| This is to notify the ONR that a withdrawal of qualifying nuclear material from civil activities is intended to be made as follows: |
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| (a) | Material Balance Area code: _____________________________ |
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| (b) | Facility code: ___________________________________________ |
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| (c) | Quantity: _______ g/kg total weight of element _____________ |
| ___________ g/kg fissile isotope(s), if applicable |
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| (d) | Chemical composition: ____________________________________ |
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| (e) | Enrichment or isotopic composition (if appropriate): ______________ |
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| (f) | Physical form: ____________________________________________ |
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| (g) | Number of items: _________________________________________ |
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| (h) | Description of containers and seals: ____________________________ |
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| (i) | Shipment identification data: _________________________________ |
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| (j) | Name of the operator: _______________________________________ |
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| (k) | Proposed date of withdrawal: |
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| | ______________________ |
| | (Signature) |
| | For the operator |