OMB Appendix M Utility customer information

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Utility Name ___________________________ EventID _____________________

Affected Utility Customer Information

No.	Last Name	First Name	Street Address	City	State	Zip	Reclaimed Water Service (Yes or No)
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Please attach additional sheets as necessary.

Utility Name ___________________________ EventID _____________________

Unaffected Utility Customer Information

No.	Last Name	First Name	Street Address	City	State	Zip	Reclaimed Water Service (Yes or No)
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Please attach additional sheets as necessary.

Public reporting burden of this collection of information is estimated to average 3 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).