0923-0048 Form 400

Appendix I6.

Form Approved

OMB No. 0923-0048 Exp. Date 06/30/2022

FORM 400

ATSDR estimates the average public reporting burden for this collection of information as 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering, and maintaining the data/information 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 (0923-0048).

Private Well Water Collection

___________________________	___________________________
Place ID Sticker Here	Inspector and Date
Sample Number: W-1
General Comments: