Event Notification Report for October 29, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/28/2004 - 10/29/2004

** EVENT NUMBERS **


40824 41103 41139 41146 41147 41148 41154 41155 41156 41157

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 40824
Facility: HATCH
Region: 2 State: GA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: BARRY COLEMAN
HQ OPS Officer: JOHN MacKINNON
Notification Date: 06/17/2004
Notification Time: 06:17 [ET]
Event Date: 06/17/2004
Event Time: 05:21 [EDT]
Last Update Date: 10/28/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ROBERT HAAG (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

HIGH PRESSURE COOLANT INJECTION (HPCI) DECLARED INOPERABLE

While changing out a light bulb in the Unit 1 HPCI room, the surveillance operator noticed that the bolts for the HPCI pump discharge check valve, 1E41-F005, bonnet on pressure seal were loose. All six bolts could be turned by hand. HPCI was declared inoperable until an investigation is performed. The bolts were properly torqued and HPCI pump run is complete and sat. Licensee entered Technical Specification 3.5.1 (14 day Limiting Condition of Operation). All other Emergency Core Cooling Systems are fully operable including the Reactor Core Isolation Cooling System.

The NRC Resident Inspector was notified of this event by the licensee.

* * * RETRACTION FROM DISMUKE TO CROUCH AT 1700 EDT ON 10/28/04 * * *

The following information was obtained from the licensee via facsimile:

"A subsequent investigation revealed that a hot torque of the Unit 1 HPCI pump discharge check valve (1E41-F005) was performed during the 165 psig pump operability surveillance test which was performed following reassembly during the Unit 1 refueling outage. During this surveillance, the pump discharge pressure and thus internal pressure on the pressure seal cover, is maintained between 265 and 305 psig. However, during the rated pressure run, the pump discharge pressure achieved is required to be greater than or equal to 1135 psig. This difference in internal pressure (1135-305 = 830 psig minimum), acting on the bottom of the pressure seal cover, forced the pressure seal cover to move upward toward the cover retainer, compressing the pressure seal more tightly. As the pressure seal cover moved toward the cover retainer, the retainer bolts also moved upward, but the cover retainer remained stationary, due to gravity. Therefore, the retainer bolts were no longer torqued against the retainer cover, creating the 'as found' condition. It is site and vendor (Flowserve) experience that once the pressure seal cover is wedged upward, sufficient friction exists between the pressure seal cover, the pressure seal, and the valve body to prevent the pressure seal cover from relaxing the sealing force on the pressure seal once the valve internal (system) pressure is removed. Furthermore, no gap existed between the head of any of the retainer bolts and the retainer cover. The sealing function of the pressure seal was never lost, and the valve would have performed its design function while the retainer bolts were in the 'as found' 'finger tight' condition. Therefore, the valve remained operable at all times when the HPCI system was required to be operable following the Unit 1 refueling outage. This was further substantiated by the fact that no leakage was observed during the rated pressure pump operability run on 3/14/04. Following discovery of the 'finger tight' condition, the retainer bolts were cold torqued to the appropriate value (370 ft-lbs) by Maintenance personnel on 6/17/04. A HPCI pump surveillance was then performed and a hot torque of 370 ft-lbs was performed immediately after the system was shutdown.

"Tampering was considered as a possible cause for the loosened bolts, but no evidence could be found to support these bolts being loosened intentionally. All evidence available suggests that the bolts were loosened by internal pressure, which is consistent with vendor experience.

"Based on the above information this event is not reportable, and this notification serves to withdraw the previous notification made on 6/17/2004."

The licensee has notified the NRC Resident Inspector.

The Headquarters Operations Officer notified R2DO (Bonser).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 41103
Facility: HATCH
Region: 2 State: GA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: GREG JOHNSON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/08/2004
Notification Time: 09:13 [ET]
Event Date: 10/08/2004
Event Time: 01:50 [EDT]
Last Update Date: 10/28/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
CHARLES R. OGLE (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 99 Power Operation 99 Power Operation

Event Text

HIGH PRESSURE COOLANT INJECTION (HPCI) SYSTEM DECLARED INOPERABLE

"On 10/08/04 on Unit Two, the HPCI Valve Operability was being performed. During the course of this evolution the suction path was transferred from the Condensate Storage Tank (CST) to the Suppression Pool. When the HPCI System was aligned to the Suppression Pool the Suction Pressure decreased from 25.5 psig to 1.5 psig. With HPCI aligned to the suppression pool and with suction pressure less than 14 psig the HPCI System was declared INOPERABLE.

"Investigation continues as to the cause of the low suction pressure. Preliminarily it is suspected that the Suppression Pool suction path was not adequately filled and vented following a recent tag out of that suction path for maintenance inspection activities. Investigation continues."

The Licensee notified the NRC Resident Inspector.

* * * RETRACTION FROM DISMUKE TO CROUCH AT 1521 EDT ON 10/28/04 * * *

The following information was obtained from the licensee via facsimile:

"The Unit 2 HPCI system was considered inoperable, since the technical information that would conclusively support its continued operability given the condition encountered could not be assembled within the time constraints of the reporting requirements. Subsequent to the event the system was confirmed be properly filled and vented with a negligible amount of air vented in the process. It was determined that this small amount of air was introduced to the suction piping as a result of an inspection activity performed for the HPCI suction check valve prior to the event. A limited amount of air remained in the torus suction piping causing the decrease in suction experienced during the event. Engineering reviewed the implications of the low suction pressure on the ability of the HPCI system to perform its safety function given the design of the system and the suction sources available. In each case Engineering was able to conclusively determine that the HPCI system would not have tripped due to low suction pressure had it received an automatic initiation signal and was actually operable during the time frame that Operations had conservatively treated the system as inoperable. Additionally, the effect of the trapped air being entrained in the pump suction was also analyzed, and the conclusion reached was that the air would not have prevented the pump's proper performance. Based on this information, the event reported on 10/08/2004 is not reportable."

The licensee has notified the NRC Resident Inspector.

The Headquarters Operations Officer notified R2DO (Bonser).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 41139
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: KEN HILL
HQ OPS Officer: JOHN KNOKE
Notification Date: 10/19/2004
Notification Time: 23:37 [ET]
Event Date: 10/19/2004
Event Time: 18:30 [CDT]
Last Update Date: 10/28/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JULIO LARA (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 85 Power Operation 85 Power Operation

Event Text

HIGH PRESSURE COOLANT INJECTION (HPCI) INOPERABLE DUE TO CONTROLLER SIGNAL CONVERTER TROUBLE.

"On October 19, 2004 at approximately 1830 hours CDT, Unit One was performing QCOS 2300-05, Quarterly HPCI Pump Operability Test. This was being performed to prove operability following maintenance work on various valves and the turning motor gear unit. At this time when the HPCI turbine was rolled, the HPCI Signal Converter Trouble alarm was received. The HPCI Flow Controller demand controlled at approximately 7250 gpm instead of controlling at the desired 5600 gpm. HPCI was determined not to be operable and was shutdown per procedure. Due to the unexpected behavior of the HPCI Flow Controller, at this time it is not certain if the HPCI will meet its safety function. Therefore, we are reporting this event under 10 CFR 50.72 (b)(3)(v)."

Licensee entered Tech Spec 3.5.1.(f) 14 day Limiting Condition of Operation (LCO) for HPCI. Reactor Core Isolation Cooling (RICI) is operable. All other Emergency Core Cooling Systems (ECCS) and the Emergency Diesel Generators (EDG) are fully operable if needed.

The NRC Resident Inspector was notified of this event by the licensee.

* * * RETRACTION J. DAVIS TO W. GOTT AT 1819 ON 10/28/04 * * *

"The purpose of this report is to retract the ENS report made on October 19, 2004 at 2237 CDT (ENS #41139). The initial report was made following HPCI operability testing in accordance with QCOS 2300-05, Quarterly HPCI Pump Operability Test. When the HPCI turbine was rolled, the HPCI Signal Converter Trouble alarm was received. The HPCI Flow Controller failed to control at the desired 5600 gpm (instead, the system ramped to 7250 gpm). Due to the unexpected behavior, it was not certain at the time if HPCI could have met its design basis requirements. However, a subsequent review of this event has determined that HPCI would have performed its safety function. The Signal Converter failed in a manner that prevented automatic flow control, but did not prevent HPCI from initiating and ramping to full flow (i.e., the turbine high speed stop). In this condition, HPCI would have met corresponding Technical Specifications and Accident Analysis requirements. The circuit board was replaced and the Signal Converter and flow controller feedback loop were re-calibrated. The Unit 1 HPCI turbine's automatic flow control was successfully tested on October 20, 2004."

The Licensee notified the NRC Resident Inspector.

Notified R3DO (R. Garner)

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General Information or Other Event Number: 41146
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: SIEMENS MEDICAL SOLUTIONS USA
Region: 4
City: BELLEVUE State: WA
County:
License #: WN-I030-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/25/2004
Notification Time: 19:10 [ET]
Event Date: 10/21/2004
Event Time: 15:00 [PDT]
Last Update Date: 10/25/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GARY SANBORN (R4)
ELMO COLLINS (NMSS)
JIM WHITNEY (TAS)
CNCS (FAX)

Event Text

AGREEMENT STATE REPORT - STOLEN RADIOACTIVE SOURCES

Received via email from Washington Department of Health, Office of Radiation Protection

"The licensee possesses and uses sealed sources for calibrating nuclear medical instrumentation. Two sources, Cobalt-57 and Americium-241 each assay activity of about 74 megabecquerel (2 millicurie), were contained in lead pigs kept in the service technician's toolbox. The toolbox was reported as "probably" locked. The toolbox was not secured in the vehicle. The vehicle was parked in the driveway of the technician's home. The toolbox and two boxes of spare parts were reported stolen. The theft was reported to Liberty Lake Police Department between 3:00 and 4:00 p.m. [PDT]."

Washington Event Report #: WAC 246-221-240

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General Information or Other Event Number: 41147
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: ATC ASSOCIATES
Region: 3
City: CINCINNATI State: OH
County:
License #: 31210310000
Agreement: Y
Docket:
NRC Notified By: STEVE JAMES
HQ OPS Officer: JOHN MacKINNON
Notification Date: 10/26/2004
Notification Time: 10:49 [ET]
Event Date: 10/25/2004
Event Time: 22:00 [EDT]
Last Update Date: 10/26/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RONALD GARDNER (R3)
LINDA GERSEY (NMSS)
JIM WHITNEY (TAS)
CANADA VIA FAX ()

Event Text

OHIO AGREEMENT STATE REPORT OF A STOLEN TROXLER MOISTURE DENSITY GAUGE

"Stolen Troxler moisture density gauge. Model 3401B, Serial # 13437. Contains Cesium-137 (8 millicuries) and Americium-241/Beryllium (40 millicuries) sources. Ohio License # 31210310000. Gauge was stolen from back of pick-up truck outside a motel on west side of Cleveland, Ohio. Gauge was in locked transfer case with radioactive material labels on outside. Case was chained to bed of pick-up truck. Theft occurred sometime between 10 PM Monday, 10/25/04 and 7 AM Tuesday, 10/26/04. Theft was discovered when worker returned to truck in morning to begin work day. Police have been notified. Awaiting additional information and police report from licensee. Initial report made to Bureau at 8:40 AM on 10/26/04. Information is current as of that time."



Reference Number: OH2004-104

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General Information or Other Event Number: 41148
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: RAYTHEON COMPANY
Region: 4
City: EL SEGUNDO State: CA
County:
License #: 1053-19
Agreement: Y
Docket:
NRC Notified By: KATHLEEN KAUFMAN
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/26/2004
Notification Time: 19:56 [ET]
Event Date: 08/02/2004
Event Time: 17:00 [PDT]
Last Update Date: 10/26/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GARY SANBORN (R4)
PATRICIA HOLAHAN (NMSS)

Event Text

AGREEMENT STATE REPORT - SAFETY EQUIPMENT FAILS TO FUNCTION

Summary report of fax provided by State of California

On August 2, 2004 at 5:00 pm PDT, a licensee employee was irradiating electrical parts using the Low Dose 142-MA Self Contained, Shielded Panoramic Irradiator. This device uses a Cobalt- 60 (Co-60) source with an activity of 2 Curies. The licensee employee was able to bypass the interlock to the chamber while the chamber was irradiating. The employee was wearing a film badge and holding his ring badge in his hand (not on finger) while working with the chamber. The film badge was first used on August 2, 2004. The ring and film badges were collected and immediately shipped for analysis.

The source of radiation within the chamber is a sealed Co-60 (2 Curies) source and is exposed by raising and lowering the source rod. Raising the rod activates the door interlock and exposes the source within the chamber. The licensee intended to place a product into the chamber and failed to notice that the source rod was up, and pulled open the door while the interlock was activated. The safety interlock failed and was unsuccessful in keeping the doors locked. The door was immediately closed (exposure time approximately 3 seconds)

On August 4, 2004, the licensee contacted a Health Physics consultant and performed a calculation to estimate the possible exposure level. They used the Gamma Constant for Co-60, the exposure time, distance, and activities that were involved.

During the afternoon of August 4, 2004, J. L. Shepherd inspected the equipment and determined that the interlock was defective and advised that they install an alternate interlock that is sturdier. They returned on August 5, 2004 and installed the new interlock.

Wear on the interlock arm caused the ultimate failure on August 4, 2004, and was most probably caused by repeated attempts by the operators of the irradiator to forcibly open the cavity lids while the source was in the "Irradiate" position. The replacement arm has been redesigned and strengthened to avoid the recurrence of a problem of this nature in the future.

California preliminary exposure estimate to the operator's hands is less than 200 millirem while licensee calculation showed exposure received to be approximately 2-3 millirem.

Incident remains open until receipt of documentation of monitoring device exposure and copies of the physicist's calculations.

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Power Reactor Event Number: 41154
Facility: CATAWBA
Region: 2 State: SC
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: GLENN HORNE
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/28/2004
Notification Time: 03:29 [ET]
Event Date: 10/28/2004
Event Time: 00:52 [EDT]
Last Update Date: 10/28/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
BRIAN BONSER (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 100 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP AFTER SHUTDOWN BANK DROPPED INTO CORE

"At 0052 on 10/28/04 the Unit 2 reactor was manually tripped after an electrical fault caused Shutdown Bank D control rods to drop into the core. An automatic start of the Auxiliary Feedwater system occurred when water levels in all four Steam Generators reduced to the Lo-Lo level setpoint. A letdown isolation occurred on Lo Pressurizer level resulting from the cooldown of the primary system after the Auxiliary Feedwater system start. Reactor Coolant system temperature has been recovered and the plant has been stabilized at Hot Shutdown conditions."

The licensee stated that there were no complications during the trip. All systems functioned as required. No significant safety systems were out of service when the trip occurred. No primary or secondary relief valves lifted during the transient. Decay heat is currently being removed using aux feedwater to the steam generators steaming to the main condenser. Tave dropped to a low point of 540 degrees F during the transient. The reactor was manually tripped in approximately 18 seconds after the shutdown bank dropped. The licensee plans to remain in mode 3.

The licensee will notify the NRC Resident Inspector. The licensee will also notify state and local authorities in North and South Carolina.

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Power Reactor Event Number: 41155
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: STEVE LOPER
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/28/2004
Notification Time: 10:52 [ET]
Event Date: 10/28/2004
Event Time: 10:03 [EDT]
Last Update Date: 10/28/2004
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
CHRISTOPHER CAHILL (R1)
TERRY REIS (NRR)
PETER WILSON (IRD)
SCOTT BARBER (R1)
GENE CANUPP (FEMA)
ARLON COSTA (DHS)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

UNUSUAL EVENT DECLARED DUE TO A TOXIC GAS RELEASE IN THE SECURITY CENTER

"At 1003 [hrs] on October 28, 2004, an Unusual Event was declared at the Hope Creek Generating Station in accordance with EAL 9.4.1.b due to an uncontrolled release of freon gas from a chiller located in the top floor of the PSEG Nuclear Security Center. Although the top floor of the security center is a normally locked security area, access restrictions to the top floor of the security center were imposed by the Site Protection (or Fire) Department with breathing apparatus required. This was due to freon concentrations of 2000 ppm at the site of the leak, which exceed the threshold limit value of 1000 ppm. No injuries resulted from the freon leak and no access restrictions were imposed to the main entry/exit level of the security center or the basement (where maximum freon levels were 100 ppm or 10% of the TLV and 1000 ppm respectively). The TLV represents a concentration acceptable for 40 hrs per week, 50 weeks per year occupancy. As of 1040 [hrs] freon levels in the top floor of the security center are 0 ppm."

The licensee informed state/local agencies and the NRC Resident Inspector.

* * * UPDATE FROM M. SHAFFER TO H. CROUCH AT 1324 ON 10/28/04 * * *

Hope Creek secured from Unusual Event at 1316. The leakage has stopped, the machine has been evacuated of freon and normal personnel access has been restored.

The licensee notified the NRC Resident Inspector.

Notified R1 (R. Blough), NRR (T. Reis), IRD (P. Wilson), DHS (A. Costa and M. Cohen), and FEMA (K. Sweetser).

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General Information or Other Event Number: 41156
Rep Org: SCIENTECH LLC
Licensee: SCIENTECH LLC
Region: 4
City: IDAHO FALLS State: ID
County:
License #:
Agreement: N
Docket:
NRC Notified By: MARTIN BOOSKA
HQ OPS Officer: BILL GOTT
Notification Date: 10/28/2004
Notification Time: 14:37 [ET]
Event Date: 10/28/2004
Event Time: [MDT]
Last Update Date: 10/28/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
CHRISTOPHER CAHILL (R1)
BRIAN BONSER (R2)
RONALD GARDNER (R3)
VERN HODGE (NRR)

Event Text

POTENTIAL DEFECT UNDER 10CFR21

"Investigation of failures of two NUS instruments modules revealed that the Kepco power supplies used in the current output circuit failed. Further investigation by the manufacturer of the power supplies revealed that these failures were due to a manufacturing error - in some cases, a surface mount capacitor had been installed with reverse polarity. The capacitor is lightly loaded and takes up to 1000 hours fail, so this problem will not usually be detected by functional testing or normal burn-in tests. The Kepco power supply with the failure is model number FCP-032K. Kepco has identified the manufacturing period of risk for the FCP-032K power supplies as being from April 2003 through July 2004; the period during which the surface mount capacitor was manually installed during a conversion to new automated manufacturing facilities. Not all Kepco FCP-032K power supply components are affected by this problem, nor are other Kepco power supply models."

The affected facilities are: Fitzpatrick, Indian Point 2 and 3, Pilgrim, Beaver Valley, Duane Arnold, and Watts Bar.

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Power Reactor Event Number: 41157
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TIM JOHNSON
HQ OPS Officer: BILL GOTT
Notification Date: 10/28/2004
Notification Time: 17:46 [ET]
Event Date: 10/28/2004
Event Time: 13:14 [EDT]
Last Update Date: 10/28/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JOEL MUNDAY (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown
2 N Y 100 Power Operation 100 Power Operation

Event Text

EMERGENCY SIRENS INOPERABLE

"At 1314 EDT on 10/28/04, all 34 of the Mecklenburg County ANS sirens failed a scheduled weekly test. The silent test checks only the radio circuitry involved in actuating the sirens. This test failure was attributed to a phenomena known as 'Tropospheric Ducting,' which is essentially radio frequency interference on the frequencies utilized for siren control. At 1448 EDT on 10/28/04, the radio frequency interference had cleared and the siren test was repeated with 100% success rate. The remaining 33 sirens in the other four EPZ counties were tested satisfactorily in the same time frame."

The licensee notified the NRC Resident Inspector.

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