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Event Notification Report for May 27, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/23/2008 - 05/27/2008

** EVENT NUMBERS **


44102 44167 44222 44224 44233 44234 44236 44237 44238 44239 44240

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 44102
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: TOM HACKLER
HQ OPS Officer: PETE SNYDER
Notification Date: 03/27/2008
Notification Time: 20:27 [ET]
Event Date: 03/27/2008
Event Time: 16:45 [EDT]
Last Update Date: 05/23/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
JAY HENSON (R2)

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

Event Text

UNACCEPTABLE FLAW FOUND IN RPV CAP TO PIPE WELD

"At 1645 EDT, it was determined that an unacceptable flaw existed in reactor pressure vessel penetration N9. This penetration leads to a capped line and the flaw is in the cap-to-pipe weld. Based on manual ultrasonic examination, the flaw is 6.2 inches in length on a 5.5 inch OD pipe. Using non-qualified ultrasonic sizing techniques, the flaw is estimated to have a maximum depth of 30 percent through-wall. The flaw was discovered during in-service inspection examination of this penetration, using an improved technique compared to the technique used during a 2004 inspection. The flaw has been found unacceptable per paragraph IWB-3514.4 of the 1989 Edition of ASME Section XI Code and is therefore reportable. A weld overlay repair is being planned.

"The safety significance of this is minimal. Unit 1 is currently in a refueling outage. Repairs of the affected weld will be completed prior to startup."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION PROVIDED BY BILL MURRAY TO JASON KOZAL AT 0946 ON 5/23/08 * * *

"On March 27,2008, at 2027 hours, the Control Room Supervisor made a notification (Event Number 44102) to the NRC Operations Center in Accordance with 10 CFR 50.72(b)(3)(ii)(A) (i.e., any event or condition that results in the condition of the nuclear power plant, including its principal safety barriers, being seriously degraded). The notification was made as a result of determining that an unacceptable flaw existed in the reactor pressure vessel penetration N9 (control rod drive system return line) nozzle-to-pipe cap weld. At the time of discovery, based on manual ultrasonic examination, the flaw was determined to be 6.2 inches in length on a 5.5-inch OD pipe. Using non-qualified ultrasonic depth sizing techniques, the flaw was estimated to have a maximum depth of 30 percent through-wall. The flaw was found unacceptable in accordance with paragraph IWB-3514.4 of the 1989 Edition of ASME Code, Section XI and therefore was reportable.

"Basis for Retraction

"On March 30, 2008, manually indexed phased-array ultrasonic examination of the CRD return line nozzle-to-array caw weld was preformed. Based on these inspections, it was determined that the indication does not exhibit stress corrosion cracking characteristics and is not consistent with ultrasonic responses associated with inside diameter (ID) connected geometry. Therefore, the CRD return line nozzle-to-pipe cap weld is acceptable from an ASME Code Section XI perspective. On this basis, the indication did not result in the condition of the nuclear power plant, including its principal safety barriers, being seriously degraded and the issue is not reportable under 10 CFR 50,72(b)(3)(ii)(A).

"Investigation of this condition is documented in the corrective action program in Nuclear Condition Report (NCR) 272454.

"The NRC resident was notified of this retraction."

Notified R2DO (Vias).

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General Information or Other Event Number: 44167
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: APPLIED TESTING AND GEOTESTING
Region: 1
City: BRIDGEPORT State: PA
County:
License #: 37-30701-01
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JEFF ROTTON
Notification Date: 04/25/2008
Notification Time: 10:55 [ET]
Event Date: 04/25/2008
Event Time: [EDT]
Last Update Date: 05/24/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN WHITE (R1)
RON ZELAC (FSME)
ILTAB via email ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

PENNSYLVANIA AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE

The State provided the following information via email:

"The RSO for Applied Testing and Authorities (37-30701-01), Bridgeport, [PA] reported [to the State of PA] that their Troxler Model 3411 portable moisture-density gauge, containing about Cs-137 (44mCi) and Am-241 (9 mCi), was stolen from a street outside an employee's home at 502 Dickinson Street in Philadelphia. It was stolen between 8:30 last night and 6:45 this morning. The RSO indicated that the gauge was stolen from a locked box which was double-chained to a flat-bed truck. It was noticed that the gauge was missing this morning.

"The Philadelphia Police Department was notified of the incident by the licensee and has responded to the area.

"[State of PA] will be doing an inspection of the licensee this afternoon."

** UPDATE FROM DAVID ALLARD TO JOHN KNOKE AT 10:16 EDT ON 05/23/08 **

State connected with Philadelphia Police detective and licensee's RP Manager. The police have the Troxler gauge. Licensee's staff will go into town to make sure the gauge isn't damaged and leaking, and then take it back to their shop and secure it.

Notified R1DO (Mel Gray) FSME DO (Patrice Bubar), ILTAB (Matt Hahn) via email

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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General Information or Other Event Number: 44222
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: BAPTIST HOSPITAL
Region: 1
City: PENSACOLA State: FL
County:
License #: 0158-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: JOHN KNOKE
Notification Date: 05/19/2008
Notification Time: 17:03 [ET]
Event Date: 05/16/2008
Event Time: [EDT]
Last Update Date: 05/19/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1)
REBECCA TADESSEE (FSME)

Event Text

AGREEMENT STATE REPORT - MISADMINISTRATION OF I-131

"A misadministration occurred on 16-May-2008 and this office was notified at 1300 hours. The patient received a prescribed dose of 150 mCi of I-131 on 9-May-2008. Patient returned to hospital on 16- May-2008 for a scan only. Nuclear medicine tech mis-administered 5 mCi of I-131. The patient and doctor have been notified. Any further action is referred to Radioactive Materials. This office will take no further action on this incident."

A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 44224
Rep Org: REID HOSPITAL
Licensee: REID HOSPITAL
Region: 3
City: RICHMOND State: IN
County:
License #: 13-03284-02
Agreement: N
Docket:
NRC Notified By: CHARLES NARAYANAN
HQ OPS Officer: PETE SNYDER
Notification Date: 05/20/2008
Notification Time: 09:44 [ET]
Event Date: 05/19/2008
Event Time: 09:44 [EDT]
Last Update Date: 05/21/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
KENNETH RIEMER (R3)
MICHELE BURGESS (FSME)

Event Text

NON-PRESCRIBED DOSE GIVEN TO A PATIENT

The prescribing physician ordered that a regular treadmill stress test be given to a patient. Instead of the correct test the hospital actually gave the patient a treadmill myocardial perfusion imaging test (MPIT) which uses a dose of Tc-99m.

At 9:44 AM on 5/19/08 the patient was given a dose of 16.3 milliCuries of Tc-99m for the resting portion of the MPIT. Then at 10:24 AM on 5/19/08 the patient was given a dose of 35.3 milliCuries of Tc-99m for the stress portion of the MPIT. This resulted in a total dose of 51.6 milliCuries of Tc-99m given to the patient which is typical for a MPIT procedure.

The hospital is currently conducting an investigation into this occurrence. The hospital will inform the patient of the error.

* * * RETRACTION PROVIDED BY CHARLES NARAYANAN TO J. KOZAL ON 05/21/08 AT 0916 EST * * *

Upon investigation the licensee has determined that the event does not meet the reporting requirements of 10 CFR 35.3045(a)(1).

Notified the R3DO (Riemer) and FSME EO (Burgess).

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General Information or Other Event Number: 44233
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: UNIV MASS LOWELL
Region: 1
City: LOWELL State: MA
County:
License #: 60-0049
Agreement: Y
Docket:
NRC Notified By: JOHN SUMARES
HQ OPS Officer: JOHN KNOKE
Notification Date: 05/22/2008
Notification Time: 13:22 [ET]
Event Date: 05/21/2008
Event Time: [EDT]
Last Update Date: 05/22/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1)
RON ZELAC (FSME)

Event Text

AGREEMENT STATE REPORT - LEAKING CHECK SOURCE

The State provided the following information via email:

"Licensee identified a leaking sealed radioactive source. Once identified, the source was taken out of service and placed in the licensee's waste stream and a contamination survey of the area was made. No measurable contamination was identified from this survey. Contamination wipes consisted of area wipes (filter paper) measured in a liquid scintillation counter.

"The Cs-137 source was used to test the response and functionality of hand-held radiation detectors. The leaking source, S/N 189-26-5, is a Cs-137 check source with an activity of 100 uCi on 3-1-87 and was manufactured by Isotope Products. The licensee stated the source may not meet the regulatory criteria for a sealed source since the front of the source is electroplated to allow for the detection of Cs-137 betas. As a precaution, the licensee reported it as a leaking source."

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Power Reactor Event Number: 44234
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: MARIA GHARAKHANIAN
HQ OPS Officer: JOHN KNOKE
Notification Date: 05/22/2008
Notification Time: 14:35 [ET]
Event Date: 05/22/2008
Event Time: 14:20 [EDT]
Last Update Date: 05/23/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
MEL GRAY (R1)

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

Event Text

REACTOR TRIP DUE TO LIGHTNING STRIKE

Lightning struck the main transformer for Millstone Unit 2 and caused actuation of the reactor protection system. The reactor had an uncomplicated trip. Reactor shutdown and all control rods fully inserted. No primary or secondary relief valves lifted. Plant is stable in Hot Standby at NOP and NOT. Level is being maintained with normal feedwater and AFW is available if required. Decay heat is being removed via steam bypass valves.

The licensee notified the NRC Resident Inspector.

* * * UPDATE PROVIDED AT 2127 EDT ON 05/23/08 FROM MARK STROLLO TO JEFF ROTTON * * *

"The purpose of this update is to clarify the stated cause of the reactor trip and plant response. The original title was 'Reactor Trip Due to lightning Strike on Main Transformer'. Although there was a lightning storm in the vicinity of Millstone 2 at the time of the reactor trip, the cause of the reactor trip may be related to a grid disturbance caused by a lightning strike on a transmission line off site. This cause remains under investigation. [Initial] event report states that no primary or secondary relief valves lifted. A steam generator safety relief valve (secondary) lifted for about 34 seconds.

"The NRC Sr. Resident Inspector has been notified."

Notified R1DO (Gray).

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Power Reactor Event Number: 44236
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [2] [ ] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: TIM BUCHAL
HQ OPS Officer: JASON KOZAL
Notification Date: 05/23/2008
Notification Time: 08:11 [ET]
Event Date: 05/23/2008
Event Time: 03:30 [EDT]
Last Update Date: 05/23/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
MEL GRAY (R1)

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

Event Text

CHARGING PUMP DECLARED INOPERABLE DUE TO RELIEF VALVE LIFTING BELOW SETPOINT

"During normal operation with 23 Charging Pump in service, 21 Charging Pump was placed in service for quarterly testing. Shortly after starting 21 Charging Pump, 23 Charging Pump relief valve lifted below its set point value. CVCS system pressure was approximately 2520 psig. This is the alternate safe shutdown pump responsible for inventory control for remote shutdown. 23 Charging Pump was declared inoperable. Recent NRC guidance indicates that a loss of a single train system not credited in accident analysis is reportable when identified in LCO 3.3.4, Remote Shutdown."

The licensee will notify the NRC Resident Inspector.

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Power Reactor Event Number: 44237
Facility: PALISADES
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: MICHAEL MLYNAREK
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/23/2008
Notification Time: 16:06 [ET]
Event Date: 05/23/2008
Event Time: 12:49 [EDT]
Last Update Date: 05/23/2008
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):
KENNETH RIEMER (R3)

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

Event Text

AUTOMATIC REACTOR TRIP ON POSSIBLE GENERATOR LOCKOUT

The reactor automatically tripped at 1249 EDT on 05/23/08. The cause of the reactor trip signal is not positively known, but it is believed to be related to trip of the 346 negative sequence relay which caused a trip of the 386C generator independent trip (coastdown) lockout relay. All plant systems performed as designed with minor deficiencies noted. EOP-1, 'Standard Post Trip Actions', and EOP-2, 'Reactor Trip Recovery', performed.

All control rods fully inserted. All atmospheric steam dump valves lifted and reseated. CV-0780 (B Steam Generator ASDV) was identified as leaking and was manually isolated. There is no known primary to secondary leakage. Auxiliary feedwater system actuated automatically as designed in response to low steam generator water levels. AFW actuation consisted on AFW pump P-8A auto start and AFW valve operation. Steam generator water levels were subsequently restored to normal and are being maintained for primary coolant system heat removal via main steam isolation valves to main condenser (via the turbine bypass valves). Plant is at Normal Operating Pressure (2060 psia) and Temperature (533 degrees F). Grid is stable with safety bus station power being provided from Safeguards transformer.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 44238
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: MARIA GHARAKHANIAN
HQ OPS Officer: PETE SNYDER
Notification Date: 05/24/2008
Notification Time: 10:03 [ET]
Event Date: 05/24/2008
Event Time: 09:54 [EDT]
Last Update Date: 05/25/2008
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
MEL GRAY (R1)
WILLIAM GOTT (IRD)
FREDERICK BROWN (NRR)
ERIC LEEDS (NRR)
MARC DAPAS (R1)
FRED HILL (DHS)
KEVIN BISCOE (FEMA)
AMANDA JIMENEZ (USDA)
JANET WILLIAMS (HHS)
THOMAS YATES (DOE)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 1 Startup 0 Hot Standby

Event Text

LOSS OF OFFSITE POWER

The licensee entered an Unusual Event after an automatic reactor trip due to a loss of offsite power per EAL Designation PU-1. Currently the plant is stable in Mode 3 with power being supplied to the "A" & "B" Emergency Diesel Generators (EDG) running supplying power to the safety buses. Decay heat is being removed by the motor driven Auxiliary Feedwater Pump supplying water to the steam generators exhausting to atmosphere via atmospheric relief valves. There are no primary to secondary tube leaks.

NRC Resident Inspector has been notified.

* * * UPDATE FROM SKIP JORDAN TO JOHN KNOKE AT1252 EDT ON 05/25/08 * * *

At 1252 EDT the licensee terminated from their Unusual Event. After the loss of offsite power due to a failure of the Reserve Station Service Transformer (RSST) the licensee began to troubleshoot the problem as well as beginning to restore offsite power. At 1106 on 5/24/08 a cross-tie from Unit 3 was connected to Unit 2 and "A" EDG was secured. At 0950 on 5/25/08 the RSST was powered up and the non-vital busses were energized. At 1136 the "B" and "D" Reactor Coolant Pumps were started. At 1230 the vital bus was energized and the "A" EDG was secured.

The licensee notified the NRC Resident Inspector. Notifications to: R1 (Marc Dupas, David Lew), R1DO (Mel Gray), NRR EO (Fred Brown), IRD MOC (William Gott), DHS (Fred Hill), FEMA (Dan Sullivan), USDA (Amanda Jimenez,), HHS (Mason Pyle), DOE (Julia Muse).

The NRC Resident Inspector was notified.

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Power Reactor Event Number: 44239
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: MICHAEL MOUSER
HQ OPS Officer: JOE O'HARA
Notification Date: 05/24/2008
Notification Time: 15:06 [ET]
Event Date: 05/24/2008
Event Time: 09:38 [EDT]
Last Update Date: 05/24/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
MEL GRAY (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 15 Power Operation 15 Power Operation

Event Text

STEAM GENERATOR LEVEL EXCURSION

"On 5/24/2008 at 0938, with Beaver Valley Power Station Unit 2 (BVPS U2) in Mode 1 at 15% power during preparations for turbine startup, the unit experienced a steam generator level excursion. Attempts to manually control steam generator water level were unsuccessful.

"Steam Generator narrow range levels exceeded the setpoint for P-14, Steam Generator Level High High Turbine Trip. The actuation of P-14 automatically actuated the following: trip of the running Main Feedwater pump, closure of the Main and Bypass Feedwater regulating valves, and closure of the Feedwater Containment isolation valves. In addition to these signals, a turbine trip signal is generated but the turbine was not yet on-line.

"The feedwater isolation signal has been reset and normal feedwater flow has been established. Preliminary investigation has revealed that a broken air line caused the 'A' Main Feedwater pump recirculation flow control valve to fail open. This initiated the steam generator level transient. Additional investigation is in progress.

"The trip of the Main Feedwater pumps automatically started both Motor Driven Auxiliary Feedwater pumps (MDAFW). The automatic start of the MDAFW pumps from this valid system actuation is reportable under 10CFR50.72(b)(3)(iv)(A).

"The plant is currently stable in Mode 1 at 15% reactor power." AFW injected into the core.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 44240
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: TOM FOWLER
HQ OPS Officer: PETE SNYDER
Notification Date: 05/25/2008
Notification Time: 09:50 [ET]
Event Date: 05/25/2008
Event Time: 09:30 [EDT]
Last Update Date: 05/25/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
MEL GRAY (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 91 Power Operation 91 Power Operation

Event Text

INVERTER FUSE FAILURE

"At 1835 on 5/24/08 CD482 inverter main power fuse failed. This inverter powers various vital ECCS channel 'C' analog instrumentation (including 'C' channel EDG start circuitry). The inverter transferred to the alternate AC power supply as designed with no abnormal plant response or transient. The main power fuse was replaced and attempts were made to place the inverter section back in service and return the inverter to the normal power supply. Logic card checks were performed as part of the normal restoration process prior to transferring to the inverter normal output. These checks could not be completed satisfactorily and indicate that there is an abnormal condition in the inverter section. The inverter, while on alternate AC, is not operable per technical specifications [TS] due to the loss of alternate AC on a LOOP/LOCA, which would prevent the 'C' EDG from starting. Additional safety related equipment that is unavailable include the 'D' Station Service Water Pump for a scheduled maintenance window. All other safety equipment is operable and functioned as required. No personnel were injured. Unit shutdown commenced at 0930 on 5/25/08 in accordance with TS 3.8.3.1. The unit is required to be in hot shutdown by 1435. This four-hour report is bring made in accordance with 10 CFR 50.72(b)(2)(i)."

The licensee notified the NRC Resident Inspector. The licensee will notify a local government agency.

* * * UPDATE FROM TOM FOWLER TO JOE O'HARA AT 1415 ON 5/25/08 * * *

The inverter logic power supply has been replaced, and the inverter has been tested satisfactorily. The inverter has been declared operable, and the licensee exited the technical specification required shutdown at 1217. Power ascension is in progress.

The licensee informed the NRC Resident Inspector, and the Lower Alloways Creek Township.

Notified R1DO(Gray)

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