Page 1 of 3 NRC FORM 7 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0027 EXPIRES: 0613012009 (6-2006) Estimated burden per response to comply with this mandatory collection request 2.4 hours. This 10CFR 110 submittal is reviewed to ensure that the applicable statutory. regulatory, and policy considerations are satisfied. Send comments regard~ng burden estimate to the Records and FOIAlPfivacy Services Branch (1-5 F52). U.S. Nuclear Regulatory Commission, Washington. DC 20555-001, APPLICATION FOR NRC EXPORTIIMPORT or by intemet e-mail to infocollects@nr:.gov, and to tie Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3151-0027), Office of Management and Budget Washington, LICENSE, AMENDMENT, OR RENEWAL DC 20503. If a means used koimpose an intormation coltection does not display a currently valid OMB control number, the NRC may not conduct or sponsor, and a person Is not required to (See Instructionson Page 5) respond to, the information collection. 0 I I I I I I I I I I I LICENSE~t0M PC PART B. TO BE COMPLETED FOR ALL LICENSES, AMENDMENTS, OR RENEWALS (If more space is needed to complete any of the Items, use Pages 3-4 first, and then attach additional sheets, Ifnecessary.) 1. NAME AND ADDRESS OF APPLICANT/LICENSEE la. NAME OF APPLICANT'S CONTACT lb. APPLICANTS REFERENCE NUMBER Halliburton Energy Services Cindy Dorris HES4037 2107 City West Blvd., Bldg 2 1c. PHONE NUMBER Id. FAX NUMBER Houston, Texas 77242 (713) 839-4566 (713) 839-4564 le. E-MAIL ADDRESS [email protected] 2. TYPE OF NRC LICENSE REQUESTED (Check One) [ EXPORT L IMPORT COMBINED EXPORT/IMPORT M,/ AMENDMENT/RENEWAL (Parts B, C, E) (Parts B, D, E) (Parts B, C, D, E) Existing License Number: CBPOO10-1R 3. CONTRACT NUMBER(S) 4. FIRST SHIPMENT DATE 5. LAST SHIPMENT DATE 6. PROPOSED EXPIRATION DATE 10/31/2015 PART C. TO BE COMPLETED FOR EXPORT ONLY OR COMBINED LICENSES, AMENDMENTS, OR RENEWALS (If more space Is needed to complete any of the Items, use Pages 3-4 first, and then attach additional sheets, ifnecessary.) 7. NAME(S) I ADDRESS(ES) OF SUPPLIERS 8. NAME(S) / ADDRESS(ES) OF INTERMEDIATE 9. NAME(S) I ADDRESS(ES) OF ULTIMATE AND/OR OTHER PARTIES TO THE EXPORT FOREIGN CONSIGNEE(S) FOREIGN CONSIGNEE(S) Indonesia SEE PAGE 3 OF THIS FORM 7a. LIST FUNCTIONS PERFORMED/SERVICE PROVIDED Ba.INTERMEDIATE USE(S) 9a. ULTIMATE END USE(S) 10. DESCRIPTION OF RADIOACTIVE MATERIALS, SEALED SOURCES, 10a. MAX TOTAL VOLUME I JOb. MAX ENRICHMENT 10c. MAX ISOTOPE NUCLEAR FACILITIES. EQUIPMENT, OR COMPONENTS ELEMENT WGT (KG), OR OR WGT % WGT (KG) TOTAL ACTIVITY (TBq) 11. FOREIGN OBLIGATIONS (BY COUNTRY AND BY PERCENTAGE OF MAXIMUM TOTAL VOLUME) NRC FORM 7 (6-20306) PRINTED ON RECYCLED PAPER Page 2 of 3 NRC FORM 7 U.S. NUCLEAR REGULATORY COMMISSION (6-2006) 10CFR110 APPLICATION FOR NRC EXPORT/IMPORT LICENSE, AMENDMENT, OR RENEWAL (Continued) CENSUtfMV DOCCKETV!8 IMAPCE$SSl.19UUMBERI~ ~t &- PART D. TO BE COMPLETED FOR IMPORT ONLY, OR COMBINED LICENSES, AMENDMENTS,. OR RENEWALS (If more space is needed to complete any of the Items, use Pages 3-4 first, and then attach additonal sheets, if necessary.) 12. NAME(S) / ADDRESS(ES) OF FOREIGN 13. NAME(S) I ADDRESS(ES) OF INTERMEDIATE 14. NAME(S) / ADDRESS(ES) OF ULTIMATE SUPPLIERS ANDIOR OTHER PARTIES CONSIGNEE(S) CONSIGNEE(S) TO IMPORT 12a. NRC EXPORT LICENSE NUMBER(S) 13a. LICENSE NUMBER(S) / EXPIRATION DATE(S) 14a. LICENSE NUMBER(S) I EXPIRATION DATE(S) (if applicable) 13b. INTERMEDIATE USE(S) 14b. INTERMEDIATE USE(S) 15. DESCRIPTION OF RADIOACTIVE MATERIALS, SEALED SOURCES, 15a. MAX TOTAL VOLUME I 15b. MAX ENRICHMENT 15c. MAX ISOTOPE NUCLEAR FACILITIES ELEMENT WGT (KG), OR OR WGT % WGT (KG) TOTAL ACTIVITY (TBq) Category 2 quantities or Americium-241 and Amedcium-241/Be for shipments that are in excess of 0.6 Terebequerels threshold. 16. FOREIGN OBLIGATIONS (BY COUNTRY AND BY PERCENTAGE OF MAXIMUM TOTAL VOLUME) PART E. TO BE COMPLETED FOR ALL LICENSES, AMENDMENTS, OR RENEWALS 17. ADDITIONAL INFORMATION 17a. COPIES OF RECIPIENTS' PROVIDED ON PAGES 3.4, R1 YES [] NO AUTHORIZATIONS PROVIDED? Li YES NO AND/OR ON SEPARATE SHEETS? 18. CERTIFICATION: I,the applicant's authorized official, hereby certify that this application is prepared in conformity with Title10, Code of Federal Regulations, and that all information provided is correct to the best of my knowledge. 18a. PRINT NAME AND TITLE OF AUTHORIZED OFFICIAL 18b. SIGNATURE - AUTHORIZED OFFICIAL 18c. DATE Intemational Trade Compliance Export Administrator 09/14/2007 Page 3 of 3 NRC FORM 7 U.S. NUCLEAR REGULATORY COMMISSION (6-2006) 10 CFR i10 APPLICATION FOR NRC EXPORT/IMPORT LICENSE, AMENDMENT, OR RENEWAL (Continued) .UCEINJ$E NUMBER DOKE NUBE A2-:ACES ADDITIONAL INFORMATION (Reference applicable block numbers from page 1 and/or page 2 for each entry) THIS APPLICATION IS FOR EXTENDING THE EXPIRATION DATE FOR LICENSE CBP001 0-1 R AND TO ADD ADDITIONAL ULTIMATE CONSIGNEES *copy of NRC License No. CBP001 0-1 R included with this Form* Ultimate Foreign Consignee (s): Indonesia: Halliburton Energy Services Halliburton Energy Services Halliburton Logging Services Indonesia PT Halliburton Logging Services Indonesia PT Cilandak Commercial Estate, Bldg. 107 Transkon Jaya JL. Ray Cilandak KKO JL. Mula Warman No. 21, RT023/RW07 Jakarta Selatan 12560, DKI Jakarta Manggar, Balikpapan 76116 Jakarta, Indonesia East Kalimantan, Indonesia Halliburton Energy Services Halliburton Energy Services Halliburton Logging Services Indonesia PT Halliburton Logging Services Indonesia PT Palaran Base, Sanga-Sanga JL. Jend. Basuki Rahmat 14A Samarinda, Indonesia Palembang, Indonesia Halliburton Energy Services Halliburton Energy Services Halliburton Logging Services Indonesia PT Halliburton Logging Services Indonesia PT JL. Raya Duri Pekanbaru Km 11 C/O PT Sekupang Logistics Duri-Riau 28884, Indonesia Palembang, Indonesia Halliburton Energy Service Halliburton Energy Services Halliburton Logging Services Indonesia PT Halliburton Logging Services Indonesia PT Jalan Marsma R Iswahyudi C/O Pt Kayo Trans Perak Balikpapan, Indonesia Gudang 300B Mirah JL. Prapat Kurung Utares Tanjung Perak Surabaya 60165, Indonesia.