appendix e, 741 - nrc form 741 am zbv zbv tr ...doe/nrc form 7.ll(10-2014) previous sditions are...

4
DOE/NRC FORM 7.ll (10-2014) Previous sditions are obsolete MANDATORY DATA COLLECTION AUTHORIZED BY 1O CFR 30,40, 50,70, 72,74,75, 150 Public Lffi 83-703, 93-438, 9t91 U, S, DEPARTMENT OF ENERGY AND U, S. NUCLEAR REGULATORY COMMISSION NUCLEAR MATERIAL TRANSACTION REPORT APPROVEDBYOMB: NO.3150-0003 EXPIRES: 10131t2017 Estimaled budsn per rosponse to comply wilh lhis mandaiory collootion roquo6t: t hour and 15 minulos, This informalion is roquired ,or lAEl accounling reports lhal 6how changes in invenlory of nucl€ar malorials. S€nd comments regarding butdon gslimale lo lho FOIA, Privacy anc lnlolmalion Colloctions Branch (T-5 F53), U.S. Nuclear Regulalory Commis6ion, Washinglon, DC 20555-0001, or by inl€rnot e{ail k lnbmllmto.Rwuro@nrc{ov, md to lhe Dsk Offs, Off@ of lnbmatio md Regulatsy Afiairs, NE0S10202, (3150{003), OffE o Mms.m.nl tnd R'dGt WzdihdtM m rnqnl I ' h6a.,'.d t^ ih^m6 a i^Idm.l;n dH; /&. -^t ri.^l-, - ^.-,-^{- --li" OMB @nlrol numbor, tlE NRC may not @nducl or sponsr, and a ptrson is rct required to respond lo, lh6 inbrmalion ooleolion, SHIPP€i'SR6 2,NECEIVER'SRI6 3,TRANSACTIONNO, 4,COiRECTPNNO, S,PROCESSINGCOOE 6, ACTION CODE I 7. O@UM EiTATtOtr (On' ir documnt i. .hdn.d 6Ec R ET) ZBY ZBV ]UNCI707 ..SH,PPERA ". srtopcn M b. RTCEMER i "^oa oF eAGEa con oF coDrEs 6ERIEg NAMEANOADDRE6S b.LtrENSE OFSHIPPER NO. NAMEAND ADDNESS b, LICENAE OF REC€NER NO, 10. NooFo^ra uNEs2 1 1, NATURE OF TRANEACTbN DIATRIBUTION OFCOPIES Cabrera Services Inc, 50 Founders Plaza ste 207 East Hartford Ct 06 I 08 ' ^TrENrroN' Mike Plonski d.rErEFHoN€: (860) 794-6915 brera Services Inc. Founders Plazaste}}T rt Hartford Ct 06108 c. ATTENTIoN Mike Plonski (860) 7e4-691s 2 5 14, TRANSFER AUTHORITY- CONTRACT, NM DRAFT, OR ORDEI NUMBER 15. EXPOFTOR IMPORIIFANSFERS LICENSE NO, 16. MATERIAL TYPE AND OESCRIPTION 17, UNE f,U[8ER OALEATbN 10. 20. OALBTED ELilENTrereHT I For Enrth.d UDnlom Or{y 22, ACTIO! OATE lDO) l l b.coNcrsE NoIEATTAGHEO L ] c.uKFEPoRTB!E? ll "." f l ". b.SHIPPER'S CORNECTION 04 26 2017 d. RrcEMERS M*URES€NI .. f ECEMER'S CORRECTION 21, TOTAL6ROSStrtGHt 25. iolAL votUME (W.tt Tr.n.t B OnM F cl !, c IIJ I o. - o @ REFENENCE LINE NO, (TEM/BATOH NAME) IIEUg t. d. cooE xry MEAg.IOENI, oRossffitGHt t. NETtrIGHI ELEMENI EIEMENT LIMIT OF ERROR ISOTOPE MEBT j 2 I GFLU1483 I z0 776 l5 15 59 13 3FLU2t98 I z0 776 ;6 8.1 1 llo f f f 2r,. s*tpy:I:<?KuffirHoRrzEoo,^""rErF2;y t ) .1, .1, 02Ts.RECETVER.SDATA SIGNATUREoFAUTHoRIZEDoFFIoIALNDDA',iEEiENED F ct a & ul Lu o UJ t il N 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 1OO1 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. oogNRc FoRM 741 (10-2014) 1 3 6 7 I l l 3 I I I I I tl I l l tt I I I I i tt i I I ttl I I I tl I I I tl tl I tl I I I tttti I I

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Page 1: Appendix E, 741 - NRC Form 741 AM ZBV ZBV TR ...DOE/NRC FORM 7.ll(10-2014) Previous sditions are obsoleteMANDATORY DATA COLLECTIONAUTHORIZED BY 1O CFR 30,40, 50,70,72,74,75, 150 Public

DOE/NRC FORM 7.ll(10-2014) Previous sditions are obsoleteMANDATORY DATA COLLECTIONAUTHORIZED BY 1O CFR 30,40, 50,70,72,74,75, 150Public Lffi 83-703, 93-438, 9t91

U, S, DEPARTMENT OF ENERGYAND

U, S. NUCLEAR REGULATORY COMMISSION

NUCLEAR MATERIAL TRANSACTION REPORT

APPROVEDBYOMB: NO.3150-0003 EXPIRES: 10131t2017

Estimaled budsn per rosponse to comply wilh lhis mandaiory collootion roquo6t: t hour and 15 minulos, This informalion is roquired ,or lAElaccounling reports lhal 6how changes in invenlory of nucl€ar malorials. S€nd comments regarding butdon gslimale lo lho FOIA, Privacy anclnlolmalion Colloctions Branch (T-5 F53), U.S. Nuclear Regulalory Commis6ion, Washinglon, DC 20555-0001, or by inl€rnot e{ail klnbmllmto.Rwuro@nrc{ov, md to lhe Dsk Offs, Off@ of lnbmatio md Regulatsy Afiairs, NE0S10202, (3150{003), OffE oMms.m.nl tnd R'dGt WzdihdtM m rnqnl I

' h6a.,'.d t^ ih^m6 a i^Idm.l;n dH; /&. -^t ri.^l-, - ^.-,-^{- --li"

OMB @nlrol numbor, tlE NRC may not @nducl or sponsr, and a ptrson is rct required to respond lo, lh6 inbrmalion ooleolion,

SHIPP€i'SR6 2,NECEIVER'SRI6 3,TRANSACTIONNO, 4,COiRECTPNNO, S,PROCESSINGCOOE 6, ACTION CODE I 7. O@UM EiTATtOtr (On' ir documnt i. .hdn.d 6Ec R ET)

ZBY ZBV ]UNCI707 ..SH,PPERA".

srtopcn M b. RTCEMER i "^oa oF eAGEa con oF coDrEs 6ERIEg

NAMEANOADDRE6S b.LtrENSEOFSHIPPER NO.

NAMEAND ADDNESS b, LICENAEOF REC€NER NO, 10. NooFo^ra uNEs2 1 1, NATURE OF TRANEACTbN DIATRIBUTION OFCOPIES

Cabrera Services Inc,50 Founders Plaza ste 207

East Hartford Ct 06 I 08

' ^TrENrroN' Mike Plonskid.rErEFHoN€: (860) 794-6915

brera Services Inc.Founders Plazaste}}Trt Hartford Ct 06108

c. ATTENTIoN Mike Plonski

(860) 7e4-691s

2

5

14, TRANSFER AUTHORITY- CONTRACT, NM DRAFT, OR ORDEI NUMBER 15. EXPOFTOR IMPORIIFANSFERS LICENSE NO,

16. MATERIAL TYPE AND OESCRIPTION17,

UNEf,U[8ER OALEATbN

10. 20.

OALBTEDELilENTrereHT

I

For Enrth.d UDnlom Or{y

22, ACTIO! OATElDO)

l lb.coNcrsE NoIEATTAGHEO

L ]

c.uKFEPoRTB!E? ll "." f l ".

b.SHIPPER'S CORNECTION

04 26 2017

d. RrcEMERS M*URES€NI

.. f ECEMER'S CORRECTION

21, TOTAL6ROSStrtGHt 25. iolAL votUME (W.tt Tr.n.t B OnM

Fcl!,cIIJIo.-o@

REFENENCELINENO, (TEM/BATOH NAME) IIEUg

t. d.

cooExry MEAg.IOENI, oRossffitGHt

t.

NETtrIGHI ELEMENI EIEMENTLIMIT OFERROR

ISOTOPEMEBT

j2

I GFLU1483 I z0 776 l5 15 59 13

3FLU2t98 I z0 776 ;6 8.1 1 llo

f f f 2r,. s*tpy:I:<?KuffirHoRrzEoo,^""rErF2;y t ) .1, .1, 02Ts.RECETVER.SDATA

SIGNATUREoFAUTHoRIZEDoFFIoIALNDDA',iEEiENED

F

cta&ul

LuoUJtilN

WARNING: FALSE STATEMENTS IN THIS CERTIFICATE MAY BE SUBJECT TO CIVIL AND/OR CRIMINAL PENALTIES. NRC REGULATIONS REQUIRE THAT SUBMISSIoNS To THE NRCBE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECTS. 18 U.S.C. SECTION 1OO1 MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT ORREPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTER WITHIN ITS JURISDICTION.

oogNRc FoRM 741 (10-2014)

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Page 2: Appendix E, 741 - NRC Form 741 AM ZBV ZBV TR ...DOE/NRC FORM 7.ll(10-2014) Previous sditions are obsoleteMANDATORY DATA COLLECTIONAUTHORIZED BY 1O CFR 30,40, 50,70,72,74,75, 150 Public

DOE/NRC FORM 74{(10-2014) Previous sditions are obsoletaMANDATORY DATA COLLECTIONAUTHORIZED BY 1O CFR 30, 40,50, 70,

72,74,75,150

U. S. DEPARTMENTOF ENERGYAND

U. S. NUCLEAR REGULATORY COTIIIISSION

PubricLawss3-703'e3'438'ss-el NUCLEAR MATERIAL TRANSAcfloN REpoRT

APPROVEDBYOMB: NO.3150{003 EXPIRES: 1013112017

Eslimal€d buden ps rspon66 lo cmply with tis mildatory @ll6lis r€qu6t t h@r and 15 minutes. This informalim i8 required lor IAEA

lnlormalion Coileclions Branch (T-5 t53), U.S. Nuclear Regulatory Commission, Washinglon, DC 20555{001, or by jnbnot o-mail tolnlocollets,Re6ource@nrc,gov, and to the Desk oflic€r, Offce of lnformation and Regulalory Affairs, NEOB-10202, (3150-0003), Ofice ofManagomonl and Budg6t, Washinglon, DC 20503, ll a m€anE used lo impos an informalion ooll@lion doo8 noi display a currently valid

OMB conkol numb€r, lho NRC may nol conducl or sponsor, and a porsm is nol required to roEpond lo, the intormalion colleclion.

IE 3, TRANEACTDN NO, 4, CORRECTIO( NO, i 5. PROCESSINGCODEr.sdtpptRS {S 2. RECENEi'E i

ZBY ZBV lUNCl709 I l' sHrPPEiA',iECENEi

.. sHrppEi M I o. n..em" i ,ree o. "*." | "o* oF c@6 SERIES

3.r. SME AID ADoiE6a

Cabrera Services I

ffi ;a...xArEAf,DADDREss |b,trcEx8Eio. I oFRECEMR l*:

IO, NO OF OATA LINES 2 11. NATUR€OFTRANSACTTON DETiEUIION OFCOPIES

Cabrera Services Inc.50 Founders Plaza sle 2O7

East Hartford Ct 06108

..ArE|roil: Mike Plonski

d.rELEPHotrE: (860) 794-6915

[:50 Founders Plaza sle 2O7

East Hartford Ct 06108

'^"'ntou'Mike Plonskid.rELEpHoNE: (860) 794-6915

2

5

6

14. TRANSFER AUTHORITY-CONTRACT NM DRAFT OR ORDER NUMBER EXTiTOR TMPORT TRANSFERSi IICENSE NO

16 MATERIAL TYPE AND DESCRIPTION 17,

LINENU[8ER

16.

O6LgTEDELEUEMEEHT

21.

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For Eilbd UEdh ody

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2' TOTALOROSSWIGHT 25. lOI AL voLuME (w..b f t ntuB OnU

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BACKHEFERENCE

NUMBER

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t. 9.

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KEY

j. t.

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EOTOPEE|6ffT

IBASIS

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WARNTNG: FALSE STATEMENTS IN THIS CERTIFICATE MAY BE SUBJECT TO CIVIL AND/OR CRIMINAL PENALTIES. NRC REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRCBE COMPLETE AND ACCUMTE IN ALL MATERIAL RESPECTS. 18 U.S.C. SECTION 1 OO1 MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY FALSE STATEMENT ORREPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTER WTHIN ITS JURISDICTION.

DOE/NRC FORM 741 (10-2014)

Page 3: Appendix E, 741 - NRC Form 741 AM ZBV ZBV TR ...DOE/NRC FORM 7.ll(10-2014) Previous sditions are obsoleteMANDATORY DATA COLLECTIONAUTHORIZED BY 1O CFR 30,40, 50,70,72,74,75, 150 Public

DOE'NRC FORiI 74I(10-20'14) PEvious editions are obsoleteMANDATORY DATA COLLECTIONAUTHORIZED BY 1O CFR 30,40, 50,70,72,-t4,75, 150Public Laws 83-703, 93-438, 95-91

iWiNUCLEAR

U. S. DEPARTIENTOF EtrtERGy

u. s. ilucLEAR *rdillro*" "otrrrssror{

MATERIAL TRANSACTION REPORT

APPROVEDBYOi|B: NO.31S0{003 EXp|RES: 10t3112017Eslimalod burden por responoe lo conply wilh this mmdatory @llslim roquest: I hou aM 15 minules. Thi6 informalion is roquired hr IAEAe@unilng ropods lhal show changes in inventdy of nudoar mateilals. Send Mmflls regarding burden slimale lo tro FOti, *ir."i.naInbrmalim collecliore Branch (T-5 F53), U.s- Nuolear Regulatory commission, wahiiglon, DC 20s5s{001, or by intorml mail tolnhmlbcts [email protected], and to lhe Desk olficer, offm ol lnbrmalion aa negulato'ry Affairu, Neoglozoz, tliso{g63j, brf.l

"jMamg€msnl and Budget, Wa8hinoton' Dc 20503, ll a means used to impom an infirmation collelion do€s not aiElay a curiendy vdiaoMB conlrcl numbel, tha NRC may nol conducl or sponsor, and a person is notrequired lo rg8pood lo, lhe inlormalion oolloction,

r.*rrenrs ] _2.nEcErvER'eRrs r.,*"roruo@*sr*cooE

lqv lzav pr.rcrzl I E*,",-A b,FFCEVER ,A,STIPDTRM b,FECEIVER DAGE OF PA{'S CCP\ .F CCPII! SERIES

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Cabrera Services Inr50 Founders Plaza s

] oFREcEIvER ] NO,_.-_ ..,_t Lro. loor olta LNes I 11, NATURE OF TRANSACTION otsIf,taunoN oF coPtEs

207LaDrera servlces lnc.50 Founders Plaza sE 207East Hartfbrd Ct 06108

c.ArErrcr: Mike Plonskid.Er€pHoNE: (860) 794-6915

b, Rt6

East Hartford Ct 06 108

"^"tntF*Mike Plonskid.rELEprcNE: (860) 7944915 5

14, TRANSFER AUTHORIry - CONTRACT, NM DRAFI, OR ORDER NUMBER i5. EXrcFtOi UrciT TiMERS: WmE No.

16, MATERIAL TYPE AND DESCRIPTION1a. 20,

OBLbAT€DELEMENTWErcHT

21.

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t.coisExorEAnrcHE" [-

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.. RECEIPT

d,iEOSVEiS MreUREME{T

05 II 20t7

.. RrcEMiScoRREcnox

24. TOTALGflOSS @6HI 25. tol AL lotuue lw..b ft ntu Onltt

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w^iilllrc: FALSE SIATEMENTS lN THls CERTIFICATEITAY gE ltlBJEBE coMPtEIE aND accUMTE lN au rvlArERlAL REsPEciIs. 18 U.sc. sEcTloN lml MAxes ne cnttrner orresl ro ueie r wuEiii-rriii EiiiE[-i* o"REPRESENTATION TO ANY OEPARTUENT OR AGENCY OF THE UNITED SIATES AS TO AI.IV UATTEN VIfrIiI rS IUNlsOrcIOI,DOE/NRC FORM 741 (10-2014)

Page 4: Appendix E, 741 - NRC Form 741 AM ZBV ZBV TR ...DOE/NRC FORM 7.ll(10-2014) Previous sditions are obsoleteMANDATORY DATA COLLECTIONAUTHORIZED BY 1O CFR 30,40, 50,70,72,74,75, 150 Public

DOE/NRC FORM 741 -."".""*,," U. S. DEPARTMENTOF ENERGY

1to-20t41 Previous editions ere obsolele g \ .,z/"a ANDi,a4lorioiy orrr coLLEcloN i {ffifi i U. S. NUGLEAR REGULATORY COl,lMlSSlONAUTHORTZED By 10 cFR 30,40,50,70, g"I(5tfJ'72,74,75,',t50PubricLa\ns83703'e3-438's$e'r

NUGLEAR MATERIAL TRANSAciloN REpoRT

APPROVED BY OMB: NO. 3150-0003 EXPIRES: '101311201f

:slimaled burden per rosponso lo comply wilh this mandalory coll4tion roquos| t hour and 15 minutes. This informatis iE required for IAEAtcoounling reports thal show changes in inventory ol nucloar matarials. Send comm6nts rogarding burden estimat€ lo lh6 FOIA, Privacy and

ntormalion Colloctions Branch (T-5 F53), U.S. Nuol€a Rogulatory Commision, Washirgton, DC 20555{001, or by inl6rn6t s-mail lonlocolecls.R*[email protected], and to itE Desk otfcer, Off@ of lnfomalion sd R€gulatoy Alfairs, NEO&10202, (3150{003), Off@ ofUanag€mml and Budgot, Washington, DC 20503. ll a m€ans us6d lo impoEo an infomation collelion doe8 nol display a cutrendy validIMB @nlrol numb€I, th€ NRC may not mf,duct or sponsor, and a person is nol rsquited lo rospond lo, lheinfomalion colloclion.

shtFpER'BRts 2,ReCENER'6R16 3.TnAN6ACTIONNO, 4,6OfiRECTIONNO. S.PROCESSINGCOOE ACTDN CODE 7. D@UMEITAT|ON (Onf td.cumnl ri cti..fi.d SECRE'

ZBV ZBV UNC 1704 ..SHTPPERA b, RECEMEi ..sHlppERM lo.aa"a"a* paGE oF p&Es cofr oF "o",a"]

SEFIES

a...il&EANDrcoFEss Iot SHIPPER

I

Cabrera Services Inr

LICENSE 9...NAMEAtrDADORESS b.LtsENSENO, OF RECEVEi NO. ro. No oF DArA L|NE62 11, NATURE OF Ti NSACIFT mmBuTbtr oF coPtEs

Cabrera Services Inc.50 Founders Plaza sle 207East Hartford Ct 06108

q.ArENrEri Mike Plonskid.rElEPHoilE, (860) 794-6915

50 F'ounders Plaza sre lu tEast Hartford Ct 06108

c.arENrEN: Mike Plonskid.rELEPrc{E: (t60) 79+6915

3

14. TRANSFER AUTHORITY - CONTRACT, NM DRAFT OR ORDER NUMBER 15, EXPORTOR IMPORT TiANSFERS: LICENSE NO.

T

16. MATERIAL ryPE AND DESCRIPTION

LItrENUMEER

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OELIGATEOELEMENTMIGXI

71. T 6

For €nrichod UnnllmOat B

{oo)

b.CONC16E NOTEANAChEO

c.uKREPoRraBLE? [] tr. fl *o

b,SHIPPEF6CORFECTION

03 t7 2017

d, f, ECEN€i'S MASUREMEtrT

., REcENEi'sCoiRECTION

24, TOTALOSOSS WEEHI 25, IAIAL VoLUME (w.st. Tr.hsl.6 aD19

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F

o?d,u.l

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WARNING: FALSE STATEMENTS lN THIS CERTIFICATE MAY BE SUBJECT TO CIVIL AND/OR CRIMINAL PENALTIES. NRC REGULATIONS REQUIRE THAT SUBMISSTONS TO THE NRCBE COMPLETE AND ACCURATE IN ALL MATERIAL RESPECTS. 18 U.S.C. SECTION 1OO1 MAKES IT A CRIMINAL OFFENSE TO MAKE A WLLFULLY FALSE STATEMENT ORREPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTER WITHIN ITS JURISDICTION.

DOSNRC FORM 741 (1O-2O14)