Nrc Form 313 - Certificate Of Disposition Of Materials Page 2
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2U.S. NUCLEAR REGULATORY COMMISSION
APPROVED BY OMB: NO. 3150-0028
EXPIRES: 02/29/2020
NRC FORM 314
(02-2017)
10 CFR 30.36(j)(1);
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
40.42(j)(1); 70.38(j)(1);
CERTIFICATE OF DISPOSITION
burden estimate to the FOIA, Privacy, and Information Collections Branch (T-5 F53), U.S. Nuclear Regulatory Commission,
and 72.54(k)(5)(1)(1)
Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.gov, and to the Desk Officer, Office of Information
OF MATERIALS
and Regulatory Affairs, NEOB-10202, (3150-0028), Office of Management and Budget, Washington, DC 20503. If a
means used to impose an information collection does not display a currently valid OMB control number, the NRC may not
conduct or sponsor, and a person is not required to respond to, the information collection.
LICENSE NUMBER
DOCKET NUMBER
LICENSEE NAME AND ADDRESS
LICENSE EXPIRATION DATE
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 under this license.
All activities authorized by this license have ceased, and all radioactive materials procured and/or possessed by the licensee
2.
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 such that any remaining residual radioactivity is within the limits of 10 CFR
Part 20, Subpart E, and is ALARA.
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:
c. was forwarded to NRC on:
a. is attached; or
b. is not attached (Provide explanation); or
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 (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
SIGNATURE
PRINTED NAME AND TITLE
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.
NRC FORM 314 (02-2017)
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