NRC FORM 653

(04-10-2024)

10 CFR 32

U. S. NUCLEAR REGULATORY COMMISSION 

TRANSFERS OF INDUSTRIAL 

DEVICES REPORT 

(TO GENERAL LICENSEES)

(Continue on NRC Form 653, 653A or 653B, as appropriate)

APPROVED BY OMB: NO. 3150-0001 EXPIRES: 04/30/2027

Estimated burden per response to comply with this mandatory collection request: 36 minutes. NRC 

requests quarterly reports to keep apprised of device movements. Send comments regarding the 

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, (3150-0001), Attn: Desk 

Officer for the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 20503. 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.

For each "licensee" to whom a device(s) has been transferred during the reporting period, supply the following:

Name of Vendor

License Number

Reporting Period

From To

Intermediate Person(s) (if any)

Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number

Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number

General Licensee Information

Name of General Licensee

Name of Responsible Individual Business Telephone Number

Title of Responsible Individual

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Transferred

Date of Transfer Type of Device Model Number Serial Number Isotope Activity and Units

Intermediate Person(s) (if any)

Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number

Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number

General Licensee Information

Name of General Licensee

Name of Responsible Individual Business Telephone Number

Title of Responsible Individual

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Transferred

Date of Transfer Type of Device Model Number Serial Number Isotope Activity and Units

NRC FORM 653 (04-10-2024) Page of
TRANSFERS OF INDUSTRIAL DEVICES REPORT 

(TO GENERAL LICENSEES) (Continued)

NRC FORM 653 (Continued)

(04-10-2024)

10 CFR 32

U. S. NUCLEAR REGULATORY COMMISSION 

Intermediate Person(s) (if any)

Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number

Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number

General Licensee Information

Name of General Licensee

Name of Responsible Individual Business Telephone Number

Title of Responsible Individual

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Transferred

Date of Transfer Type of Device Model Number Serial Number Isotope Activity and Units

Intermediate Person(s) (if any)

Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number

Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number

General Licensee Information

Name of General Licensee

Name of Responsible Individual Business Telephone Number

Title of Responsible Individual

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Transferred

Date of Transfer Type of Device Model Number Serial Number Isotope Activity and Units

NRC FORM 653 (04-10-2024) Page of
TRANSFERS OF INDUSTRIAL DEVICES REPORT 

(TO GENERAL LICENSEES) (Continued)

NRC FORM 653 (Continued)

(04-10-2024)

10 CFR 32

U. S. NUCLEAR REGULATORY COMMISSION 

Intermediate Person(s) (if any)

Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number

Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number

General Licensee Information

Name of General Licensee

Name of Responsible Individual Business Telephone Number

Title of Responsible Individual

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Transferred

Date of Transfer Type of Device Model Number Serial Number Isotope Activity and Units

Intermediate Person(s) (if any)

Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number

Name of Intermediate Persons(s) Name of Responsible Individual Title of Responsible Individual Business Telephone Number

General Licensee Information

Name of General Licensee

Name of Responsible Individual Business Telephone Number

Title of Responsible Individual

Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Transferred

Date of Transfer Type of Device Model Number Serial Number Isotope Activity and Units

NRC FORM 653 (04-10-2024) Page of
TRANSFERS OF INDUSTRIAL DEVICES REPORT (FROM GENERAL LICENSEES) 

For each "licensee" from whom a device(s) has been received during the reporting period, supply the following:

NRC FORM 653A

(04-10-2024)

10 CFR 32

U. S. NUCLEAR REGULATORY COMMISSION 

General Licensee Information

Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received

Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)

General Licensee Information

Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received

Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)

General Licensee Information

Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received

Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)

General Licensee Information

Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received

Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)

NRC FORM 653A (04-10-2024) Page of
TRANSFERS OF INDUSTRIAL DEVICES REPORT (FROM GENERAL LICENSEES) (Continued) 

For each "licensee" from whom a device(s) has been received during the reporting period, supply the following:

NRC FORM 653A (Continued)

(04-10-2024)

10 CFR 32

U. S. NUCLEAR REGULATORY COMMISSION 

General Licensee Information

Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received

Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)

General Licensee Information

Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received

Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)

General Licensee Information

Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received

Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)

General Licensee Information

Name of General Licensee Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Date of Receipt Type of Device Model Number Serial Number Manufacturer or Initial Transferor (If not reporting party)

Information on Device(s) Received

NRC FORM 653A (04-10-2024) Page of
TRANSFERS OF INDUSTRIAL DEVICES REPORT (LABEL CHANGES) 

For each device for which required label information has been changed, supply the following:

NRC FORM 653B

(04-10-2024)

10 CFR 32

U. S. NUCLEAR REGULATORY COMMISSION 

General Licensee User Information

Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received

Type of Device Model Number Previous Serial 

Number

New Serial 

Number

Previous 

Isotope

New 

Isotope

Previous Label 

Activity and Units

Label Activity 

and Units

General Licensee User Information

Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received

Type of Device Model Number Previous Serial 

Number

New Serial 

Number

Previous 

Isotope

New 

Isotope

Previous Label 

Activity and Units

Label Activity 

and Units

General Licensee User Information

Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received

Type of Device Model Number Previous Serial 

Number

New Serial 

Number

Previous 

Isotope

New 

Isotope

Previous Label 

Activity and Units

Label Activity 

and Units

General Licensee User Information

Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received

Type of Device Model Number Previous Serial 

Number

New Serial 

Number

Previous 

Isotope

New 

Isotope

Previous Label 

Activity and Units

Label Activity 

and Units

NRC FORM 653B (04-10-2024) Page of
TRANSFERS OF INDUSTRIAL DEVICES REPORT (LABEL CHANGES) (Continued) 

For each device for which required label information has been changed, supply the following:

NRC FORM 653B (Continued)

(04-10-2024)

10 CFR 32

U. S. NUCLEAR REGULATORY COMMISSION 

General Licensee User Information

Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received

Type of Device Model Number Previous Serial 

Number

New Serial 

Number

Previous 

Isotope

New 

Isotope

Previous Label 

Activity and Units

Label Activity 

and Units

General Licensee User Information

Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received

Type of Device Model Number Previous Serial 

Number

New Serial 

Number

Previous 

Isotope

New 

Isotope

Previous Label 

Activity and Units

Label Activity 

and Units

General Licensee User Information

Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received

Type of Device Model Number Previous Serial 

Number

New Serial 

Number

Previous 

Isotope

New 

Isotope

Previous Label 

Activity and Units

Label Activity 

and Units

General Licensee User Information

Name of General Licensee User Mailing Address at the Location of Use (No P.O. Boxes, include zip code)

Information on Device(s) Received

Type of Device Model Number Previous Serial 

Number

New Serial 

Number

Previous 

Isotope

New 

Isotope

Previous Label 

Activity and Units

Label Activity 

and Units

NRC FORM 653B (04-10-2024) Page of