NHTSA Form 1062 Tire Inspection Form

ATTACHMENT D3

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 and inspection, 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 1062

U.S. Department of Transportation National Highway Traffic Safety Administration

TIRE INSPECTION FORM (4/07/10 Draft)

Form Approved O.M.B. No. 2127-0626 Expiration Date: XXXX National Automotive Sampling System Tire Pressure Monitoring System-Special Study

1. Primary Sampling Unit Number ____ ____ 2. Site Number ____ ____ 3. Observation Number ____ ____ 4. Date of Observation ____ ____/____ ____/2010 5. Time of Day

6. Vehicle Model Year 7. Vehicle Make 8. Vehicle Model 9. Ambient Air Temperature ____ ____ 10. Weather: Clear, Cloudy, Fog, Rain, Sleet, Snow

11. TIRE	12. TIRE MANUFACTURER	13. TIRE MODEL	14. TIRE SIZE (eg. P215/70R14)	15. MAXIMUM PRESSURE	16. MEASURED PRESSURE	17. TIRE TEMPERATURE	18. MEASURED MIN. TREAD DEPTH	TIRE
LF				___ ___ psi	___ ___ psi	___ ___ __ ○F	___ ___ /32"	LF
LR				___ ___ psi	___ ___ psi	___ ___ __ ○F	___ ___ /32"	LR
RR				___ ___ psi	___ ___ psi	___ ___ __ ○F	___ ___ /32"	RR
RF				___ ___ psi	___ ___ psi	___ ___ __ ○F	___ ___ /32"	RF