Form 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:
This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB 2060-0015. Responses to this
collection of information are voluntary. 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. The public reporting and recordkeeping burden for this collection of information is estimated to 7-20 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 to the Regulatory Support Division Director, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include
the OMB control number in any correspondence. Do not send the completed form to this address.
EPA Form 5900-23

Please DO NOT FAX