Form DOE/NRC Form 742C DOE/NRC Form 742C Physical Inventory Listing

NRC FORM 742C

(MM-DD-YYYY)
MANDATORY DATA COLLECTION
AUTHORIZED BY 10 CFR 30, 40,
50, 70,72, 74, 75, 150,
Public Laws 83-703, 93-438, 95-91

U.S. DEPARTMENT OF ENERGY
AND
U.S. NUCLEAR REGULATORY COMMISSION
PHYSICAL INVENTORY LISTING

APPROVED BY OMB: NO. 3150-0058

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory collection request: 2 hours for small licensees and 6 hours for large licensees. This information is required
by NRC to fulfill its safeguards responsibilities, bilateral agreements, and responsibilities as a participant in the US/IAEA Safeguards Agreement. 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, (3150-0058), Attn: Desk Officer for the Nuclear
Regulatory Commission, 725 17Street 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. NAME AND ADDRESS

2. REPORTING IDENTIFICATION SYMBOL (RIS)

STREET ADDRESS

CITY

STATE

ZIP CODE

3. INVENTORY DATE

4. LICENSE NUMBER(S)

5. BATCH DATA
a.
b.
MATERIAL COMP/FAC
TYPE
CODE

c.
ELEMENT WEIGHT

d.
ISOTOPE WEIGHT

e.
DOE PROJECT NO.

f.
SCRAP
PROGRAM

g.
WEIGHT PERCENT ISOTOPE

h.
i.
OWNER SEQUENCE
CODE
NUMBER

j.
BATCH NAME

k.
NO. OF
ITEMS

l.
KEY
MEASURE
POINT

m. MEASUREMENT I.D.
MEAS.
BASIS

OTHER MEAS.
POINT

MEAS.
METHOD

n.
ENTRY
STATUS

o.
MBA

p.
SITE
IDC

q.
PROCESS
CODE

6. TOTALS

7. SIGNATURE

8. TITLE

9. 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.
NRC FORM 742C (MM-DD-YYYY)

To the best of my knowledge and belief, the information given above and in any attached schedules is true, complete, and correct.