NRC Form 748h Disassemble Source

Submit by Email
U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 748H
(MM-DD-YYYY)
10 CFR 20.2207

DISASSEMBLE SOURCE
NATIONAL SOURCE TRACKING TRANSACTION REPORT

EXPIRES: (MM/DD/YYYY)

APPROVED BY OMB: NO. 3150-0202

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, Library, and Information
Collections 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, (3150-0202), 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.

1. LICENSEE INFORMATION
B. LICENSE NO.

A. LICENSEE NAME

2. TRANSACTION DATE

C. LICENSEE STREET ADDRESS

3A. TRANSACTION INFORMATION

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

NEW

CORRECTION

IF CORRECTION, PREVIOUS TRANSACTION DATE:

D. CITY

E. STATE F. ZIP CODE

3B. TRANSACTION TYPE (Check all that apply)
REPORT SOURCE

TRANSFER

RECEIPT

DISPOSAL

IMPORT

EXPORT

DISASSEMBLE

INVENTORY
NEW SOURCE
MANUFACTURED

4. PREPARER INFORMATION
A. NAME OF PREPARER

B. DATE PREPARED

C. PREPARER PHONE

D. PREPARER E-MAIL (REQUIRED FOR CONFIRMATION)

12. SOURCE DISASSEMBLE DATA
A1. SOURCE MAKE

I1. SOURCE LOCATION ADDRESS

B1. SOURCE MODEL

J1. CITY

C1. SOURCE SERIAL D1. ISOTOPE E1. ACTIVITY
NUMBER
AND UNIT

K1. STATE

L1. ZIP CODE

F1. ACTIVITY
DATE

G1. DISASSEMBLE
DATE

H1. COMMENTS

M1. SAME AS
STREET ADDRESS

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 748H (MM-DD-YYYY)

Page 1

NRC FORM 748H

(MM-DD-YYYY)
10 CFR 20.2207

U.S. NUCLEAR REGULATORY COMMISSION

LICENSEE NAME

LICENSE NO.

DISASSEMBLE SOURCE
NATIONAL SOURCE TRACKING TRANSACTION REPORT
(continued)
12. SOURCE DISASSEMBLE DATA (continued)

A2. SOURCE MAKE

I2. SOURCE LOCATION ADDRESS

A3. SOURCE MAKE

I3. SOURCE LOCATION ADDRESS

A4. SOURCE MAKE

I4. SOURCE LOCATION ADDRESS

A5. SOURCE MAKE

I5. SOURCE LOCATION ADDRESS

B2. SOURCE MODEL

J2. CITY

B3. SOURCE MODEL

J3. CITY

B4. SOURCE MODEL

J4. CITY

B5. SOURCE MODEL

J5. CITY

C2. SOURCE SERIAL D2. ISOTOPE E2. ACTIVITY
NUMBER
AND UNIT

K2. STATE

K4. STATE

L5. ZIP CODE

H2. COMMENTS

G3. DISASSEMBLE
DATE

H3. COMMENTS

M3. SAME AS
STREET ADDRESS

F4. ACTIVITY
DATE

L4. ZIP CODE

C5. SOURCE SERIAL D5. ISOTOPE E5. ACTIVITY
NUMBER
AND UNIT

K5. STATE

F3. ACTIVITY
DATE

L3. ZIP CODE

C4. SOURCE SERIAL D4. ISOTOPE E4. ACTIVITY
NUMBER
AND UNIT

G2. DISASSEMBLE
DATE

M2. SAME AS
STREET ADDRESS

L2. ZIP CODE

C3. SOURCE SERIAL D3. ISOTOPE E3. ACTIVITY
NUMBER
AND UNIT

K3. STATE

F2. ACTIVITY
DATE

G4. DISASSEMBLE
DATE

H4. COMMENTS

M4. SAME AS
STREET ADDRESS

F5. ACTIVITY
DATE

G5. DISASSEMBLE
DATE

H5. COMMENTS

M5. SAME AS
STREET ADDRESS

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 748H (MM-DD-YYYY)

Page 2

NRC FORM 748H

(MM-DD-YYYY)
10 CFR 20.2207

U.S. NUCLEAR REGULATORY COMMISSION

LICENSE NO.

LICENSEE NAME

DISASSEMBLE SOURCE
NATIONAL SOURCE TRACKING TRANSACTION REPORT
(continued)
12. SOURCE DISASSEMBLE DATA (continued)

A6. SOURCE MAKE

I6. SOURCE LOCATION ADDRESS

A7. SOURCE MAKE

I7. SOURCE LOCATION ADDRESS

A8. SOURCE MAKE

I8. SOURCE LOCATION ADDRESS

A9. SOURCE MAKE

I9. SOURCE LOCATION ADDRESS

B6. SOURCE MODEL

J6. CITY

B7. SOURCE MODEL

J7. CITY

B8. SOURCE MODEL

J8. CITY

B9. SOURCE MODEL

J9. CITY

C6. SOURCE SERIAL D6. ISOTOPE E6. ACTIVITY
AND UNIT
NUMBER

K6. STATE

K8. STATE

L9. ZIP CODE

H6. COMMENTS

G7. DISASSEMBLE
DATE

H7. COMMENTS

M7. SAME AS
STREET ADDRESS

F8. ACTIVITY
DATE

L8. ZIP CODE

C9. SOURCE SERIAL D9. ISOTOPE E9. ACTIVITY
NUMBER
AND UNIT

K9. STATE

F7. ACTIVITY
DATE

L7. ZIP CODE

C8. SOURCE SERIAL D8. ISOTOPE E8. ACTIVITY
NUMBER
AND UNIT

G6. DISASSEMBLE
DATE

M6. SAME AS
STREET ADDRESS

L6. ZIP CODE

C7. SOURCE SERIAL D7. ISOTOPE E7. ACTIVITY
NUMBER
AND UNIT

K7. STATE

F6. ACTIVITY
DATE

G8. DISASSEMBLE
DATE

H8. COMMENTS

M8. SAME AS
STREET ADDRESS

F9. ACTIVITY
DATE

G9. DISASSEMBLE
DATE

H9. COMMENTS

M9. SAME AS
STREET ADDRESS

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 748H (MM-DD-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 E-mail" 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
9737 Washingtonian Blvd, Room #5145, Mail Stop #11
Gaithersburg, MD 20878