NRC-540_Form.pdf

PDF 658 KB Posted Aug 11, 2016

Attached to: Processing and Disposal of Low Level Radioactive Waste (LLRW) material
Solicitation number: SB1341-16-RQ-0828
Issued by: Department of Commerce National Institute of Standards and Technology

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NRC-540 Form

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SB1341-16-RQ-0828.docx	DOCX document	Aug 11, 2016

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COLLECTOR

UNIFORM LOW-LEVEL RADIOACTIVE WASTE MANIFEST

SHIPPING PAPER

NRC FORM 540

(05-2016)

U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 540 (05-2016)

APPROVED BY OMB: NO. 3150-0164

EXPIRES: 12/31/2016

PROCESSOR

7. NRC FORM 540 AND 540A PAGE 1 OF

NRC FORM 541 AND 541A

NRC FORM 542 AND 542A

ADDITIONAL INFORMATION

PAGE(S)

ORGANIZATION

GENERATOR TYPE

(Specify)

TELEPHONE NUMBER (Include Area Code)

EPA I.D. NUMBER

SHIPPING DATE

TELEPHONE NUMBER

(Include Area Code)

2. IS THIS AN "EXCLUSIVE USE" SHIPMENT?

YES

3. TOTAL NUMBER OF

PACKAGES IDENTIFIED

ON THIS MANIFEST

YES

DATE

10. CERTIFICATION

This also certifies that the materials are classified, packaged, marked, and labeled and are in proper condition for transportation and disposal as described in accordance with the applicable requirements of 10 CFR Parts 20 and 61, or equivalent state regulations.

AUTHORIZED SIGNATURE TITLE DATE

TOTAL PACKAGE

ACTIVITY IN SI UNITS

TOTAL WEIGHT

OR VOLUME

(Use appropriate units)

IDENTIFICATION

NUMBER OF

PACKAGE

FOR CONSIGNEE USE ONLY

Estimated burden per response to comply with this information collection request: 45 minutes. This uniform manifest is required by NRC to meet reporting requirements of Federal and State Agencies for the safe transportation and disposal of low-level waste. Send comments regarding burden estimate to the FOIA, Privacy and Information Collections Branch (T-5 F53), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.gov, and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0164), 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.

1. EMERGENCY TELEPHONE NUMBER (Include Area Code)

EPA MANIFEST NUMBER4. DOES EPA REGULATED

WASTE REQUIRING A

MANIFEST ACCOMPANY

THIS SHIPMENT?

If "Yes," provide Manifest Number

5. SHIPPER - NAME AND FACILITY

USER PERMIT NUMBER SHIPMENT NUMBER

CONTACT

6. CARRIER - Name and Address

CONTACT

SHIPPER I.D. NUMBER

TELEPHONE NUMBER

(Include Area Code)

DATE

8. MANIFEST NUMBER

(Use this number on all continuation pages)

9. CONSIGNEE - Name and Facility Address

SIGNATURE - Authorized consignee acknowledging waste receipt

CONTACT

U. S. DEPARTMENT OF TRANSPORTATION DESCRIPTION

(Including proper shipping name, hazard class, UN ID number, and any additional information)

12. DOT LABEL

"RADIOACTIVE"

SIGNATURE - Authorized carrier acknowledging waste receipt

13.

TRANSPORT

INDEX

14. PHYSICAL AND

CHEMICAL FORM

15.

INDIVIDUAL RADIONUCLIDES

16. 17. LSA/SCO

CLASS

11. 18. 19.

Instructions: See NUREG/BR-0204 for detailed instructions for completing this form:

http://www.nrc.gov/reading-rm/doc-collections/nuregs/brochures/br0204/ http://www.nrc.gov/reading-rm/doc-collections/nuregs/brochures/br0204/ c:\temp\ffdah1.wpf

DAH1

COLLECTOR

UNIFORM LOW-LEVEL RADIOACTIVE WASTE MANIFEST

SHIPPING PAPER

NRC FORM 540

(05-2016)

U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 540 (05-2016)

APPROVED BY OMB: NO. 3150-0164

EXPIRES: 12/31/2016

PROCESSOR

7. NRC FORM 540 AND 540A PAGE 1 OF

NRC FORM 541 AND 541A

NRC FORM 542 AND 542A

ADDITIONAL INFORMATION

PAGE(S)

ORGANIZATION

GENERATOR TYPE

(Specify) TELEPHONE NUMBER (Include Area Code)

EPA I.D. NUMBER

SHIPPING DATE

TELEPHONE NUMBER

(Include Area Code)

2. IS THIS AN "EXCLUSIVE USE" SHIPMENT?

YES

3. TOTAL NUMBER OF

PACKAGES IDENTIFIED

ON THIS MANIFEST

YES

DATE

10. CERTIFICATION

This is to certify that the herein-named materials are properly classified, described, packaged, marked, and labeled and are in proper condition for transportation according to the applicable regulations of the Department of Transportation. This also certifies that the materials are classified, packaged, marked, and labeled and are in proper condition for transportation and disposal as described in accordance with the applicable requirements of 10 CFR Parts 20 and 61, or equivalent state regulations.

AUTHORIZED SIGNATURE

TITLE

DATE

TOTAL PACKAGE

ACTIVITY IN SI UNITS

TOTAL WEIGHT

OR VOLUME

(Use appropriate units)

IDENTIFICATION

NUMBER OF

PACKAGE

FOR CONSIGNEE USE ONLY

G:\FORMS\LOGOS\NRCSEALblack (4).JPG

1. EMERGENCY TELEPHONE NUMBER (Include Area Code)

EPA MANIFEST NUMBER

4. DOES EPA REGULATED

WASTE REQUIRING A

MANIFEST ACCOMPANY

THIS SHIPMENT?

If "Yes," provide Manifest Number

5. SHIPPER - NAME AND FACILITY

USER PERMIT NUMBER

SHIPMENT NUMBER

CONTACT

6. CARRIER - Name and Address

CONTACT

SHIPPER I.D. NUMBER

TELEPHONE NUMBER

(Include Area Code)

DATE

8. MANIFEST NUMBER

(Use this number on all continuation pages)

9. CONSIGNEE - Name and Facility Address SIGNATURE - Authorized consignee acknowledging waste receipt

CONTACT

U. S. DEPARTMENT OF TRANSPORTATION DESCRIPTION

(Including proper shipping name, hazard class, UN ID number, and any additional information) 12.

DOT LABEL

"RADIOACTIVE"

SIGNATURE - Authorized carrier acknowledging waste receipt 13.

TRANSPORT

INDEX

14.

PHYSICAL AND

CHEMICAL FORM

15.

INDIVIDUAL RADIONUCLIDES

16.

17.

LSA/SCO

CLASS

11.

18.

19.

Instructions: See NUREG/BR-0204 for detailed instructions for completing this form:

http://www.nrc.gov/reading-rm/doc-collections/nuregs/brochures/br0204/

C_Exclusive Shipment: Off

C_EPA Reg: Off

Collector: Off

Processor: Off

Generator Type (Specify): Off

EPA I.D. NUMBER:

Shipping Date: (MM/DD/YYYY):

7. NRC Form 540 and 540A: Page 1 of ___________:

7. NRC Form 541 and 541A: ______ Page(s):

7. NRC Form 542 and 542A: ________ Page(s):

7. Additional Information: ______ (Page)(s):

9 Consignee - Name and Facility Address:

10. Certification Signature Date: (MM/DD/YYYY):

10. Certification: Title:

11. U. S. Department of Transportation Description (Including proper shipping name, hazard class, UN ID number, and any additional information): 1:

12. DOT Label "Radioactive": 1:

13. Transport Index: 1:

14. Physical and Chemical Form: 1:

15. Individual Radionuclides: 1A:

15. Individual Radionuclides: 1B:

15. Individual Radionuclides: 1C:

16. Total Package Activity in SI Units: 1:

17. LSA/SCO Class: 1:

18. Total Weight or Volume 1 (Use appropriate units):

19. Identification Number of Package 1:

11. U. S. Department of Transportation Description (Including proper shipping name, hazard class, UN ID number, and any additional information): 2:

12. DOT Label "Radioactive": 2:

13. Transport Index: 2:

14. Physical and Chemical Form: 2:

15. Individual Radionuclides: 2A:

15. Individual Radionuclides: 2B:

15. Individual Radionuclides: 2C:

16. Total Package Activity in SI Units: 2:

17. LSA/SCO Class: 2:

18. Total Weight or Volume 2 (Use appropriate units):

19. Identification Number of Package 2:

11. U. S. Department of Transportation Description (Including proper shipping name, hazard class, UN ID number, and any additional information): 3:

12. DOT Label "Radioactive": 3:

13. Transport Index: 3:

14. Physical and Chemical Form: 3:

15. Individual Radionuclides: 3A:

15. Individual Radionuclides: 3B:

15. Individual Radionuclides: 3C:

16. Total Package Activity in SI Units: 3:

17. LSA/SCO Class: 3:

18. Total Weight or Volume 3 (Use appropriate units):

19. Identification Number of Package 3:

11. U. S. Department of Transportation Description (Including proper shipping name, hazard class, UN ID number, and any additional information): 4:

12. DOT Label "Radioactive": 4:

13. Transport Index: 4:

14. Physical and Chemical Form: 4:

15. Individual Radionuclides: 4A:

15. Individual Radionuclides: 4B:

15. Individual Radionuclides: 4C:

16. Total Package Activity in SI Units: 4:

17. LSA/SCO Class: 4:

18. Total Weight or Volume 4 (Use appropriate units):

19. Identification Number of Package 4:

11. U. S. Department of Transportation Description (Including proper shipping name, hazard class, UN ID number, and any additional information): 5:

12. DOT Label "Radioactive": 5:

13. Transport Index: 5:

14. Physical and Chemical Form: 5:

15. Individual Radionuclides: 5A:

15. Individual Radionuclides: 5B:

15. Individual Radionuclides: 5C:

16. Total Package Activity in SI Units: 5:

17. LSA/SCO Class: 5:

18. Total Weight or Volume 5 (Use appropriate units):

19. Identification Number of Package 5:

11. U. S. Department of Transportation Description (Including proper shipping name, hazard class, UN ID number, and any additional information): 6:

12. DOT Label "Radioactive": 6:

13. Transport Index: 6:

14. Physical and Chemical Form: 6:

15. Individual Radionuclides: 6A:

15. Individual Radionuclides: 6B:

15. Individual Radionuclides: 6C:

16. Total Package Activity in SI Units: 6:

17. LSA/SCO Class: 6:

18. Total Weight or Volume 6 (Use appropriate units):

19. Identification Number of Package 6:

11. U. S. Department of Transportation Description (Including proper shipping name, hazard class, UN ID number, and any additional information): 7:

12. DOT Label "Radioactive": 7:

13. Transport Index: 7:

14. Physical and Chemical Form: 7:

15. Individual Radionuclides: 7A:

15. Individual Radionuclides: 7B:

15. Individual Radionuclides: 7C:

16. Total Package Activity in SI Units: 7:

17. LSA/SCO Class: 7:

18. Total Weight or Volume 7 (Use appropriate units):

19. Identification Number of Package 7:

11. U. S. Department of Transportation Description (Including proper shipping name, hazard class, UN ID number, and any additional information): 8:

12. DOT Label "Radioactive": 8:

13. Transport Index: 8:

14. Physical and Chemical Form: 8:

15. Individual Radionuclides: 8A:

15. Individual Radionuclides: 8B:

15. Individual Radionuclides: 8C:

16. Total Package Activity in SI Units: 8:

17. LSA/SCO Class: 8:

18. Total Weight or Volume 8 (Use appropriate units):

19. Identification Number of Package 8:

FOR CONSIGNEE USE ONLY:

1. Emergency Telephone Number (Enter 9 numeric digits):

Organization:

Total Number of Packages Identified on this Manifest:

EPA MANIFEST NUMBER:

5. Shipper - Name and Facility:

User Permit Number:

SHIPMENT NUMBER:

Contact - Shipper:

6. Carrier: Name and Address:

Contact - Carrier:

Shipper ID Number:

C7_Specify:

Shipper Telephone Number (Enter 9 numeric digits):

Authorized Signature Carrier Date: (MM/DD/YYYY):

8. MANIFEST NUMBER (Use this number on all continuation pages):

Contact - Consignee:

Consignee Telephone Number (Enter 9 numeric digits):

Carrier Telephone Number (Enter 9 numeric digits):

File details come from the government source that posted it. Updated Nov 14, 2017.