NRC FORM 314

(07-31-2023)

10 CFR 30.36(j)(1); 

40.42(j)(1); 70.38(j)(1); 

and 72.54(k)(5)(1)(1)

U.S. NUCLEAR REGULATORY COMMISSION 

CERTIFICATE OF DISPOSITION 

OF MATERIALS

APPROVED BY OMB: NO. 3150-0028 EXPIRES: 05/31/2026

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 burden estimate to the 

FOIA, Library, and Information Collections Branch (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, 

or by email to Infocollects.Resource@nrc.gov, and the OMB reviewer at: OMB Office of Information and Regulatory Affairs, 

(3150-0028), Attn: Desk Officer for the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 20503; email: 

oira_submission@omb.eop.gov. The NRC may not conduct or sponsor, and a person is not required to respond to, a collection of 

information unless the document requesting or requiring the collection displays a currently valid OMB control number.

Licensee Name and Address License Number

Docket Number

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.

2. All activities authorized by this license have ceased, and all radioactive materials procured and/or possessed by the licensee 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, any remaining residual radioactivity is within the limits of 10 CFR Part 20, Subpart E, and is ALARA. 

d. Acknowledgment of receipt of the material by transfer or by disposal site is attached: 

Email Address:

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:

a. is attached; or b. is not attached (Provide explanation); or

c. was forwarded to the NRC 

on:

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 Number (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

Printed Name and Title Signature of Certifying Official 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.

Date:
CERTIFICATE OF DISPOSITION OF MATERIALS

PLEASE READ THESE INSTRUCTIONS BEFORE COMPLETING NRC FORM 314.

Subpart E of 10 CFR Part 20 establishes the radiological criteria for license terminations/decommissioning of facilities 

licensed under 10 CFR Parts 30, 40, 50, 60, 61, 70, and 72, as well as other facilities subject to the Commission's 

jurisdiction under the Atomic Energy Act of 1954, as amended, and the Energy Reorganization Act of 1974, as amended.

INSTRUCTIONS

Section B, Item 2. 

Licensees should describe the specific radioactive material transfer actions. If radioactive wastes were generated in 

terminating this license, the licensee should describe the disposal actions taken, including the disposition of low-level 

radioactive waste, mixed waste, greater-than-Class-C waste, and sealed sources.

Section B, Item 2.a.

The information provided concerning the transfer of radioactive material to another licensee should specify the date of the 

transfer, the name of the licensee recipient, an individual contact name and telephone number for the licensee recipient, 

and the recipient's NRC or Agreement State license number.

Section B, Item 2.b.

For disposal of radioactive materials, licensees should describe the specific disposal method or procedure (e.g., decay-instorage). For those cases when radioactive materials are disposed of by a licensed disposal site or by a waste 

contractor, the licensee should specify the name, address, and telephone number of the licensed disposal site operator or 

waste contractor.

Section B, Item 2.c.

"Residual radioactivity," as defined in 10 CFR 20.1003, means radioactivity in ‘areas' (structures, materials, soils, etc.) 

remaining as a result of activities (licensed and unlicensed) under the licensee's control from sources used by the 

licensee, excluding background radiation. ALARA is defined in 10 CFR 20.1003.

Section B, Item 2.d.

For transfer of radioactive materials licensees should attach a record of receipt from the recipient that contains 

information regarding what was received (e.g., radioactive materials for disposal or transfer.)

FILE CERTIFICATES AS FOLLOWS:

IF YOU ARE LOCATED IN:

ALABAMA, CONNECTICUT, DELAWARE, DISTRICT OF 

COLUMBIA, FLORIDA, GEORGIA, KENTUCKY, MAINE, 

MARYLAND, MASSACHUSETTS, NEW HAMPSHIRE, NEW 

JERSEY, NEW YORK, NORTH CAROLINA, PENNSYLVANIA, 

PUERTO RICO, RHODE ISLAND, SOUTH CAROLINA, 

TENNESSEE, VERMONT, VIRGINIA, VIRGIN ISLANDS, OR 

WEST VIRGINIA, SEND CERTIFICATES TO:

LICENSING ASSISTANCE TEAM 

DIVISION OF RADIOLOGICAL SAFETY AND SECURITY 

U.S. NUCLEAR REGULATORY COMMISSION, REGION I 

475 ALLENDALE ROAD, SUITE 102 

KING OF PRUSSIA, PA 19406-1415 

R1DRSSMail.Resource@nrc.gov

*Note: The preferred method to submit NRC Form 314 is email. 

ILLINOIS, INDIANA, IOWA, MICHIGAN, MINNESOTA, 

MISSOURI, OHIO, OR WISCONSIN, SEND CERTIFICATES 

TO:

MATERIALS LICENSING SECTION 

DIVISION OF RADIOLOGICAL SAFETY AND SECURITY 

U.S. NUCLEAR REGULATORY COMMISSION, REGION III 

2443 WARRENVILLE ROAD, SUITE 210 

LISLE, IL 60532-4352 

R3-DRSSMAIL.Resource@nrc.gov

*Note: The preferred method to submit NRC Form 314 is email.

IF YOU ARE LOCATED IN:

ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, 

COLORADO, HAWAII, IDAHO, KANSAS, LOUISIANA, 

MISSISSIPPI, MONTANA, NEBRASKA, NEVADA, NEW 

MEXICO, NORTH DAKOTA, OKLAHOMA, OREGON, 

PACIFIC TRUST TERRITORIES, SOUTH DAKOTA, TEXAS, 

UTAH, WASHINGTON, OR WYOMING, 

SEND CERTIFICATES TO:

MATERIALS LICENSING BRANCH 

DIVISION OF RADIOLOGICAL SAFETY AND SECURITY 

U.S. NUCLEAR REGULATORY COMMISSION, REGION IV 

1600 E. LAMAR BOULEVARD 

ARLINGTON, TX 76011-4511 

R4licensing@nrc.gov

*Note: The preferred method to submit NRC Form 314 is email.