NHTSA Form 1061 Daily Site Form Refueling

ATTACHMENT D2

	U.S. Department of Transportation National Highway Traffic Safety Administration			DAILY SITE FORM REFUELING (5/18/10 Draft)					Form Approved O.M.B. No. 2127-0626 Expiration Date: XXXX National Automotive Sampling System Tire Pressure Monitoring System-Special Study
		Primary Sampling Unit Number:				Site Number:				Date of Observation: _______/_______/2010
		Station Characteristics: Cash Only Pay-at-Pump Cashier Window Store Car Wash Auto Repair [All that apply]									Page ____ of ____ Pages
REFUELING
Body Type (Check One)			Other Descriptors (e.g. Color)		Time In		Time Out	Activities
Auto: Small Large SUV Van PU			1.					Pay and Leave [Only Activity] OR Store Auto-Related Other [All that apply]
Auto: Small Large SUV Van PU			2.					Pay and Leave [Only Activity] OR Store Auto-Related Other [All that apply]
Auto: Small Large SUV Van PU			3.					Pay and Leave [Only Activity] OR Store Auto-Related Other [All that apply]
Auto: Small Large SUV Van PU			4.					Pay and Leave [Only Activity] OR Store Auto-Related Other [All that apply]
Auto: Small Large SUV Van PU			5.					Pay and Leave [Only Activity] OR Store Auto-Related Other [All that apply]
Auto: Small Large SUV Van PU			6.					Pay and Leave [Only Activity] OR Store Auto-Related Other [All that apply]
Auto: Small Large SUV Van PU			7.					Pay and Leave [Only Activity] OR Store Auto-Related Other [All that apply]
Auto: Small Large SUV Van PU			8.					Pay and Leave [Only Activity] OR Store Auto-Related Other [All that apply]
Auto: Small Large SUV Van PU			9.					Pay and Leave [Only Activity] OR Store Auto-Related Other [All that apply]
Auto: Small Large SUV Van PU			10.					Pay and Leave [Only Activity] OR Store Auto-Related Other [All that apply]
Auto: Small Large SUV Van PU			11.					Pay and Leave [Only Activity] OR Store Auto-Related Other [All that apply]
Auto: Small Large SUV Van PU			12.					Pay and Leave [Only Activity] OR Store Auto-Related Other [All that apply]
Auto: Small Large SUV Van PU			13.					Pay and Leave [Only Activity] OR Store Auto-Related Other [All that apply]
Auto: Small Large SUV Van PU			14.					Pay and Leave [Only Activity] OR Store Auto-Related Other [All that apply]

Paperwork Reduction Act Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2127-0626. Since data will be collected on this form via observation, public reporting for this collection of information is estimated to be approximately 0 minutes per response, including the time for reviewing instructions, completing and reviewing the collection of information. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590. NHTSA Form 1061