111I11111 11111 11111I 11II1I 11111 IIII IIII IIIII IIII IIIIII … · 2015. 3. 3. · 111i11111 iiiii 11111 11111i iiiiii 11ii1i 11111 iiii iiii iiiii iiii iiiiii 111111miiiiiiiii

111I11111 IIIII 11111 11111I IIIIII 11II1I 11111 IIII IIII IIIII IIII IIIIII 111111MIIIiiiiii 111111MIII IliiilIIiSECTION 1

PAGE 1 of 2U.S. NUCLEAR REGULATORY COMMISSION

GL-714332-19

01/05/2015

NRC FORM 664

02 - 2004

10 CFR 31.5GENERAL LICENSEE REGISTRATION

APPROVED BY OMB: NO. 3150-0198 EXPIRES: 03131/2010Estimated burden per response to comply with this mandatory coilection request: 20 minutes. NRC will use ths information to track general licensees and their deuces to ensure a higherleve ot device accountability. Send conmmnts regarding burden estimate to the Records and FOlAPrivacy Ser'lces Branch (T-5 F52), U.S. Nuclear Regulatory Cornrnssion, Washington,DC 20555-0001, or by internet e-mai to [email protected] to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0000). Office of Management endBudget 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, end aerson is not reouired to resoond to. the information collection.

Complete all six sections of this registration form. If any of the preprinted information is incorrect, provide thechanges in the applicable boxes. USE CAPITAL LETTERS.

General License

Registration Number

GL-714332-19

SECTION 1 - GENERAL LICENSEE INFORMATION

Enter the company name and the street address/physical location of use for your device(s). Forportable devices, specify the primary storage location. Do not use a P.O. Box address.

Company Name: PACIFICORP

I I I I I I I I I I I I I III I I I I I I I IDepartment: WYODAK POWER PLANT

I I II I I I I I I I I I I I I I I I I I I IAddress Line 1: 48 WYODAK ROAD

I I 1 -1l l 1 1IAddress Line 2: GARNER LAKE RTI I 1 -1 1I 1 1City: GILLETTE

I I I I I I I I p

I I I I I I I I I I

State: WY Zip Code: 82718 - E IiI I B Z

A A

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01/05/2015

I IllMil MIIII IIII IU III1 I III ISECTION 1

PAGE 2 of 2SECTION 1 - GENERAL LICENSEE INFORMATION (Continued)

Enter the name, telelphone number and title of the person who is the responsible individual for the device(s).

Last Name: BASTIAN

First Name: KEITH Middle Initial: L

Telephone: (307) 687-4230 Extension:

I III I I I T ] IITitle: PLANT MANAGING DIRECTOR

I I I I I I I I I I I III I I I I I I I I I I

Enter the mailing address where correspondence regarding your device(s) should be sent.This address should be specific to the use or storage location of your device(s).

Department: WYODAK POWER PLANT

Address Line 1: 48 WYODAK ROAD

Address Line 2: GARNER LAKE RT

I l l I 1 I I11 1 1 1 1 1 1 1City: GILLETTE

State: WY L] Zip Code: 82718- iiE• L• I - L __L

II

II

A A

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01/05/2015 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SEC

Our records indicate that you have these devices. Please update the information as necessary. PAGE

NRC Device Key 735715 (Internal Control Number)

Distributor/Distributed By: Stock Equipment Company

Distributor License Number: 1370-1

Manufacturer Name: STOCK EQUIPMENT COMPANY

Device Model (Not Source Model): D14400

Device Serial Number: SE3865

Transfer Date (Receipt Date): 11/09/1989Not in possession of device (Also

E] complete Section 4.)

MM DD YYYY

11111iiiIITION 2

- 1 of 14

Isotope (e.g. AM241)

1 CS137

2

3 DIDID4

5

6

Activity (e.g. 100)

25.000000000

Unit (e.g. mCi)

mCi

Dlii

Dlii

A A

GL-714332-19

01/05/2015 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SEC







Device Serial Number: SE3866I I I I I I I I I III I I I Il I I -Transfer Date (Receipt Date): 11/09/1989

Not in possession of device (AlsoEl complete Section 4.)

MM DD YYYY

,TION 2- 2 of 14


1 CS137

2

3

4

5

6 KIILLZI

Activity (e.g. 100)

25.000000000

Unit (e.g. mCi)

mCi

DID_

A A

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01/05/2015 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2

Our records indicate that you have these devices. Please update the information as necessary. PAGE 3 of 14








_[ complete Section 4.)

MM DD YYYY

Isotope (e.g. AM241) Activity (e.g. 100) Unit (e.g. mCi)

1 CS137 25.000000000

2

3 DILIIILZI4

5

6

FTT1

mCi

ElillillDIDDIEZZIDIDLwLIDI

A

1111111 IIIII 11111 11111 II 111111 0111111111111111 I IIIII 1111111 111111 IIII 11111 IIII iiiI IIIIGL-714332-19









Transfer Date (Receipt Date): 11/09/1989Not in possession of device (Alsocomplete Section 4.)

MM DD YYYY


1 CS137

W I[]2

3

4

5

6

Activity (e.g. 100)

25.000000000

Unit (e.g. mCi)

mCi

WIJIZ

A A

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01/05/2015 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SE(





I I I I I II I I ITManufacturer Name: STOCK EQUIPMENT COMPANY




E complete Section 4.)

MM DD YYYY

IIIII IIIII'TION 2E 5 of 14

I


1 CS137

2

3 IWIW4

5

6 EWIW

Activity (e.g. 100)

25.000000000

Unit (e.g. mCi)

mCi

LiiiLIJIJ

A A

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01/05/2015 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECTION 2Our records indicate that you have these devices. Please update the information as necessary. PAGE 6 of 14





I I I I I I I -TiI I IDevice Model (Not Source Model): D14400



E] complete Section 4.)

MM DD YYYY


1 CS137 25.000000000

'DID2

3

4

5

Dliii'6 ililll'

Flý

I I FTTI

Din

Din

111111II II~IIII II 1111II IIII IIII 11111 11111 11111 III 111111I IIIII 1111111 iii lii liii 1111GL-714332-19

01/05/2015 SECTION 2 - DEVICES SUBJECT TO REGISTRATION SECOur records indicate that you have these devices. Please update the information as necessary. PAGE




Manufacturer Name: STOCK EQUIPMENT COMPANYI I I I I I I I I I I I I I I IDevice Model (Not Source Model): D14400


1 1 1 1 1 1 1 I I I 11Transfer Date (Receipt Date): 11/09/1989

Not in possession of device (Also[] complete Section 4.)

MM DD YYYY

II IIIIIIII,TION 2

S7 of 14


1 CS137

2

3

4

5

6 DIDIZ.I

Activity (e.g. 100)

25.000000000

Unit (e.g. mCi)

mCiDIEZII_1_IDWECWE[_DIDIDE

A A

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I I I I I I I III I I I I IIDevice Serial Number: SE3872


_ complete Section 4.)

MM DD YYYY


1 CS137

2

3

4

5

6

EDJFTI

Activity (e.g. 100)

25.000000000

Unit (e.g. mCi)

mCi

DI_!II

A A

GL-714332-19






Manufacturer Name: STOCK EQUIPMENT COMPANYI I I I I I I I III I I I IDevice Model (Not Source Model): D14400



El complete Section 4.)

MM DD YYYY


1 CS137 25.000000000 mCi

2

3

4

5

6

A

EDZDiiDID

DliiiDuD

A

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Transfer Date (Receipt Date): 11/09/1989Not in possession of device (Alsocomplete Section 4.)

MM DD YYYY


1 CS137 25.000000000 mCi

2

3

4

5

6

LIIJIII

I I IIIIII

LiiizDIJIEDIIWEDIDDID

A

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Distributor/Distributed By: TN TECHNOLOGIES, INC.

Distributor License Number: L01105

Manufacturer Name: TN TECHNOLOGIES, INC.

Device Model (Not Source Model): 5201

Device Serial Number: B309


- complete Section 4.)

MM DD YYYY


1 CS137 100.000000000 mci

2

3

4

5

6

A

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Manufacturer Name: TN TECHNOLOGIES, INC.I I I I I I I I I III I I I I I I I IIIDevice Model (Not Source Model): 5201



-I complete Section 4.)

MM DD YYYY


1 CS137 100.000000000

DII2

3 DI4

DI1ILIJ5

6

iAl

I111]1111111

mCi

DIDDIDEDIZIDliiDiiDii

A

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I I I I I I I III I I I I I T -ITransfer Date (Receipt Date): 05/15/1985

Not in possession of device (AlsoD complete Section 4.)

MM DD YYYY


1 CS137 200.000000000 mCi

ZEL I2

3 wDl4

5

6

A

71

DID•

A

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TE complete Section 4.)

MM DD YYYY


1 CS137 200.000000000

2

3

4

5

6

A

~I I 17TTr l l

mCi

DIIIKillDliiiDIDDliiDlii

A

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01/05/2015 SECTION 3SECTION 3 -ADDITIONAL DEVICES SUBJECT TO REGISTRATION PAGE 1 of 1

Provide information about other devices you have that are subject to registration. Do not report specifically licensed devices.

Manufacturer Name

Initial Transferor Name

Initial Transferor License Number (if known)

Device Model Number (Not Source Model)

Device Serial NumberI

0 Manufacturer/Initial Transferor listed aboveHow acquired and date (e.g.,from a distributor/manufacturer, 0 Other General Licensee Date Transferred: fj [jj [ J•jother licensee, other source)? II

U Other Source (Received) MM DD YYYY

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.


K 11 =fZ~Tfli1

Activity (e.g. 100)

IIIII1III1

Unit (e.g. mCi)

"_'llEZIZEZ

K i il

A A

I IEIII

11111111II1111111 liiiI111IIII11111I111I1111IiiiHI111111111III11111I IIII"GL-714332-19 SECTION 4 - NOT IN POSSESSION OF DEVICE01/05/2015

Provide information about devices listed in Section 2 or 6, but no longer in your possession.

HIIII liiiI lIII lIII IIIiiSECTION 4

PAGE 1 of 1

Part I Transfer Date:

NRC Device Key: F TF L](from Section 2 or 6)MM DD YYYY

Location of the Device:

O Whereabouts Unknown (complete Part 1 only) 0 Transferred to another general licensee (complete Parts 2 and 3)

O Never Possessed the Device (complete Part 1 only) 0 Transferred to a Specific Licensee (Not the manufacturer)

O Returned to Manufacturer (complete Part 1 only) (complete Part 2)

Part 2 License Number of Recipient (if transferred to a specific licensee):

Company Name:

Department:

sI I I I I:I I I I I I I I I I I I I

Address Line 1:

Address Line 2:

City:

State: Zip Code: I I I - I I I

Part 3 Enter the name of the individual responsible for this device:

Last Name:

First Name: Middle Initial:

Telephone Number: Z:IL I 1 Extension:Title:

A A

IIII IIII III I 11IIII IIIII1111111111111 IIIII 11II11 111 IIII iiiIII 11111 IIIIII IIII IIII iii III IIGL-714332-19

01/05/2015SECTION 5 - CERTIFICATION SECTION 5

PAGE 1 of 1

I hereby certify that:

A. All information contained in this registration is true and complete to the best of my knowledge and belief.

B. A physical inventory of the devices subject to registration has been completed, and the device information on

this form has been checked against the device labeling.

C. I am aware of the requirements of the general license, provided in 10 CFR 31.5.

(Copies of applicable regulations may be viewed at the NRC website at:

httpj:w .g ovlreadinm/doc-collections/cfr)

21411<SIGNATURE - RESPONSIBLE INDIVIDUAL (Listed in Section 1) DATE

WARNING: FALSE STATEMENTS MAY BE SUBJECT TO CIVIL AND/OR CRIMINAL PENALTIES. NRC

REGULATIONS REQUIRE THAT SUBMISSIONS TO THE NRC BE COMPLETE AND ACCURATE IN ALL

MATERIAL ASPECTS. 18 U.S.C. SECTION 1001 MAKES IT A CRIMINAL OFFENSE TO MAKE A WILLFULLY

WRONG STATEMENT OR REPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED

STATES AS TO ANY MATTER IN ITS JURISDICTION.

A i

I IIIII IH 111111111111111111 II II IIIIIII HII lIi IIII111111111 IIIIII III111 lIII lIIIGL-714332-1901/05/2015 SECTION 6 - DEVICES NOT SUBJECT TO REGISTRATION SECTION 6

PAGE 1 of 1

NRC Device Key: Manufacturer License No:

Manufacturer Name:

Model Number: Serial #: Transfer Date:

IqPACuIFCORP ENERGYWyodak Plant48 Wyodak RoadGillette, WY 82718

January 29, 2015

Director, Office of Nuclear Material Safety and SafeguardsAttn: GLTSUS Nuclear Regulatory CommissionWashington DC 20555-0001

Re: Wyodak PlantRegistration Number GL-714332-19

Dear Sir:

Enclosed are General Licensee Registration Forms for the PacifiCorp-Wyodak PowerPlant.

Should you have any questions or require any additional information, please callBernadette Hinshaw at (307) 687-4283.

Sincerely,

Keith L. BastianPlant Managing Director

Aitachments

bxc: Bernadette Hinshaw

Documents

111I11111 11111 11111I 11II1I 11111 IIII IIII IIIII IIII IIIIII … · 2015. 3. 3. · 111i11111 iiiii 11111 11111i iiiiii 11ii1i 11111 iiii iiii iiiii iiii iiiiii 111111miiiiiiiii