible Individual

Business Telephone Number

Title of Responsible Individual

Information on Device(s) Transferred
Date of Transfer

NRC FORM 653 (MM-YYYY)

Type of Device

Model Number

Serial Number

Isotope

Activity and Units

Page

of

NRC FORM 653A
(MM-YYYY)
10 CFR 32

U. S. NUCLEAR REGULATORY COMMISSION

TRANSFERS OF INDUSTRIAL DEVICES REPORT (FROM GENERAL LICENSEES)

For each "licensee" from whom a device(s) has been received during the reporting period, supply the following:
General Licensee Information
Name of General Licensee

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received
Date of Receipt

Type of Device

Model Number

Serial Number

Manufacturer or Initial Transferor (If not reporting party)

General Licensee Information
Name of General Licensee

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received
Date of Receipt

Type of Device

Model Number

Serial Number

Manufacturer or Initial Transferor (If not reporting party)

General Licensee Information
Name of General Licensee

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received
Date of Receipt

Type of Device

Model Number

Serial Number

Manufacturer or Initial Transferor (If not reporting party)

General Licensee Information
Name of General Licensee

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received
Date of Receipt

Type of Device

NRC FORM 653A (MM-YYYY)

Model Number

Serial Number

Manufacturer or Initial Transferor (If not reporting party)

Page

of

NRC FORM 653A (Continued)

(MM-YYYY)
10 CFR 32

U. S. NUCLEAR REGULATORY COMMISSION

TRANSFERS OF INDUSTRIAL DEVICES REPORT (FROM GENERAL LICENSEES) (continued)

For each "licensee" from whom a device(s) has been received during the reporting period, supply the following:
General Licensee Information
Name of General Licensee

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received
Date of Receipt

Type of Device

Model Number

Serial Number

Manufacturer or Initial Transferor (If not reporting party)

General Licensee Information
Name of General Licensee

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received
Date of Receipt

Type of Device

Model Number

Serial Number

Manufacturer or Initial Transferor (If not reporting party)

General Licensee Information
Name of General Licensee

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received
Date of Receipt

Type of Device

Model Number

Serial Number

Manufacturer or Initial Transferor (If not reporting party)

General Licensee Information
Name of General Licensee

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received
Date of Receipt

Type of Device

NRC FORM 653A (MM-YYYY)

Model Number

Serial Number

Manufacturer or Initial Transferor (If not reporting party)

Page

of

NRC FORM 653B
(MM-YYYY)
10 CFR 32

U. S. NUCLEAR REGULATORY COMMISSION

TRANSFERS OF INDUSTRIAL DEVICES REPORT (LABEL CHANGES)

For each device for which required label information has been changed, supply the following:
General Licensee User Information
Name of General Licensee User

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received
Type of Device

Model Number

Previous Serial
Number

New Serial
Number

Previous
Isotope

New
Isotope

Previous Label
Activity and Units

Label Activity
and Units

General Licensee User Information
Name of General Licensee User

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received
Type of Device

Model Number

Previous Serial
Number

New Serial
Number

Previous
Isotope

New
Isotope

Previous Label
Activity and Units

Label Activity
and Units

General Licensee User Information
Name of General Licensee User

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received
Type of Device

Model Number

Previous Serial
Number

New Serial
Number

Previous
Isotope

New
Isotope

Previous Label
Activity and Units

Label Activity
and Units

General Licensee User Information
Name of General Licensee User

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received
Type of Device

Model Number

NRC FORM 653B (MM-YYYY)

Previous Serial
Number

New Serial
Number

Previous
Isotope

New
Isotope

Previous Label
Activity and Units

Page

Label Activity
and Units

of

NRC FORM 653B (Continued)

(MM-YYYY)
10 CFR 32

U. S. NUCLEAR REGULATORY COMMISSION

TRANSFERS OF INDUSTRIAL DEVICES REPORT (LABEL CHANGES) (continued)
For each device for which required label information has been changed, supply the following:
General Licensee User Information

Name of General Licensee User

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received
Type of Device

Model Number

Previous Serial
Number

New Serial
Number

Previous
Isotope

New
Isotope

Previous Label
Activity and Units

Label Activity
and Units

General Licensee User Information
Name of General Licensee User

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received
Type of Device

Model Number

Previous Serial
Number

New Serial
Number

Previous
Isotope

New
Isotope

Previous Label
Activity and Units

Label Activity
and Units

General Licensee User Information
Name of General Licensee User

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received
Type of Device

Model Number

Previous Serial
Number

New Serial
Number

Previous
Isotope

New
Isotope

Previous Label
Activity and Units

Label Activity
and Units

General Licensee User Information
Name of General Licensee User

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received
Type of Device

Model Number

NRC FORM 653B (MM-YYYY)

Previous Serial
Number

New Serial
Number

Previous
Isotope

New
Isotope

Previous Label
Activity and Units

Page

Label Activity
and Units

of