5900-29 RadNet Drinking Water Report

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

United States Environmental Protection Agency
National Analytical Radiation Environmental Laboratory
540 South Morris Avenue
Montgomery, AL 36115-2601
(334) 270-3400

RADNET DRINKING WATER REPORT
SECTION I: STATION INFORMATION
Principal City:

______________________________________

Name of Collector:

______________________________________

Office Address:

___________________________________________________________________________

Please check box to left if reporting
a change in collector or address.

_____________________________________________________________________________________________
Shipping Address:

___________________________________________________________________________

_____________________________________________________________________________________________
Telephone:

________________________________

E-mail:

___________________________________________________________________________

Fax:

________________________________

SECTION II: SAMPLE INFORMATION
Collection Date:

______________________________________

Tap Location:

__________________________________________________________________________

Water Authority (if known): _____________________________________________________________________
Water Source (circle one, if known):

River

Reservoir

Well

Other: ______________________

Comments (use back of sheet if necessary): _________________________________________________________
_____________________________________________________________________________________________
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 5900-29