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NRC FORM664 (04-2019)

111111111 ml tlHI 1IJl'l 1lllllll :Ill illll lHt SECTION 1

PAGE 1 of 2 U.S. NUCLEAR REGULARTORY COMMISSION

10 CFR 31.5 GENERAL LICENSEE REGISTRATION

APPROVED BY 0MB: NO. 3150-0198 0MB EXPIRATION DATE: 04/30/2019 Estimated burden per response to oomply with this mandatory collection request 20 minutes. NRC wiU use this informationto track general Mcencees and their devices to ensure a higher level ol device accountability. Send comments regarding burden estimate to the FOIA, Privacy, and lnfonnation Collection Branch (T-6A10M), U.S. Nuclear RegulatOI)' Commisaion, Wahington, DC 205555-0001, or by Internet e-mail to lnfooollects. RetOUn:e@flle.gov, and to the Desk0ffic:er, Office of Information and Regulatory Affairs, NEOB-10202, (315().()198), Office of M~ment and Budget, WUhington, DC 20503. If a means used to Impose an information collection does not display a currently valid 0MB control number, the NRC may not conduct or sponsor, and • person is not required to respond to, the information oollectlon.

Complete all six sections of this registration form. If any of the preprinted Information is Incorrect, provide the changes in the applicable boxes. USE CAPITAL LETTERS.

General License Registration Number GL-53793-24

SECTION 1 - GENERAL LICENSEE INFORMATION

Enter the company name and the street address for the physical location of use for your device(s). For

portable devices, specify the primary storage location. Do not use P.O. Boxes.

Company Name: ANTELOPE COAL LLC

. -· Address Line 1: 55 MILl:S NORTH OF DOUGLAS

T"l3lfl OlW[TJt.lL.10!PJtTJM~lA1[E.l I-1 . I Address line 2:

11111111111111111111111111111111111111111111111111111111111111111 · GL~793-24

04/10/2019

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SECTION 1

SECTION 1- - GENERAL LICENSEE INFORMATION (Continued) PAGE 2 of2

Enter the name, te_lephone number and title of the· person who is the responsible individual fot the device(s).

Last .Name: HOKANSON

First Name: BRUCE . · ::J11i~·c11e Initial: . .,. .~. ~

~-: -;)-'\

Bu~iness :T~l~phone Number: (307) 4.64-2566 · ·

1~.;W\;J: :,tJ ::.: :; . . . 2566

111111111111111111111111111111111111111111111111111111111 11111111 I llllllll llll 11111111111111111 GL-53793-24

SECTION 2 - DEVICES SUBJECT TO REGISTRATION 04/10/2019

Our records indicate that you have these devices. Please updtae the information as necessary.

N RC Device Key

Distributor/Dustributed By:

Distributor License Number:

785521 (Internal Control Number)

Scan Technologies, Inc. •-,." .-, '' '

Manufacturer name: SCAN TECHNOLOGIES, I.NC.

De~ice Model (Not Source Model): COALSCAN . · ... .. . ' .... '

Device Serial Number: 4391

'--··>;' ·':

SECTION 2

PAGE 1 of2

D No~ )~J.1c>i}s'essie>n of device (Also . compiete:Sffction 4.) .

, MM . · DD YYYY

Isotope (e.g. AM241)

. CS137

.. I I I I I I

;A

·: ··-")<:>

Activity (e.g:.1ob5j 5 '

I I · I I . I ·1 · I . I I I I 1 ·::·r,.

Unit (e.g. mCi)

rilCi ·

11111111111111 1111 llll 111111111111111111111111 1111111111111111111 · I IHIIIIUlll 11111111111111111 .. · GL~53793-2.4 04/10/2019 SECTION 2 - DEVIC'ES SUBJECT TO REGISTRATION ' SECTION 2

PAGE 2of2 Our records indicate thi:it you have these devices. ~lease·updi*e.the information as necessary.

NR"C Device Key

Distributof/Dustributed By: Scan Technol<>'gies, Inc. ~~

Distributor License Number: GA1299-1 ,

:~ •, '

----··------

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SECTION 3 - ADDITIONAL DEVICES SUBJECT TO REGISTRATION SECTION 3

PAGE 1 of 1 Provide information about other devices you have that are subject to registration. Do not report specifically licensed devices.

Manufacturer Name

I I I I I I I I I I I I I I J .I I. I I l I I I I I I Initial Transferor Name

I I I I I I I I I I I . I I I I I I -I 1--·L.I I I I I I Initial Transferor License.Number (if known)

I I I I- I I I I I I I I I Device Model. Number (Not Source Model)

·_ . I I. J · t I I I 1 · I I I 1···.1. I 1 ·· 1 l·.l.1.1 · ·1 . I I ·· 1 I I I Device Serial Number

I I I I I I I I I I I 11 I I I I -I I iJ.,-:·l I I I I I -:· '-:: , ' ,

I

How acquired and date (e.g., . · b. Manufacturer/Initial Transferor listed above . · · ··• .,,-_.:··.: _·.,·_::·_·._,_ .•. ,,·.· i.·,•·.-_: ......... I;___ I

. from a ~istributor/ma~ufaci:urer; 0 Other General Licensee Date Traniferrecl; . _ _ _ _ other licensee, other source)? · · . · . , · . ·_;_,_,,,.,.,. ~,;;,~..,,..,.,'J '--'--~~

, l:_ ••

0 Other Sources

I

• : . \ 't ;·.

yyyy

I 11111~ II 11111111111111111 ~ 11111111111111111 IIIII I IIIII Ill I I Ill I llllllf I llll 11111111111111111 GL-53793-24 0411012019 SECTION 4 w _NOT IN POSSESSION-OF DEVICE

Provide information about devices listed in Section 2 or 6, but no longer in your possession.

Part 1

DD Location of the Device:

SECTION 4

PAGE 1 of 1

0 Whereabouts Unknown (Complete Part 1 only) · · 0 Ti'l:¥h~fert~~Jo another general licensee (Complete Parts 2 and 3) 0 Never Possessed the Device (Complete Part 1 only) · 0 Transferr~ii:t~ if Specific Licensee (Not the manufacturer)

(co.mplete.P. '.liiH i). · .. o Returned to Manufacturef'(Complete Part 1· only) ·: .•. ·. ·:'-.

Part 2. · . .· License Number of Recipient (if transferred to a specific lit"Arliili:.l:.'

m::t•. ·• i•• ·•. !J ...• · ~r ·•···• ·:[:· •. 1·· '1': .·.•f ·•··•·• :r:• :1.·. •.•rn·• ·•:r··• .. · .• ·it:•·•.•t.••u:• .. •••11~.m .. :;1.•.~ti~f ~~~t •. ii· ;1•.·•: .. ·1••· .. ·t:.· .. ·•·i: .; ··• I

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04/10i2019

I hereby certify that:

SECTION 5 • CERTIFICATl'ON

/

I IHlllll llll lllll llll 11111111 SECTION 5 PAGE 1 of 1

A. Ail information contained in this registration is true and complete to the l,e-st ofrny,Rnowledge and belief.

B. A physical inventory of the devices subject to registration has been ij~n1~!~fed/~~1f't~'6 device information on

this form has been checked against the device labeling.

C. · I am aware of-the requirements of the general license, provided in 10~CFR 31,5. · (Copied of applicable regul~tions ·ry1ay be \ii~Wed. at the N RC website at: , . . :S ;, . ' . . - ,, . '

··,::;({?·· . . t>ATE·. ,,.c:,

: ;~: '.~:;\:{;.£I .. . vvAr<Nrfiti: ·FALSE STATEMENTS MAY BE SUBJECT TO CIVILA~D/OR.CRiM;r,JtJ~~~ALTIES. NRC

·. REGdLAflQNS R~au1RE THAt. susrv11ss1c>Ns; To THE NRC·:BE; ;COMPLEt~A~~}ffequRATE IN ALL ",_-·_'-~:-··-··,, •• - • _ ,·_ :·. ·-:. 1 :.~ •. -_'_ • __ : ·-~~~-·-~ \-.· • _ :' _ • ,'. __ ,;" ,<'·''(•1'":- ~ •. ,7,J:~:-._ , _ _.

·. . . l\llA''rERIALASPECTS. 1 a. U:s;t SECTi6N,i"oo}~MAKES IT A CRlMrNAL OFFEt•iiEl:r&5iilnAKEA wn:.LFUL:LY

~kG>~_&~r~reMENt d~k'.e~tkseNrAr;o~:;4~:;Nv o~PARfMeNT 6~ A~~;(· · · · ,JHE. uN1r1=0 sTAtEs As To

• ' -~-.. , ~? . ' ' , ' , .. . ,

. ,,:;;}'

SJl;NATURif, rtti~6NsiBLE rNDIVIDUAL (Listed in' S~tiidt, 1) .

ANY!YiAfreR1N 1rs JuRistl1et,oN;

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,· .•. :·.f. -~ . !.'., •. •,, ,:

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04/10/2019

NRC Device Key:

Manufacturer Name:

Model Number:

Isotope:.

,,;c&. · . . :&.

SECTION 6 - DEVICE NOT SUBJECT TO REGISTRATION

Manufacturer License No:

Serial#: Transfer Date:

Activity: Unit:

' I·_,-,,'

'' ., .. :,, - ' '.).

SECTION 6 PAGE 1 of 1