NRC Form 748d Dispose Source

Submit by Email
U.S. NUCLEAR REGULATORY COMMISSION

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

DISPOSE SOURCE
NATIONAL SOURCE TRACKING TRANSACTION REPORT

APPROVED BY OMB: NO. 3150-0202

EXPIRES: (MM/DD/YYYY)

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)

8. SOURCE DISPOSAL DATA
A1. WASTE MANIFEST NUMBER

D1. SOURCE MAKE

B1. CONTAINER ID

E1. SOURCE MODEL

K1. SOURCE DISPOSAL ADDRESS L1. CITY

F1. SOURCE SERIAL
NUMBER

C1. METHOD OF DISPOSAL

G1. ISOTOPE H1. ACTIVITY AND UNIT I1. ACTIVITY DATE

M1. STATE

N1. ZIP CODE

J1. COMMENTS

O1. 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 748D (MM-DD-YYYY)

Page 1

U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 748D

(MM-DD-YYYY)
10 CFR 20.2207

LICENSEE NAME

LICENSE NO.

DISPOSE SOURCE
NATIONAL SOURCE TRACKING TRANSACTION REPORT
(continued)
8. SOURCE DISPOSAL DATA (continued)

A2. WASTE MANIFEST NUMBER

D2. SOURCE MAKE

B2. CONTAINER ID

E2. SOURCE MODEL

F2. SOURCE SERIAL G2. ISOTOPE H2. ACTIVITY AND UNIT I2. ACTIVITY DATE
NUMBER

K2. SOURCE DISPOSAL ADDRESS L2. CITY

A3. WASTE MANIFEST NUMBER

D3. SOURCE MAKE

C2. METHOD OF DISPOSAL

M2. STATE

N2. ZIP CODE

B3. CONTAINER ID

E3. SOURCE MODEL

K3. SOURCE DISPOSAL ADDRESS L3. CITY

J2. COMMENTS

O2. SAME AS STREET
ADDRESS

C3. METHOD OF DISPOSAL

F3. SOURCE SERIAL G3. ISOTOPE H3. ACTIVITY AND UNIT I3. ACTIVITY DATE
NUMBER

M3. STATE

N3. ZIP CODE

J3. COMMENTS

O3. 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 748D (MM-DD-YYYY)

Page 2

NRC FORM 748D

(MM-DD-YYYY)
10 CFR 20.2207

U.S. NUCLEAR REGULATORY COMMISSION

LICENSEE NAME

LICENSE NO.

DISPOSE SOURCE
NATIONAL SOURCE TRACKING TRANSACTION REPORT
(continued)
8. SOURCE DISPOSAL DATA (continued)

A4. WASTE MANIFEST NUMBER

D4. SOURCE MAKE

B4. CONTAINER ID

E4. SOURCE MODEL

F4. SOURCE SERIAL G4. ISOTOPE H4. ACTIVITY AND UNIT I4. ACTIVITY DATE
NUMBER

K4. SOURCE DISPOSAL ADDRESS L4. CITY

A5. WASTE MANIFEST NUMBER

D5. SOURCE MAKE

C4. METHOD OF DISPOSAL

M4. STATE

N4. ZIP CODE

B5. CONTAINER ID

E5. SOURCE MODEL

K5. SOURCE DISPOSAL ADDRESS L5. CITY

J4. COMMENTS

O4. SAME AS STREET
ADDRESS

C5. METHOD OF DISPOSAL

F5. SOURCE SERIAL G5. ISOTOPE H5. ACTIVITY AND UNIT I5. ACTIVITY DATE
NUMBER

M5. STATE

N5. ZIP CODE

J5. COMMENTS

O5. 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 748D (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