Form 5900-23 RADNET EQUIPMENT AND SUPPLY REQUEST FORM

OMB Control No. 2060-0015

Approval Expires XX/XX/XX

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY NATIONAL AIR AND RADIATION ENVIRONMENTAL LABORATORY 540 SOUTH MORRIS AVENUE MONTGOMERY, AL 36115-2601 PHONE: (334) 270-3400 FAX: (334) 270-3454

RADNET EQUIPMENT AND SUPPLY REQUEST FORM

SECTION I: STATION INFORMATION

D ATE OF REQUEST:

S TATION LOCATION: STATION #:

S TATION OPERATOR:

S HIPPING ADDRESS:

T ELEPHONE: FAX:

SECTION II: EQUIPMENT/SUPPLIES REQUESTED

AIR SUPPLIES	PRECIPITATION SUPPLIES
___ MAILING ENVELOPES	___ CUBITAINERS
___ GLASSINE ENVELOPES	___ SHIPPING CARTONS
___ AIR REPORT FORMS	___ VOLUME LABELS
___ AIR FILTERS	___ RETURN LABELS
___ FILTER FORCEPS	___ PARTS (PLEASE SPECIFY)

PARTS (PLEASE SPECIFY):

PLEASE CHECK IF REPORTING CHANGE OF ADDRESS OR COLLECTOR. (CIRCLE ONE)

PLEASE FAX OR RETURN THIS FORM TO THE ATTENTION OF:

RadNet/SAMPLE PREPARATION

US EPA/NAREL

540 SOUTH MORRIS AVE.

MONTGOMERY, AL 36115-2601

FAX: (334) 270-3454

FOR EPA USE ONLY:

D ATE REQUEST RECEIVED: DATE REQUEST PROCESSED:

R EQUEST PROCESSED BY:

The public reporting and recordkeeping burden for this collection of information is estimated to average 5 minutes per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed [form or survey] to this address.

EPA Form 5900-23