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pdfNRC 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
| File Type | application/pdf |
| File Modified | 2019-07-17 |
| File Created | 2019-07-11 |