Form DHS Form 9036 DHS Form 9036 Request for An Extension

REQUEST FOR EXTENSION INSTRUMENT

1. Paperwork Reduction Act Statement

In accordance with the Paperwork Reduction Act, no one is required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) Control Number. The valid OMB Control Number for this information collection is 1670-0014. The time required to complete this information collection is estimated to average 0.08 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.

2. PRIVACY NOTICE

Authority: 6 U.S.C. §§ 621-29 (Protecting and Securing Chemical Facilities from Terrorist Attacks Act of 2014) and the Chemical Facility Anti-Terrorism Standards, 6 C.F.R. Part 27 authorize the collection of this information.

Purpose: The primary purpose of this collection is to obtain information regarding a facility's request, including the submitter's contact information

Routine Uses: This information will be used by and disclosed to Department of Homeland Security (DHS) personnel, contractors, or other agents to assist when a CFATS covered chemical facility requests an extension to its’ CFATS regulatory requirements. This information may also be required in order to contact the facility, if necessary.

Disclosure: Providing this information is voluntary. If you choose not to provide this information, then DHS may not be able to fulfill the request or contact you.

3. BASIC REPORTING FIELDS

The following basic reporting fields are required by the Request for Extension instrument:

• Identification of CVI Authorized User status.

• Submitter’s CVI Authorized User Status Number.

• Name of the Submitter: (Last, First, MI).

• Phone Number of the Submitter.

• Facility Name

• CSAT Facility ID #.

• Facility's Address (Street, City, State, Zip).

• Date Submitted.

4. REQUEST FOR EXTENSION

In this section, the instrument will collect the following information when a CFATS covered chemical facility requests an extension to its’ CFATS regulatory requirements. Pursuant to 6 CFR § 27.210(c), the Assistant Secretary has authority to modify the submission schedule for CSAT surveys (i.e. the CSAT TS, the CSAT Security Vulnerability Assessment (SVA), or the CSAT Site Security Plan (SSP)/Alternative Security Program (ASP)). Facilities that require additional time to submit a CSAT survey may request an extension from the Department using this instrument. By completing this instrument the Department of Homeland Security (DHS) will consider extending the submission deadline for a particular facility. The facility must provide the information listed below to support the extension request:

• The extension request is requesting an extension to one of the following reports:

• A Top-Screen.

• A Security Vulnerability Assessment/Site Security Plan.

• Justification for the request (narrative).

• Proposed new due date for the selected report (month, day, year).

• Purpose of the request (narrative).

• Desired outcome of the request (narrative).