Form 5900-29 RADNET DRINKING WATER REPORT

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 Drinking Water Report

1. Date of Collection:

2. Quarter: (CIRCLE ONE) Jan-Mar Apr-Jun Jul-Sep Oct-Dec Year:

3. Station (City,State):

4. Tap Location:

5. Name of Collector:

6 . Office Address:

7. Shipping Address:

8. Telephone: 9. FAX:

10. Comments:

□ Please check here if reporting change of address or collector.

(CIRCLE ONE)

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 5900-29