NRC Form 540 Uniform Low-Level Radioactive Waste Manifest (Shipping P

APPROVED BY OMB: NO. 3150-0164
EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this information collection request: 45 minutes. This uniform manifest or its equivalent is required by NRC to meet reporting requirements of Federal and State Agencies for the safe transportation and disposal
of low-level waste (10 CFR 20, App G). 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, (3150-0164), 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.
NRC FORM 540

U.S. NUCLEAR REGULATORY COMMISSION

UNIFORM LOW-LEVEL RADIOACTIVE
WASTE MANIFEST SHIPPING PAPER
See NUREG/BR-0204 for detailed instructions for completing this form:
http://www.nrc.gov/reading-rm/doc-collections/nuregs/brochures/br0204/

5. Shipper - Name and Facility

Shipper ID Number

Collector
User Permit Number

Shipment Number

7. NRC Form 540 and 540A Page 1 of

Processor

Generator Type (Specify)

Page(s)

NRC Form 541 and 541A

Page(s)

NRC Form 542 and 542A

Page(s)

Additional Information

Page(s)

Electronic

8. Manifest Number

Contact

1. Emergency Telephone Number (Include area code)

Contact

Phone No (Include Area Code)

9. Consignee - Name and Facility Address

Phone No (Include Area Code)

Organization

6. Carrier - Name and Address

EPA I.D. Number

Signature - Authorized consignee acknowledging waste receipt

Date

2. Is this an "Exclusive Use"
Shipment?
Yes

3. Total Number of packages identified
on this manifest?

Shipping Date

10. CERTIFICATION

Contact

Phone No (Include Area Code)

“This is to certify that the herein-named materials are properly classified, described, packaged, marked, and labeled and are in
proper condition for transportation according to the applicable regulations of the Department of Transportation, the Commission,
and equivalent state regulations. For materials that are consigned to a land disposal facility or waste collector, this certifies that
the materials are classified per the applicable requirements of 10 CFR Part 61, meet the land disposal facility's waste acceptance
criteria, and are in proper condition for disposal as described in accordance with the applicable requirements of 10 CFR Parts 20
and 61, or equivalent state regulations. A collector in signing the certification is certifying that nothing has been done to the
collected waste which would invalidate the waste generator's certification.”

Signature - Authorized carrier acknowledging waste receipt

Date

Authorized Signature and Title

No

4. Does EPA regulated waste requiring a
manifest accompany this shipment?
(If "Yes," provide Manifest Number).
Yes

EPA Manifest Number

11. U. S. Department of Transportation Description
(Including UN ID number, proper shipping name,
hazard class, and any additional information)

For Consignee Use Only

NRC FORM 540 (MM-YYYY)

Date

No
12. DOT Labels

13. Transport
Index

14. Physical and
Chemical Form

15. Individual Radionuclides

16. Maximum Package
Activity in SI Units

17. Total Weight
or Volume
(Use appropriate units)

18. Identification
Number of
Package