Form 241 Report of Proposed Activities in Non-Agreement State Are

1
NRC FORM 241

U.S. NUCLEAR REGULATORY COMMISSION

(MM-DD-YYYY)

REPORT OF PROPOSED ACTIVITIES IN NONAGREEMENT STATES, AREAS OF EXCLUSIVE
FEDERAL JURISDICTION, OR OFFSHORE WATERS
(Please read the instructions before completing this form)

APPROVED BY OMB: NO. 3150-0013

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory collection request: 30 minutes. This notification is required so that NRC
may schedule inspection of the activities to ensure that they are conducted in accordance with requirements for protection of the public
health and safety. 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, (3150-0013), 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.

2. Type of Report

1. Name of Licensee (Person or firm proposing to conduct the activities described below)

Initial
3. Address of Licensee (Mailing address or other location where licensee may be located)

Change
5. Business Telephone Number

4. Licensee Contact and Title

5a. Business Cellular Telephone Number

6. Business Facsimile Telephone Number

7. Business Email Address

8. Activities to be conducted under the general license given in 10 CFR 150.20

Well Logging

Leak Testing and/or Calibrations

Portable Gauge

Other (Specify)

Type of Service

Registered as user of packaging (Certificates of Compliance Numbers)

Radiography
9. [Client Name and Address] [Point of Contact Name and Title]

10. Actual physical address of work location (Street, Number or other location, GPS Coordinates if known)

11. Client Business Telephone Number
Business Office

13. Dates Scheduled
From

To

14. Number of Work Days

Weekends

Yes

15. Add

12. Work Location Telephone Number
Business Office

Business Cell

16. Delete

Business Cell

17. Location Refer. Num. (Assigned by NRC)

No

LIST ADDITIONAL WORK SITES ON SEPARATE SHEET(S) TO INCLUDE ALL INFORMATION IN ITEMS 10-17 ABOVE.
18. List Radioactive Material, which will be possessed, used, installed,
serviced, or tested. (Include description of type and quantity of
radioactive material, sealed sources, or devices to be used.)

Model Number

Device Type / Sealed Sources

License Number

19. Agreement State Specific License which authorizes the undersigned to conduct
activities which are the same, except for location of use, as specified in item 10 above.
(One copy of the specific license must accompany the initial NRC Form 241.)

State

Expiration Date

20. CERTIFICATION (Must be completed by applicant)
I, THE UNDERSIGNED, HEREBY CERTIFY THAT:
a. All information in this report is true and complete.
b. I have read and understand the provision of the general license 10 CFR 150.20 reprinted on the instructions of this form; and I understand that I am required to comply with these
provisions as to all byproduct, source, or special nuclear material which I possess and use in Non-agreement States or offshore waters under the general license for which this
report is filed with the U. S. Nuclear Regulatory Commission.
c. I understand that activities, including storage, conducted in non-Agreement States under general license 10 CFR 150.20 are limited to a total of 180 days in calendar year. With the
exception of work conducted in off-shore waters, which is authorized for an unlimited period of time in the calendar year.
d. I understand that I may be inspected by NRC at the above listed work site locations and at the Licensee home office address for activities performed in non-Agreement States or
offshore waters.
e. I understand that conduct of any activities not described above, including conduct of activities on dates or locations different from those described above or without NRC
authorization, may subject me to enforcement action, including civil or criminal penalties.
Approved by RSO or Management Representative (Printed Name and Title)

Signature

Date

Total Usage - Days to 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 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.

FOR
NRC
USE
ONLY

Approved by (Typed/Printed Name and Title)

Sensitive-Security Related MD 3.4 Non-Public a.3

Signature

Date

ADAMS ML #

Total Usage - Days to Date

APPROVED BY OMB: NO. 3150-0013
EXPIRES: (MM/DD/YYYY)

NRC FORM 241
(MM-DD-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION
EXCLUSIVE FEDERAL JURISDICTION, OR OFFSHORE WATERS
PLEASE READ THIS INFORMATION AND THESE INSTRUCTIONS BEFORE COMPLETING NRC FORM 241
Section 150.20 of 10 CFR 150 establishes a general license authorizing any person who holds a specific license from an "Agreement
State" (a State with which the U.S. Nuclear Regulatory Commission has entered into an effective agreement under subsection 274b of
the Atomic Energy Act of 1954) where the licensee maintains an office for directing the licensed activity and at which radiation safety
records are normally maintained, to conduct the same activity in Non-Agreement States, areas of exclusive Federal jurisdiction, or in
offshore waters if the specific license issued by the Agreement State does not limit the authorized activity to specified locations or
installations.

INSTRUCTIONS
Licensees cannot perform work in areas of exclusive Federal jurisdiction without either (a) filing NRC Form 241 for reciprocity in
accordance with 10 CFR 150.20(b) or (b) applying for a specific NRC license. An area of exclusive Federal jurisdiction is an area over
which the Federal government exercises legal control without interference from the jurisdiction and administration of State law. For
example: If the work is to be performed on Federal property in an Agreement State, the licensee must first determine the jurisdictional
status of the area where the licensee plans to work. If the jurisdictional status of the work site is unknown to the licensee, the
Agreement State licensee should contact the Federal agency that controls the facility where the work is to be performed. A written
statement concerning the jurisdictional status is not required in order to file for reciprocity; however, it is recommended that the
Agreement State licensee obtain such a statement for the file for future reference and inspection purposes.
For licensees seeking to conduct activities under reciprocity for the first time in a calendar year, submit this Form, one copy of the
Agreement State specific license and the fee specified in fee Category 16, 10 CFR 170.31. NRC must receive this filing at least 3 days
before the licensee engages in activities permitted under the General License established by Section 150.20 of 10 CFR 150.
In general, the preferred method of filing is through email of NRC Form 241, a copy of the Agreement State license, and evidence that
the appropriate fee requirements will be met within 3 days. This evidence can be a copy of the check or a copy of NRC Form 629, if
paying by credit card, that will be mailed to the NRC. The licensee should receive confirmation (by email, telephone, or facsimile) that
NRC has received the facsimile. Alternatively, the licensee may file the required information through the mail or other means as long
as NRC receives the information at least 3 days before the licensee engages in the activity.
In completing NRC Form 241, it is important that the information submitted on NRC Form 241 be specific regarding the location and
date of use as well as the activity requested. If it is not possible to provide complete information, such as addresses for the locations
of work, the licensee should contact the appropriate Regional Office to discuss proposed work activities. The licensee is responsible
for providing additional information as revisions or clarifications as soon as such information becomes available.
Item 2. For licensees seeking to conduct activities under reciprocity for the first time in a calendar year, submit this Form, one copy of
the Agreement State specific license and the fee specified in fee Category 16, 10 CFR 170.31. NRC must receive this filing at least 3
days before the licensee engages in activities permitted under the General License established by Section 150.20 of 10 CFR 150. The
licensee should check the "initial" box if this is the first submission of NRC Form 241 for the year.
For modification such as the information submitted on the initial NRC Form 241, such as additional work locations, changes to
radioactive material, work activities, information that clarifies or deletes specific locations, or work sites, work site contacts, or adds or
deletes dates of work, licensees should file by NRC Form 241 or letter, so that NRC receives the filing at least 3 days prior to engage
in such activity. Licensees should check the "change" box to indicate changes to the information provided on the initial NRC Form
241. It is not necessary to resubmit the Agreement State license unless the license has been amended since the filing of the initial
NRC Form 241. No fee is required for changes. NRC Form 241 may be used for submitting multiple work locations and clients for
initial filings of NRC Form 241, as well as for submitting changes to previous filings. Separate sheets maybe used provided it includes
all of the requested information in Items 10-17 of NRC Form 241.
Under the general license, reciprocity activities are authorized only as long as the licensee holds a valid radioactive material license.
If the license expires during the year, an extension letter or a renewed license issued by the regulating agency must be submitted to
NRC before performing any additional work under reciprocity.
Item 8. Licensees should be advised that the documents containing sensitive information must be marked and protected in
accordance with any applicable security requirements. This applies to information transmitted to and from the NRC as well as
maintained for record keeping purposes.
Item 9. Licensees should provide the contact information for the applicant's field staff, the individual who directs the work of the
applicant for the client.
Item 10. Licensees should provide driving directions for locations of work without physical addresses or in remote locations. If known,
licensees should include Global Positioning System (GPS) coordinates.
NRC FORM 241 (MM-DD-YYYY)

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APPROVED BY OMB: NO. 3150-0013
EXPIRES: (MM/DD/YYYY)

NRC FORM 241
(MM-DD-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION
EXCLUSIVE FEDERAL JURISDICTION, OR OFFSHORE WATERS
INSTRUCTIONS (Continued)
Items 13. - 17. Under the general license, reciprocity activities, including storage (usage), conducted in non-Agreement States and
areas of exclusive Federal jurisdiction, are limited to a total of 180 days in any calendar year except for work conducted in off-shore
waters, which is authorized for an unlimited period of time in a calendar year. NRC tracks reciprocity usage on the basis of approved
usage days. NRC will not approve any activity under the general license which causes the total usage days to exceed 180 days,
except for work conducted in off-shore waters. NRC may note and notify the licensee that a filing proposes reciprocity activities which
approach or would exceed the 180-day limit. It is important that licensees track the days of use and clarify or delete dates of work
when applicable. Item 13. should reference the proposed beginning and ending dates of work for each work location, and indicate if
work will be performed on weekends, with the total number of days worked recorded in Item 14. Item 15. should be completed to
show additional work dates different from those provided on the initial NRC Form 241 and Item 16. should indicate dates when work
was not performed, as initially requested, that need to be deleted from the total work days. The Location Reference Number in Item
17. is generated by the NRC for use in tracking reciprocity activities and is specific for each work location. The Location Reference
Number should be referenced for any changes to work location information.
Item 18. Licensees should identify the specific make and model numbers of sealed sources and devices.
NOTE:

Inspections by NRC of activities performed in non-Agreement States, areas of exclusive Federal jurisdiction, or offshore
waters by Agreement State licensees operating under the general license in 10 CFR 150.20 will be conducted at the listed
work site location(s). Failure to file an NRC Form 241 may result in the issuance of a notice of violation, the proposed
imposition of a civil penalty, or an order suspending, modifying, or revoking the license as specified in the "General
Statement of Policy and Procedures for NRC Enforcement Actions."

Agreement State licensees seeking to conduct activities under Reciprocity should file this Form, one copy of the Agreement State
license, and the appropriate fee with the U.S. Nuclear Regulatory Commission Regional Administrator listed below for the region in
which the Agreement State that issued the specific license is located:

Note: Email is the preferred method to submit NRC Form 241.
IF THE AGREEMENT STATE LICENSE IS ISSUED BY:

IF THE AGREEMENT STATE LICENSE IS ISSUED BY:

Alabama, Florida, Georgia, Kentucky, Maine, Maryland,
Massachusetts, New Hampshire, New Jersey, New York,
North Carolina, Pennsylvania, Rhode Island,
South Carolina, Vermont, Virginia, or Tennessee

Illinois, Iowa, Minnesota, Ohio, or Wisconsin,

SEND APPLICATION AND FEE PAYMENT TO:
Regional Administrator
Division of Radiological Safety and Security
ATTN: Reciprocity Request
U.S. Nuclear Regulatory Commission, Region I
475 Allendale Road, Suite 102
King of Prussia, PA 19406-1415
[email protected]
Telephone Number (800) 432-1156
Facsimile Number (610) 337-5349

SEND APPLICATION AND FEE PAYMENT TO:
Regional Administrator
Division of Nuclear Material Safety
ATTN: Reciprocity Request
U.S. Nuclear Regulatory Commission, Region III
2443 Warrenville Road, Suite 210
Lisle, IL 60532-4352
[email protected]
Telephone Number (630) 829-9887
Facsimile Number (630) 515-1259

IF THE AGREEMENT STATE LICENSE IS ISSUED BY:
Arizona, Arkansas, California, Colorado, Kansas,
Louisiana, Mississippi, Nebraska, Nevada, New Mexico,
North Dakota, Oklahoma, Oregon, Texas, Utah, or
Washington
SEND APPLICATION AND FEE PAYMENT TO:
Regional Administrator
Division of Nuclear Material Safety
ATTN: Reciprocity Request
U.S. Nuclear Regulatory Commission, Region IV
1600 E. Lamar Boulevard
Arlington, TX 76011-4125
[email protected]
Telephone Number (817) 200-1100
Facsimile Number (817) 200-1188
NRC FORM 241 (MM-DD-YYYY)

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