Form 5900-28 RADNET PASTEURIZED MILK 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 PASTEURIZED MILK REPORT

1. DATE OF COLLECTION:

2. QUARTER: JAN-MAR APR-JUN JUL-SEPT OCT-DEC YEAR: ___________

3 . PRINCIPAL CITY:

4 . NAME OF COLLECTOR:

5 . OFFICE ADDRESS:

6 . SHIPPING ADDRESS:

7 . TELEPHONE NUMBER OF COLLECTOR:

1. Fax Number of Collector:

2. EPA Bottle Number:

3. Names of Contributing Plants/Dairies:

4. Specify pounds or gallons produced per day on the sample collection date by the contributing plants/dairies:

5. Comments:

Please check here if reporting change of address or collector.

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 5900-28