BLS-Green Form 484 Green Form 484110

Green Goods and Services Survey

O.M.B. No. 1220−xxxx

Expires Month Day Year

Please return this form within 14 days. If you need help completing this form, contact information is listed on the last page. Thank you!

West Dakota

012345678

Please report for location(s) in using Unemployment Insurance account number

1

What is the address where your business is physically located?

Report data for the location below. If this address is no longer correct, please provide us with an updated address in the space provided.

Enter Physical Location Address Corrections Here

XYZ ADVISORS

4TH FLOOR

1310 SILVER STREET

SOMECITY WD 12345-6789

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2

ave we identified your main business activity correctly?

We have listed below a description of your main business activity at this location. If this description is incorrect, please call XXX-XXX-XXXX or email [email protected].

NAICS code: 484110 General freight trucking, local
We have identified your main business activity as the following:		Does NOT include:
Establishments primarily engaged in: Local general freight trucking These establishments: Handle a wide variety of commodities, generally palletized and transported in a container or van trailer Usually provide trucking within a metropolitan area which may cross state lines Generally make the trips in same-day		Operating independent trucking terminals Providing general freight long-distance trucking including all North American international travel

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3

hat is your business’s fiscal year?

Please provide us with your fiscal year that includes the month of June 2010.

Start of Fiscal Year				End of Fiscal Year
MM	DD	YYYY		MM	DD	YYYY

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4

hat percent of your fleet operates using specific fuel types or technology?

In Column 1, please estimate the percent of your fleet at the location listed in Item 1 that operates using the following fuel types or technologies. Only vehicles that use the listed fuel types for 100% of their trips should be included. Please report these estimates for your fiscal year listed in Item 3.

Note: This section may best be completed by someone at your firm with access to detailed fleet information.

Percent of fleet in operation for Fiscal Year listed in Item 3
1 Percent of fleet using this fuel type or technology	2 Fuel types or technology
	Biofuels
	E85 fuel
	Hybrid technology

5

What is your percent revenue from specific cargo type?

In Columns 1 and 3, please estimate the percent of your total revenue that comes from transportation of the renewable energy products shown in the table below for the location listed in Item 1. Please base your estimate on total revenues for the fiscal year listed in Item 3. The sum of Column 1 may not equal 100%.

Note: This section may best be completed by someone at your firm with access to financial data.

Percent of Revenue for Fiscal Year listed in Item 3

1 Percent of total revenue for your fiscal year	2 Cargo type
	Transporting wind turbine blades (65 feet long or greater)
	Transporting wind turbine towers (60 feet tall or greater)

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6

hat is your contact information? For the person or persons who helped complete this form.

1. Contact 1’s name: __________________________________________

Title:___________________________________

Phone number: (_____)________ - _____________________ email:__________________________________

Business website:______________________________________________

2. Contact 2’s name: ____________________________________________

Title:___________________________________

Phone number: (_____)________ - _____________________ email:________________________________

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7

o you have any questions about completing this form?

Please send email to [email protected], or call (202)-691-XXXX.

Confidentiality Statement. The Bureau of Labor Statistics, its employees, agents, and partner statistical agencies, will use the information you provide for statistical purposes only and will hold the information in confidence to the full extent permitted by law. In accordance with the Confidential Information Protection and Statistical Efficiency Act of 2002 (Title 5 of Public Law 107-347) and other applicable Federal laws, your responses will not be disclosed in identifiable form without your informed consent. This report is authorized by law 29 U.S.C.2. Paperwork Reduction Act Statement. Your voluntary cooperation is needed to make the results of this survey comprehensive, accurate, and timely. We estimate that completing this form will take an average of 20 minutes. This estimate takes into account time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. If you have any comments regarding this survey, including suggestions for reducing the burden, send them to the Bureau of Labor Statistics, Office of Industry Employment Statistics, Paperwork Reduction Project, 2 Massachusetts Avenue, N.E., Room 4840, Washington, DC 20212. The OMB control number for this voluntary survey is 1220-NEW and expires on month day, year. Without a currently valid number BLS would not be able to conduct this survey.

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