Information Collection

Activity 1 - Facility Sampling Collection Form

IC 222456 under ICR 201607-0923-001 · OMB 0923-0054.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0054 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Activity 1 - Facility Sampling Collection Form	Form and Instruction
Activity 1 - Tire Recycling Plant Sample Collection Form Att4d TireRecyclingPlant Sampling Collctn Form_20160716 clean.docx	Form and Instruction

IC Title:

Activity 1 - Facility Sampling Collection Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	Activity 1 - Tire Recycling Plant Sample Collection Form	Att4d TireRecyclingPlant Sampling Collctn Form_20160716 clean.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-19-0001 Record of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances

FR Citation: 57 FR 62814

Number of Respondents: 9

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	9	9
Annual IC Time Burden (Hours)	14	14
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.