ANNEX A

TLLRWDCC §675.23—IMPORTATION FORM

TEXAS LOW-LEVEL RADIOACTIVE WASTE DISPOSAL COMPACT COMMISSION APPLICATION
FOR IMPORTATION OF NON-PARTY LOW-LEVEL RADIOACTIVE WASTE (NOTE: PURSUANT TO
TEXAS HEALTH AND SAFETY CODE, §401.207(j), THIS PETITION MUST BE COMPLETED BY
APPROPRIATE REPRESENTATIVES OF THE DEPARTMENT OF DEFENSE OR THE GENERATOR OF
THE WASTE UNLESS THE GENERATOR IS A SMALL QUANTITY GENERATOR AS DEFINED IN 31
TAC §675.20(19), IN WHICH CASE THE PETITION MAY BE SUBMITTED BY AN APPROPRIATELY
LICENSED BROKER) (Article III, Sec. 3.05(7) of the Compact)

I. Applicant Information

Entity Name:
Contact Person:
Phone:
Email:
Website:
Business Address:
Mailing Address (if different):
Applicant is:

II. Generator Specifications

Generator Type:
Is waste coming from a "small quantity generator"?

III. Agreement Period

Import applications generally will be granted only in single fiscal-year increments.
If you are seeking a term that would extend beyond the end of a current fiscal year,
please explain the unusual experiences that would justify a deviation from this general rule?

IV. Waste Proposed for Importation

Waste Volume (Cubic Feet):
Waste Radioactivity (Curies):
Waste Classification:
Waste Form:
Does the proposed waste consist solely of sealed sources?

Compact and/or unaffiliated state, territory, possession, or district of the United States where the waste was generated (please list)

Waste Description:

V. Compliance

Does Applicant have any unresolved violation(s), complaint(s), unpaid fee(s),
or past due report(s) with the Texas Low-Level Radioactive Waste Disposal Compact Committee?

Does Applicant have any unresolved violation(s), complaint(s), unpaid fee(s),
or past due reports associated with radioactive waste receipt, storage, handling,
management, processing, or transportation pending with any other regulatory agency
with jurisdiction to regulate radioactive material including, without limitation,
the Texas Commission on Environmental Quality (TCEQ)?

VI. Certifications

Applicant hereby certifies the following:

VII. Authorized Signatory

Name:
Title:
Date/Time:

VIII. Attachments

Applicable Documents #1: None Submitted
Applicable Documents #2: None Submitted
Other Comments:
Other Applicable Documents: None Submitted