5900-23 RadNet Supply Request Form

OMB Control No. 2060-0015
Approval Expires XX/XX/XX

RADNET SUPPLY REQUEST FORM
SECTION I: STATION INFORMATION
DATE OF REQUEST:
STATION LOCATION:

STATION #:

STATION OPERATOR:
SHIPPING ADDRESS:

TELEPHONE:

email:

SECTION II: EQUIPMENT/SUPPLIES REQUESTED
AIR SUPPLIES

Precipitation Supplies

__ MAILING ENVELOPES

__ Cubitainers

__ GLASSINE ENVELOPES

__ Inner, white box
__ Outer, brown box

__ AIR FILTERS

__ Report form

__ AIR REPORT FORMS

__ Mailing labels

__ FILTER FORCEPS

__ Bags & zip ties

OTHER (Please Specify):

Please check if reporting change of ADDRESS or COLLECTOR. (CIRCLE one or both)

Please return this form in standard brown mailer WITH ROUTINE SAMPLE MAILING
(if you need supplies quickly please call/email Scott Telofski or Dan Askren)

US EPA/NAREL
540 SOUTH MORRIS AVE.
MONTGOMERY, AL 36115-2601
FOR EPA USE ONLY:
DATE REQUEST RECEIVED:

DATE REQUEST PROCESSED:

REQUEST PROCESSED BY:
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 5900-23

Please DO NOT FAX