NRC Form 314 Certificate of Disposition of Materials

U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 314

(MM-DD-YYYY)
10 CFR 30.36(j)(1);
40.42(j)(1); 70.38(j)(1);
and 72.54(k)(5)(1)(1)

CERTIFICATE OF DISPOSITION
OF MATERIALS

Licensee Name and Address

EXPIRES: (MM/DD/YYYY)

APPROVED BY OMB: NO. 3150-0028

Estimated burden per response to comply with this mandatory collection request: 30 minutes. This submittal is used by NRC as part
of the basis for its determination that the facility is released for unrestricted use. 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 email to [email protected], and the OMB reviewer at: OMB Office of Information and Regulatory Affairs,
(3150-0028), Attn: Desk Officer for the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 20503; email:
[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.

License Number

Expiration Date

Docket Number

A. LICENSE STATUS (Check the appropriate box)

This license has expired.

This license has not yet expired; please terminate it.
B. DISPOSAL OF RADIOACTIVE MATERIAL
(Check the appropriate boxes and complete as necessary. If additional space is needed, provide attachments)

The licensee, or any individual executing this certificate on behalf of the licensee, certifies that:
1. No radioactive materials have ever been procured or possessed by the licensee.
2. All activities authorized by this license have ceased, and all radioactive materials procured and/or possessed by the licensee under this license
number cited above have been disposed of in the following manner.
a. Transfer of radioactive materials to the licensee listed below:

b. Disposal of radioactive materials:
1. Directly by the licensee:

2. By licensed disposal site:

3. By waste contractor:

c. All radioactive materials have been removed, any remaining residual radioactivity is within the limits of 10 CFR Part 20, Subpart E, and is ALARA.
d. Acknowledgment of receipt of the material by transfer or by disposal site is attached:
C. SURVEYS PERFORMED AND REPORTED

1. A radiation survey was conducted by the licensee. The survey confirms:
a. the absence of licensed radioactive materials
b. that any remaining residual radioactivity is within the limits of 10 CFR 20, Subpart E, and is ALARA.
2. A copy of the radiation survey results:
a. is attached; or
b. is not attached (Provide explanation); or
c. was forwarded to the NRC
on:
Email Address:
Date:
3. A radiation survey is not required as only sealed sources were ever possessed under this license, and
a. The results of the latest leak test are attached; and/or
b. No leaking sources have ever been identified.
The person to be contacted regarding the information provided on this form:
Name

Title

Telephone Number (Include area code)

E-mail Address

Mail all future correspondence regarding this license to:

C. CERTIFYING OFFICIAL
I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT
Printed Name and Title

Signature of Certifying Official

Date

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 RESPECT. 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.

CERTIFICATE OF DISPOSITION OF MATERIALS
PLEASE READ THESE INSTRUCTIONS BEFORE COMPLETING NRC FORM 314.
Subpart E of 10 CFR Part 20 establishes the radiological criteria for license terminations/decommissioning of facilities
licensed under 10 CFR Parts 30, 40, 50, 60, 61, 70, and 72, as well as other facilities subject to the Commission's
jurisdiction under the Atomic Energy Act of 1954, as amended, and the Energy Reorganization Act of 1974, as amended.
INSTRUCTIONS
Section B, Item 2.
Licensees should describe the specific radioactive material transfer actions. If radioactive wastes were generated in
terminating this license, the licensee should describe the disposal actions taken, including the disposition of low-level
radioactive waste, mixed waste, greater-than-Class-C waste, and sealed sources.
Section B, Item 2.a.
The information provided concerning the transfer of radioactive material to another licensee should specify the date of the
transfer, the name of the licensee recipient, an individual contact name and telephone number for the licensee recipient,
and the recipient's NRC or Agreement State license number.
Section B, Item 2.b.
For disposal of radioactive materials, licensees should describe the specific disposal method or procedure (e.g., decay-instorage). For those cases when radioactive materials are disposed of by a licensed disposal site or by a waste
contractor, the licensee should specify the name, address, and telephone number of the licensed disposal site operator or
waste contractor.
Section B, Item 2.c.
"Residual radioactivity," as defined in 10 CFR 20.1003, means radioactivity in ‘areas' (structures, materials, soils, etc.)
remaining as a result of activities (licensed and unlicensed) under the licensee's control from sources used by the
licensee, excluding background radiation. ALARA is defined in 10 CFR 20.1003.
Section B, Item 2.d.
For transfer of radioactive materials licensees should attach a record of receipt from the recipient that contains
information regarding what was received (e.g., radioactive materials for disposal or transfer.)
FILE CERTIFICATES AS FOLLOWS:
IF YOU ARE LOCATED IN:
ALABAMA, CONNECTICUT, DELAWARE, DISTRICT OF
COLUMBIA, FLORIDA, GEORGIA, KENTUCKY, MAINE,
MARYLAND, MASSACHUSETTS, NEW HAMPSHIRE, NEW
JERSEY, NEW YORK, NORTH CAROLINA, PENNSYLVANIA,
PUERTO RICO, RHODE ISLAND, SOUTH CAROLINA,
TENNESSEE, VERMONT, VIRGINIA, VIRGIN ISLANDS, OR
WEST VIRGINIA, SEND CERTIFICATES TO:
LICENSING ASSISTANCE TEAM
DIVISION OF RADIOLOGICAL SAFETY AND SECURITY
U.S. NUCLEAR REGULATORY COMMISSION, REGION I
475 ALLENDALE ROAD, SUITE 102
KING OF PRUSSIA, PA 19406-1415
[email protected]
*Note: The preferred method to submit NRC Form 314 is email.

ILLINOIS, INDIANA, IOWA, MICHIGAN, MINNESOTA,
MISSOURI, OHIO, OR WISCONSIN, SEND CERTIFICATES
TO:
MATERIALS LICENSING SECTION
DIVISION OF RADIOLOGICAL SAFETY AND SECURITY
U.S. NUCLEAR REGULATORY COMMISSION, REGION III
2443 WARRENVILLE ROAD, SUITE 210
LISLE, IL 60532-4352
[email protected]
*Note: The preferred method to submit NRC Form 314 is email.

IF YOU ARE LOCATED IN:
ALASKA, ARIZONA, ARKANSAS, CALIFORNIA,
COLORADO, HAWAII, IDAHO, KANSAS, LOUISIANA,
MISSISSIPPI, MONTANA, NEBRASKA, NEVADA, NEW
MEXICO, NORTH DAKOTA, OKLAHOMA, OREGON,
PACIFIC TRUST TERRITORIES, SOUTH DAKOTA, TEXAS,
UTAH, WASHINGTON, OR WYOMING,
SEND CERTIFICATES TO:
MATERIALS LICENSING BRANCH
DIVISION OF RADIOLOGICAL SAFETY AND SECURITY
U.S. NUCLEAR REGULATORY COMMISSION, REGION IV
1600 E. LAMAR BOULEVARD
ARLINGTON, TX 76011-4511
[email protected]
*Note: The preferred method to submit NRC Form 314 is email.