<table>
<colgroup>
<col style="width: 19%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 9%" />
<col style="width: 14%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 10%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 17%" />
<col style="width: 0%" />
</colgroup>
<thead>
<tr class="header">
<th colspan="15"><strong>UNCLASSIFIED</strong></th>
<th></th>
</tr>
</thead>
<tbody>
<tr class="odd">
<td colspan="2"><h5 id="date">DATE</h5>
<p>     </p></td>
<td colspan="8"><h2 id="section"></h2></td>
<td colspan="5"><h2 id="authorization-no.">AUTHORIZATION NO.</h2>
<h2 id="prl--">PRL -      </h2></td>
<td></td>
</tr>
<tr class="even">
<td><h5 id="section-1"></h5></td>
<td colspan="9"><h2 id="product-return-liaison">PRODUCT RETURN
LIAISON</h2>
<p><strong>B&amp;W Y-12, LLC</strong></p>
<p><strong>P.O. BOX 2009</strong></p>
<h2 id="oak-ridge-tennessee-37831">OAK RIDGE, TENNESSEE 37831</h2></td>
<td colspan="4"><h2 id="email-phone-fax">Email<br />
Phone<br />
Fax</h2></td>
<td><h2 id="prly12.doe.gov-865-576-5002-865-241-4719"><a
href="mailto:prl@y12.doe.gov">prl@y12.doe.gov</a><br />
865-576-5002<br />
865-241-4719</h2></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="15"><h2
id="request-for-authorization-to-ship-snm-or-non-snm-material-u">REQUEST
FOR AUTHORIZATION TO SHIP SNM OR NON-SNM MATERIAL (U)</h2></td>
<td></td>
</tr>
<tr class="even">
<td colspan="7"><h2
id="shipper-facility-contact-namephone-number">SHIPPER FACILITY (Contact
Name/Phone Number)</h2>
<blockquote>
<p>     </p>
</blockquote></td>
<td colspan="8"><h2 id="ris">RIS</h2>
<p>     </p></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="7" rowspan="3"><h2 id="address">ADDRESS</h2>
<blockquote>
<p>     </p>
</blockquote></td>
<td colspan="5"><h2 id="number-if-required">741 NUMBER (IF
REQUIRED)</h2>
<p>     </p></td>
<td colspan="3"><h2 id="trip-number-if-required">TRIP NUMBER (IF
REQUIRED)</h2>
<p>     </p></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"><h2 id="gross-weight">GROSS WEIGHT</h2>
<h2 id="section-2">     </h2></td>
<td colspan="4"><h2 id="net-weight">NET WEIGHT</h2>
<h2 id="section-3">     </h2></td>
<td colspan="2"><h2 id="shipment-classification">SHIPMENT
CLASSIFICATION</h2>
<h2 id="section-4">     </h2></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="8" rowspan="2"><strong><em>THE FOLLOWING QUESTION SHOULD BE
ANSWERED BY YOUR RADCON ORGANIZATION PRIOR TO SHIPMENT:<br />
</em>DOES THIS PROPOSED SHIPMENT MEET Y-12 ACCEPTANCE CRITERIA?<br />
</strong> YES NO</td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"><h2 id="requested-ship-date">REQUESTED SHIP DATE</h2>
<h2 id="section-5">     </h2></td>
<td colspan="4"><h2 id="mode-of-transportation">MODE OF
TRANSPORTATION</h2>
<h2 id="section-6">     </h2></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="7"><h2
id="signature-of-authorized-shipper-representative">SIGNATURE OF
AUTHORIZED SHIPPER REPRESENTATIVE</h2>
<p>     </p></td>
<td colspan="8"><h2
id="contact-at-shippers-location-re-contaminant-or-radiation-levels">CONTACT
AT SHIPPER’S LOCATION RE: CONTAMINANT OR RADIATION LEVELS</h2>
<p>Name:       Phone:      </p></td>
<td></td>
</tr>
<tr class="even">
<td colspan="7"><h2 id="person-designated-as-contact-of-material">PERSON
DESIGNATED AS CONTACT OF MATERIAL</h2>
<p>Name:       Phone:      </p></td>
<td colspan="8" rowspan="2"><h2
id="reason-for-material-being-shipped-recovery-retirement-evaluation-etc.-state-part-disposition-on-packing-list.">REASON
FOR MATERIAL BEING SHIPPED (Recovery, Retirement, Evaluation, etc.)
<em>(State part disposition on packing list.)</em></h2>
<p>     </p></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="7"><h2 id="transfer-to-name-building-mba">Transfer To: Name
      Building:      MBA:      </h2></td>
<td></td>
</tr>
<tr class="even">
<td colspan="8"><h2
id="if-material-was-shipped-to-you-reference-the-doenrc-741-number">IF
MATERIAL WAS SHIPPED TO YOU, REFERENCE THE DOE/NRC 741 NUMBER</h2>
<p>     </p></td>
<td colspan="2"><p>P.O. NUMBER</p>
<p>     </p></td>
<td colspan="5"><h2 id="scrap-declaration-number">SCRAP DECLARATION
NUMBER</h2>
<p>     </p></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="15"><h2 id="receiving-facilities-authorization">RECEIVING
FACILITIES AUTHORIZATION</h2></td>
<td></td>
</tr>
<tr class="even">
<td><h2 id="signature-of-product-return-liaison">SIGNATURE OF PRODUCT
RETURN LIAISON</h2></td>
<td colspan="7">     </td>
<td colspan="2"><p>DATE</p>
<p>     </p></td>
<td colspan="5"><h2 id="phone-number">PHONE NUMBER</h2>
<p>     </p></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="15"><h2 id="general-material-description">GENERAL MATERIAL
DESCRIPTION</h2></td>
<td></td>
</tr>
<tr class="even">
<td colspan="10"><h2 id="material-chemical-element">MATERIAL (CHEMICAL
ELEMENT)</h2>
<p>     </p></td>
<td colspan="5"><h2 id="quantity">QUANTITY</h2>
<p>     </p></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="15"><h2 id="physical-description">PHYSICAL DESCRIPTION</h2>
<h2 id="section-7">     </h2></td>
<td></td>
</tr>
<tr class="even">
<td colspan="15"><h2 id="physical-impurities">PHYSICAL IMPURITIES</h2>
<h2 id="section-8">     </h2></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><h2 id="program-if-applicable">PROGRAM (If
Applicable)</h2>
<p><strong>     </strong></p></td>
<td colspan="2"></td>
<td colspan="10"><h2
id="vouchershipping-order-number-if-applicable">VOUCHER/SHIPPING ORDER
NUMBER (If Applicable)</h2>
<p><strong>     </strong></p></td>
</tr>
<tr class="even">
<td colspan="15"><h2 id="accountable-material">ACCOUNTABLE MATERIAL</h2>
<p>Yes No </p></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="15"><h2 id="hazardous-material">HAZARDOUS MATERIAL</h2>
<p>Yes No </p>
<h2 id="section-9"></h2></td>
<td></td>
</tr>
<tr class="even">
<td colspan="15"><h2 id="y-12-charge-number-to-process-prl-form">Y-12
CHARGE NUMBER TO PROCESS PRL FORM</h2>
<h2 id="section-10">     </h2></td>
<td></td>
</tr>
<tr class="odd">
<td rowspan="3"><h2 id="section-11"></h2>
<h2 id="derivative-classifier">DERIVATIVE CLASSIFIER</h2></td>
<td colspan="14"><p>NAME</p>
<p>     </p></td>
<td></td>
</tr>
<tr class="even">
<td colspan="14"><h2 id="title">TITLE</h2>
<h2 id="section-12">     </h2></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="14"><h2 id="date-1">DATE</h2>
<h2 id="section-13">     </h2></td>
<td></td>
</tr>
<tr class="even">
<td colspan="15"><h2 id="unclassified">UNCLASSIFIED</h2></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="15"><h2 id="material-history">MATERIAL HISTORY</h2></td>
<td></td>
</tr>
<tr class="even">
<td colspan="15"><h2
id="known-hazards-connected-with-the-handling-of-material">KNOWN HAZARDS
CONNECTED WITH THE HANDLING OF MATERIAL</h2>
<p>     </p></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="15"><h2
id="radionuclides-such-as-fission-products-other-actinides-tritium-etc.-in-which-material-has-been-exposed-include-concentrations-of-contaminants-and-methods-of-analysis.">RADIONUCLIDES,
SUCH AS FISSION PRODUCTS, OTHER ACTINIDES, TRITIUM, ETC. IN WHICH
MATERIAL HAS BEEN EXPOSED (Include concentrations of contaminants and
methods of analysis.)</h2>
<h2 id="section-14">     </h2></td>
<td></td>
</tr>
<tr class="even">
<td colspan="15"><h2
id="hazardous-material-or-unusual-processing-or-tests-in-which-the-material-has-undergone-detail-radiation-or-contaminant-levels.">HAZARDOUS
MATERIAL OR UNUSUAL PROCESSING OR TESTS IN WHICH THE MATERIAL HAS
UNDERGONE (Detail radiation or contaminant levels.)</h2>
<h2 id="section-15">     </h2></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="15"><h2
id="we-hereby-certify-according-to-process-knowledge-or-thorough-analytical-determination-that-the-contents-of-the-containers-do-not-contain-rcra-hazardous-waste-as-identified-in-40-cfr-261.3">"We
hereby certify according to process knowledge or thorough analytical
determination that the contents of the container(s) do not contain RCRA
Hazardous waste as identified in 40 CFR 261.3"</h2></td>
<td></td>
</tr>
<tr class="even">
<td colspan="5"><h2 id="signature-of-shipper">SIGNATURE OF SHIPPER</h2>
<p>     </p></td>
<td colspan="6"><p>COMPANY NAME</p>
<p>     </p></td>
<td colspan="4"><h2 id="date-2">DATE</h2>
<p>     </p></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="15"><h2 id="method-of-packing">METHOD OF PACKING</h2></td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"><h2 id="outside-container-type">OUTSIDE CONTAINER
TYPE</h2>
<p>     </p></td>
<td colspan="4"><h2 id="approximate-number-oc">APPROXIMATE NUMBER
(OC)</h2>
<p>     </p></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><h2 id="inside-container-type">INSIDE CONTAINER
TYPE</h2>
<p>     </p></td>
<td colspan="4"><h2 id="approximate-number-ic">APPROXIMATE NUMBER
(IC)</h2>
<p>     </p></td>
<td></td>
</tr>
<tr class="even">
<td colspan="15"><h2 id="other-container-information">OTHER CONTAINER
INFORMATION</h2>
<h2 id="section-16">     </h2></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="15"><h2 id="sealtid-no.">SEAL/TID NO.</h2>
<p><strong>     </strong></p></td>
<td></td>
</tr>
<tr class="even">
<td colspan="15"><h2
id="special-precautions-to-be-observed-when-opening-the-containers">SPECIAL
PRECAUTIONS TO BE OBSERVED WHEN OPENING THE CONTAINER(S)</h2>
<h2 id="section-17">     </h2></td>
<td></td>
</tr>
</tbody>
</table>

## 1. ENSURE ALL RADIOACTIVE CONTAMINATION SURVEY DATA IS INCLUDED WITH THIS FORM.

## 2.\* A detailed packing list must be attached to this authorization providing the following information:

-   **Six-digit Drawing Number**

-   **Serial Number**

-   **Part Name**

-   **Program**

-   **Consignor ID**

-   **Part Classification**

-   **Identify part as accountable or non-accountable**

-   **Container identification and seal number**

-   **Disposition of item to be returned**

## 3.\* Attach unclassified packing information to OUTSIDE of container

## 4. Authorization must be submitted to Y-12 for approval PRIOR to the shipping of material.

## 5. Notification of shipment and DOE/NRC 741 MUST include the Y-12 Authorization number.

## 6. Provide approved Authorization number, ID, gross weights and tare weights on outside of a container in the shipment for all containers (Outside and Inside).

\*These items not necessary for university returns.

+-----------------------------------------------------------------------+
| ##  UNCLASSIFIED {#unclassified-1}                                    |
+-----------------------------------------------------------------------+