United States Information Resources April 1989 Environmental Protection Management Agency (PM-211) Forms Catalog ------- Table of Contents Page Introduction - iii Current Forms Numerical List of EPA Forms 1 1100-1199 -- Organization and Functions 1 1300-1399 -- Administrative Management 1 1400-1499 -- Protective Services 2 1500-1599 -- Public Affairs 3 1600-1699 -- Interagency Agreements 3 1700-1799 -- Personal Property 3 1900-1999 -- Contracts Management 4 2000-2099 -- Emergency Programs 5 2100-2199 - - Library Systems 6 2200-2299 -- Publications and Communications Materials 6 2300-2399-- Printing and Distribution 6 2400-2499 -- Budget and Administration 6 2500-2599 -- Accounting and Finance 6 2600-2699 -- Travel and Transportation 8 2700-2799 -- Audit Investigation Management 8 2800-2899-- Data Processing Systems 8 3100-3199 -- Human Resources Management 9 3300-3399-- Legal 11 3500-3599 -- Enforcement 12 3700-3799 -- Program Review and Reporting 13 4500-4599-- International Activities 13 4700-4799 -- Equal Opportunity 14 4800-4899 -- Buildings, Facilities, Space, and Site Management 14 4900-4999 -- Motor Vehicle and Aircraft Management 14 5000-5099 -- Telecommunications 14 5100-5199 -- Office Services 15 5200-5299 -- Legislative 15 5300-5399-- Research and Development 16 5700-5799 -- Grants 16 6000-6099 -- Minority and Women’s Business 17 7500-7599 -- Water 17 7700-7799 -- Toxic Substances 18 8500-8599 -- Pesticides 19 8700-8799 -- Solid Waste 20 9000-9999 -- Superfund 21 Alphabetical List of EPA Forms 22 List of EPA Forms by Function 36 Acknowledge 36 Advise 36 Agree 36 Amend 36 Apply 36 Approve 38 Assign 38 Bifi 38 Certify 38 Claim 39 Confirm 39 Contract 39 Cover 39 ------- Table of Contents List of EPA Forms by Function (Continued) Describe 39 Designate 40 Determine — 40 Display 40 Distribute 40 Estimate 40 Evaluate 40 Guide 41 Identify 41 Index 41 Initiate 41 Inquire 41 Invite 42 Mail 42 Notify 42 Obligate 43 Plan 43 Receipt 43 Recommend 43 Record 43 Report 47 Request 49 Respond 50 Review 50 State 51 Support 51 Transcribe — 51 Transmit — 51 Update ------ — — 52 Verily —--- 52 Void — — 52 Worksheet — ---- -- — 52 Appendices List of EPA Forms Available in Electronic Format E List of New EPA Forms (Created Since September 1, 1984) New List of EPA Forms Revised Since September 1, 1984 Revised List of EPA Forms Declared Obsolete since September 1, 1984 Obsolete Numerical List of EPA Public-Use Forms 0MB List of EPA Public-Use Forms by 0MB Number 0MB No. List of Standard Forms SF List of Optional Fonus — — OF I I ------- Introduction What This Catalog Does EPA forms are designed to improve the flow of information, thereby making your paperwork more efficient, less tedious, and generally easier. This catalog is provided to help you find the best form for your needs. It identifies all EPA Headquarters and Agencywide forms. There are also lists of new forms created or forms declared obsolete since publication of the last catalog. It tells you where forms are stocked and how to order forms. Getting the Form You Need Paper Forms: First, check this catalog to identify the form and to find out where it is stocked. The stock location is indicated by a letter code, which is explained below. If it is not stocked locally, fill out a Publications/Forms Request (EPA Form 2360-1) and submit it to your Forms Officer. If you can’t find a form to fill your need, contact your Forms Officer. She/he may be able to find a form for you or, if there is no form available, will work with you to create a new form. Electronic Forms: Several forms are now available on IBM-PC-compatible format and/or Apple Macintosh compatible format and can be printed, with or without fill-in data, on your desktop laser printer. Forms that are available electronically are indicated by an asterisk (*) before the form number, and there is a separate list of electronic forms. To obtain a diskette containing a form, to have an existing form converted to electronic media, or for further information, contact the Headquarters Forms Office. Location of the Headquarters Forms Office The Forms Office is a part of the Information Management and Services Division, Information Management Branch (Mail Code PM-21 1D). It is located in room 2003 of the Waterside Mall Building, phone ( 2Q - VF3>-382- 142-E-Mail box EPA3239. k - J S Z- - Jj Catalog Terminology Form Number: The form number is derived from the Classification Numbering System as described in the Directives Management Manual. The number is in the form xxxx-xx, with the first four digits being the classification series, and the digits after the dash being assigned in sequence, generally in the order in which the forms in a given classification series were developed. Standard and Optional Forms: Standard Forms (SF) are prescribed for Government- wide use, and their use is mandatory for their relevant purposes; thus, if you wish to apply for a Federal job, you must use SF 171, Application for Federal Employment. Optional Forms (OF) are prescribed for use by two or more agencies, and may be used by others; you may use OF 41, Routing and Transmittal Slip, or you may develop a route slip of your own. III ------- How To Use the “Current Forms” Section of This Catalog Numerical Listing: Forms are listed in order according to the numbering system described above. Find the classification series number in the Table of Contents, turn to the indicated page, and you will find the form in sequential number order within the classification series. Alphabetical and Functional Listings: Alternatively, you may look up a form in the alphabetical list of form titles or by function (such as Reporting, Requesting, etc.) Public-Use Forms: Many EPA Forms are used to gather information from the public. These forms must be cleared by the Office of Management and Budget (0MB), and may not be used after the expiration date of the clearance. The fomis are listed by EPA Form Number and by 0MB Qearance Number. Explanation of Columns and Codes Edition Date: The edition date indicates the date the current version of the form was printed. Normally, a new edition of a form will supersede all previous editions. Originating Office: The code shown is the current mail code of the Headquarters office responsible for the form. You should contact the originating office for information on how to use the form. Also, if the Stock Code for a form is “C,” the originating office will be the only place that maintains a stock of the form. Unit of Issue: The unit of issue indicates the physical characteristics of the form. The units of issue are abbreviated as follows: Sht a single sheet of paper (normally one or two pages) Set a multicopy form, using either interleaved carbon paper or carbonless paper Card a postcard as well as a form printed on heavy paper (card stock) Pam a pamphlet, usually bound, consisting of several pages of forms and often including instructions Stock Code: The stock code indicates where supplies of the forms are maintained. The codes are as follows: A Forms and Publications Distribution Center (FPDC), Cincinnati, OH 45268 B Headquarters Self-Service Store (SSS), Room G-100, Waterside Mall C Originating office only D Other facilities (e.g., the General Services Administration, the National Technical Information Service, EPA-RTP, etc.) iv ------- Current EPA Forms asof April 1989 ------- Numerical List of EPA Forms Date of Con- Current struc- Stock Form No. Edition Originator Title tion Code 1100-1199 -- Organization and Functions 1110 -- Organization 1110 1 Jul-83 PM-213 Request for Change in Organization Structure Sht A,B 1130 -- Committees, Boards, Panels, and Councils 1130 1 Nov-72 PM-213 Request for Approval of Nominees for Public Sht C Advisory Committees 1130 3 Jan-81 PM-213 Notification of Advisory Committee Meeting Set C 1130 4 Feb-84 PM-213 Committee Inventory Record Sht C 1300-1399 -- Administrative Management 1300 -- General 1300 1 May-71 PM-21 1D Stock Reorder Notice Sht A,B 1300 2 Jun-71 PM-223 Clearance Record Sht A,B 1300 5 Jun-87 PM-21 1D Request for Reprint of Article Can! A,B 1300 11 Apr-81 TS-793 OTT Document Clearance Form Sht C 1300 13 Apr-86 PM-211D Clerical Work Request Sht A,B 1300 14 Nov-83 TS-799 Document Clearance Request Sht C 1300 19 Feb-83 PM-211D ThingsToDoTothy Sht A,B 1300 24 Mar-85 PM-21 1D Vacation and Training Schedule Sht A,B 1305 -- Administrative Procedure 1305 4 Apr-72 PM-215 Official US Government Identification Card C 1315 -- Directives 1315 4 Aug-86 PM-213 Checklist of EPA Transmittals Sht A,B 1315 5 Jul-82 PM-213 DirectivesProcessingWocksheet Sht A,B 1315 10 Dec-79 PM-213 Directive Number Assignment Card C 1315 11 May-86 PM-213 Notice Sht A,B 1315 12 Jul-82 PM-213 Transmittal Sht A 1315 12A May-86 PM-213 EPA Order Sht A,B 1315 14 Aug-78 PM-213 Status of Pending Directives Sht C * 1315 16 Feb-89 PM-2 13 Clearance/Approval Record Sht A,B * 1315 16A Dec-83 PM-213 Clearance/Approval Record (Continuation) Sht C * 1315 17 May-87 OS-100 OSWER Directive Initiation Request Sht C 1320 -- Correspondence 1320 1 Dec-70 PM-21 1D Concurrence Sheet (Official File Copy) Sht A,B 1320 1 Dec-70 PM-215 Concurrence Sheet (Official File Copy) Set A,B 1320 2 Apr-77 A-101 Correspondence Signature Tab Can! A,B 1320 3 Mar-84 PM-215 Mailing Label Label B 1320 3A Feb-81 PM-215 Postal Card--Contractor’s 4th Class Card C 1320 3B Feb-81 PM-215 EGD Contractor’s 4th Class Mailing Label Label C 1320 5 Jan-78 PM-215 EPA Postcard (Headquarters) Card C 1320 5A Jun-82 PM-215 EPA Postcard (Field Elements) Can! A 1320 8 Apr-73 PM-213 Special Mail Label Label A,B 1320 9 Apr-74 A-101 OA Priority Correspondence Folder Folder C 1320 11 Jul-83 A-101 Executive Communications Transmittal Sht C 1320 12 Jan-78 A-10l OLPriority Correspondence Folder Folder C 1320 15 Mar-82 TS-799 AA/OPTS Routing and Transmittal Slip Sht C 1320 17 Dec-84 A-104 OFA Routing Slip/Assignment Form Set C * Available in Electronic Format. Contact the Forms Office for details. 1 ------- Con- struc- tion LE-131 Sht C PM-215 Env C TS-799 Caul C 1325 -- Reports * 1325 4 Jan-87 Sht A,B Sht C Sht C Set A,B Pam C Label C p l C 1340 -- Records 1340 1 Mar-82 PM-211D Sht A,B 1340 4 Nov-78 PM-211D Sht A,B 1340 7 Feb-88 PM-211D Sht C 1345 -- Files 1345 1 Mar-81 H7505C Jacket Locator Card 1400-1499 -- Protective Services 1400 •- General 1400 1 Feb-84 PM-215 Credential Acknowledgement Statement 1440 -. Safety 1440 6 Jun-84 PM-273 Report of Unhealthful or Unsafe Conditions Set A,B 1440 9 Jan-82 PM-273 Supervisors Report of Accident/Illness Set A,B Officer’s Operations Log Personnel Security Action Request FBI Record Check Request Security File Review Security Termination Statement Security investigation Review/Analysis EPA Headquarters Building Pass EPA Bomb Data Information Report of Loss or Theft Official US Government Identification Authority for Release of Information Record of Communication (Records Check lClearances) Inspector’s Credential Contract Guard Duty Register Visitor and Employee Sign-in Register Record of Keys Issued Guard Inspection Report * Available in Electronic Format. Contact the Forms Office for details. Numerical List of EPA Forms Date of Current Form No. Edition Originator 1320 -- Correspondence (Continued) 1320 18 Feb-83 Typing Instruction Sheet 1320 19 Feb-83 Special Communications 1320 20 Sep-86 Information Transmittal Title Stock Code PM-223 Clearance Control 1335 -- Forms 1335 1 Feb-85 1335 4 Nov-80 1335 5 Feb-71 1335 8 Aug-83 1335 9 Sep-85 1335 17 Apr-83 1335 18 Sep-83 Set C PM-21 1D PM-21 1D PM-21 1D PM-21 1D PM-21 1D PM-215 PM-21 lD Form Action Request Forms Number Assignment Sheet Printing Specification Sheet Request/Receipt of Accountable Forms Forms Distribution Guide Forms/Publications Shipping Label Form Approval Vital Records Transmittal Files Maintenance Plan Records Control Schedules Cant C Sht A 1480 - - Physical * 1480 46 May-87 1480 2 Jan-80 1480 6 Jun-71 1480 7 Mar-80 1480 19 Feb-74 1480 27 Feb-85 * 1480 33 Feb-88 1480 36 Oct-83 1480 38 Jul-81 1480 39 Dec-82 1480 40 Feb-84 1480 41 Jan-86 Security PM-215 A-109 A-109 A-109 A-i® A-i® PM-215 PM-215 PM-215 PM-215 A-i® A-i® EN-397F PM-215 PM-215 PM-215 PM-215 * 1480 43 * 1480 44 * 1480 45 * 1480 47 * 1480 48 May-88 May-87 May-87 May-87 May-87 Sht C Sht A Sht C Sht C Sht A,B Sht C Cant C Card C Set A,B Cant C Set A,B Sht C Cant C Sht C Sht C Sht C Pal C 2 ------- Aug-87 Aug-87 Aug-87 * 1480 50 Aug-87 PM-215 * 1480 51 Aug-87 PM-215 * 1480 52 Aug-87 PM-215 * 1480 53 Dec-87 PM-215 * 1480 55 May-88 EN-342 Guard Post Orders Guard Post Orders (Continuation Sheet) Guard Post Orders (Continuation Sheet: Schedule of Activities) Alarm Monitor Log Key Issuance Register Special Onler Request for Lock Work AARP Inspector’s Credential Con- struc- tion Sht C Sht C Sht C 1500-1599 -- Public Affairs 1550 -- Freedom * 1550 2 Apr-87 * 1550 3 Jun-87 1550 4 Jul-81 1550 5 May-79 1550 6 Apr-80 1550 7 Dec-80 1550 9 May-81 1550 9A May-81 1550 10 May-81 A-101 A-101 A-101 A-107 H7502C H7502C H7502C H7502C H7502C 1600-1699 -- Interagency Agreements Set C Set C Sht A 1610 -- Interagency Agreements * 1610 1 Oct-88 PM-216 Interagency Agreement Pam A,B 1640 -- Other Agencies’ Impact Statements 1640 1 Jan-75 A-104 Section 309 Action Log 1700-1799 - - Personal Property 1700 -- General 1700 1 Jun-81 PM-215 Notification of Designation of Shipping Officer 1700 2 Oct-72 PM-215 Personal Property Loan Agreement 1700 3 Nov-73 PM-215 Storeroom Request and Issue Record 1700 4 Nov-72 PM-215 Request for Shipping Service 1700 6 Jun-74 PM-215 Receiving Report 1700 7 Oct-74 PM-215 Property Receipt and Transfer Document * Available in Electronic Format. Contact the Forms Office for details. Sht A,B Numerical List of EPA Forms Date of Cunent Form No. Edition Originator 1480 -- Physical Security (Continued) * 1480 49 PM-215 * 1480 49A PM-215 * 1480 49B PM-215 Title Stock Code Sht Sht Sht Set Card C C C C C 1540 -- Informational and Educational Materials 1540 9 Oct-81 A-107 8 1t2 X 11 Layout Sheet Sht A,B 1540 10 Jul-79 A-107 Request for EPA-Produced Videotape Sht C 1540 11 Jul-79 A-107 Request for Non-EPA-Produced Videotape Sht C 1540 12 Aug-79 A-107 Publications Grid for4X9 Sht C 1540 13 Aug-79 A-107 Publications Grid for 5-5/8 X 8-3/4 Sht C 1540 14 Aug-79 A-107 Leaflet Grid Sht C of Information FOIA Request Acknowledgement FOI Request Acknowledgement (Regions) Acknowledgement Receipt for FOl Appeal EPA Journal Subscription Notice FOl Case Receipt Log FOl Case Status Report Freedom of Information Request Response FOI Request Response Company Data Review in Response to FOl Request 1550 11 May-81 H7502C FOI Invoice 1550 12 Sep-85 A-101 Freedom of Information Request Log Card Card Card Sht Sht Card Set Shi C A C C C C C C Sht A,B Sht Sht Set Set Set A,B A,B A,B A,B A,B 3 ------- Numerical List of EPA Forms Date of Con- Current struc- Stock Form No. Edition Originator Title tion Code 1700 -- General (Continued) 1700 8 Nov-80 A-135 Voucher for Payment and Release Sht C 1700 9 Jun-84 PM-215 Property Pass Set C 1710 -- Equipment and Supplies 1710 1 Sep-84 PM-215 Audio-Visual EquipmentLoan Record Sht C 1710 3A Jun-77 A-107 Videotape Label (30 Minutes) Label C 1710 3B Jun-77 A-107 Videotape Label (60 Minutes) Label C 1730 -- Contract and Grant Property * 1730 1 Sep-88 PM-215 Report of Nonexpendable Government Sht C Property Acquired by Contractor 1740 -- Inventory Management 1740 9 Jun-79 PM-215 Owned Personal Property System Input Data Sht A 1740 10 Aug-72 PM-215 Property Action Request and Memorandum Set A,B Receipt 1740 12 Dec-82 PM-215 Report of Survey Sht A,B 1740 13 Oct-73 PM-215 Adjustment Voucher Sht A,B 1740 16 Feb-79 PM-215 Stock Record Card B 1740 17 Aug-81 PM-215 VoucherRegister Sht A,B 1740 18 Mar-77 PM-215 Simplified Stock Record Card A,B 1740 19 Apr-79 PM-215 Shipping and Receiving Record Card C 1740 21 Aug-85 PM-215 Personal Property Custody Card Card A,B 1750 -- Utilization and Disposal 1750 7 Sep-72 PM-215 Equipment Maintenance Record Card A,B 1900-1999 -- Contracts Management 1900 -- General 1900 2 Dec-81 PM-214 Profit/Fee Objectives Sht A,B 1900 3 Jun-75 PM-214 Assignee’s Release Sht A,B 1900 4 Jun-71 PM-214 Assignee’s Assignment of Refunds, Rebates, Set A,B Credits, and Other Amounts 1900 5 Jun-71 PM-214 Contracto?s Assignment of Refunds, Rebates, Set A,B and Credits 1900 6 Feb-81 PM-214 Contractor’s Release Set A,B 1900 7 Apr-85 PM-214 Request for Cost Analysis Sht A,B 1900 8 Sep-86 PM-214 Procurement Request/Requisition Set A B 1900 8A Apr-84 PM-214 Procurement Request/Requisition Set A,B (Continuation) 1900 10 Nov-76 PM-214 Contractor’s Cumulative Claim and Sht A,B Reconciliation 1900 13 Apr-85 PM-214 Worksheet for Small Purchases Sht A,B * 1900 19 Aug-88 PM-214 ContractMemorandumofTransmiualand Card A,B Checklist 1900 20 Apr-85 PM-214 Contract Checklist Sht A,B 1900 26 Apr-85 PM-214 Contracting Officer’s Evaluation of Contractor Set A,B Perfon a e 1900 27 Apr-84 PM-214 Project Offices’s Evaluation of Contractor Set A,B Performance 1900 34 Apr-83 PM-214 Guide for Preparation of Contractor’s Claims Pam A,B 1900 34A Apr-83 PM-214 Guide for Preparation of Contractor’s Claim Pam A B * Available in Electronic Fonnat. Contact the Forms Office for details. 4 ------- Date of Current Form No. Edition Originator 1900 -- General (Continued) 1900 35 Jul-84 PM-214 Numerical List of EPA Forms Request for Equal Opportunity Clearance of Contract Award 1900 37 Apr-85 PM-214 Record of Procurement Request Review 1900 41A Jun-79 PM-214 CPAF Contract Summary of Significant Performance Observation 1900 41B Jun-79 PM-214 CPAF Contract Individual event Performance Observation 1900 41C Dec-78 PM-218 WCC Quarterly Performance Report 1900 44 Feb-79 PM-214 Purchase Order Register 1900 48 Apr-85 PM-214 Order for Services-Emergency Response to Hazardous Substance Release 1900 49 Apr-85 PM-214 Notice To Proceed with Emergency Response to Hazardous Substance Release 1900 51 Apr-85 PM-214 Worksheet for Order for Services 1900 53 Apr-84 PM-214 Determination and Findings: Authorization To Use a Time and Materials Contract 1900 54 Apr-85 PM-214 Memorandum to the File: Synopsis Exemption 1900 55 Jan-82 PM-214 Hazardous Substance Response Fund 1900 56 Apr-85 PM-214 Letter Contract for State/Local Government Response to Emergency Hazardous Substance Release 1900 57 Apr-84 PM-214 Determination and Findings: Method of Contracting 1900 58 Apr-84 PM-214 Notice Regarding WOrk Stoppage 1900 59 Nov-83 PM-214 Delivery Order for Emergency Response 1900 60 Feb-84 PM-214 Announcement of Contract Award 1900 61 Feb-84 PM-214 Proposal Technical Evaluation 1900 62 Feb-84 PM-214 Determination and Findings: Authority To Use a Letter Contract 1900 63 Apr-84 PM-214 Monthly Requisition and/or Receiving Report for Blanket Purchase Orders 1900 64 Jul-84 PM-214 Termination Settlement Memorandum of Transmittal and Checklist 1900 65 Jun-85 PM-214 Designation & Appointment of Project Officer/ Set Work Assignment Manager/Delivery Order 1900 66 Sep-86 PM-214 Purchase Order Record (Small Purchases) 1900 67 Sep-86 PM-214 Purchase Order/Subcontract Record 2000-2099 -- Emergency Programs 2070 -- Environmental Programs 2070 11 Jul-81 OS-240 PotentialHazardousWasteSite ldentiflcation Sht 2070 12 Jul-81 05-240 Potential Hazardous Waste Preliminary Pam Assessment 2070 13 Jul-81 OS-240 Potential Hazardous Waste Site--Site Inspection Pam Report 2070 14 Jul-81 OS-240 Potential Hazardous Waste Site Current Pam Disposition Con- struc- Stock Title tion Code Sht A,B Set A,B Sht A Sht A Sht C Sht C Pam C Pam C Sht C Sht C Sht C Set A Pam C Sht C Sht Set Sht Sht Sht C A A,B A,B C Set A,B Card C A,B Sht C Sht C C C C C * Available in Electronic Format. Contact the Forms Office for details. 5 ------- Numerical List of EPA Forms Date of Current Form No. Edition Originator 2100-2199 - - Library Systems 2130 -- Translations 2130 1 Oct-77 PM-21 1D Translation Service Request 2170 -- Services * 2170 6 Feb-88 PM-21 1D Response to Request for Publication Sht A,B Cant C 2200-2299 -- Publications .and Communications Materials Mailing List Update (OPA) Mailing List Update (OSW) Card C Card C 2220 -- Style, Format, and Editorial Policy Review 2220 1 Apr-77 PM-211D TechnicaiReport Data 2300-2399 -- Printing and Distribution 2340 -- Printing and Duplication 2340 1 Apr-84 PM-215 Publication Review/Printing Request 2340 15 Jan-81 PM-215 Federal Register Typesetting Request 2340 17 Jul-84 PM-215 Notice of Pending Delivery/Shipment 2340 18 Mar-84 PM-215 Revised Estimate Sht A,B 2350 -- Graphics and Arts 2350 2 Jul-84 A-107 Audiovisual Service Request Set C 2360 -- Distribution 2360 1 Feb-84 2360 2 Dec-73 PM-215 Publications/Forms Request PM-215 Publications Distribution Record Set A,B Sht C 2400-2499 -- Budget and Administration 2410 -- Budget Formulation 2410 9A Jun-83 PM-214 Contract Planning Submission Annual Plan Sht 2410 9B Jun-83 PM-214 Contract Planning Submission Quarterly Plan Sht 2410 20 Jul-82 PM-225 Change Request/Notification-Funding Sht 2410 23 Apr-80 PM-225 Regional Decision Unit Program Contract/Grant Sht Dollar Allocations 2410 24 Apr-80 PM-225 Regional Decision Unit Work Year Proposal Sht 2500-2599 - - Accounting and Finance 2500 - - General 2500 1 Apr-77 2500 2 Nov-77 2500 3 Jul-73 2500 4 Aug-73 2500 5 Feb-80 PM-226 PM-226 PM-226 PM-226 PM-226 * Available in Electronic Format. Contact the Forms Office for details. A B A,B C C A Title Con- struc- tion Stock Code 2200 -- General 2200 3 Jan-85 2200 4 Jan-85 A-107 OS-305 Set Set Set Card A,B A,B C C A,B A,B A,B A,B A B Notice of Administrative Exception Set Accounting Code Sheet Sht GeneralLedgerCodcSheet Sht Advanee Travel Code Sheet Sht Accounts Receivable General Ledger Code Sheet Sht 6 ------- 2570 -- Travel Con- siruc- tion Sht Set Sht Set Card 2570 3 Dec-71 PM-226 Substitute Memorandum of US Transportation Card Request * Available in Electronic Format. Contact the Forms Office for details. Stock Code A,B A,B A,B A,B A,B A,B Numerical List of EPA Forms Date of Current Form No. Edition Originator Title 2505 -- Collections and Securities 2505 1 Jan-72 PM-226 Register of Collections 2505 2 May-81 PM-226 Record of Public Funds Received 2505 3 Jan-72 PM-226 Schedule of Collections 2505 4 Sep-73 PM-226 Bill for Collection 2505 5 Mar-76 PM-226 Collection Officer Designation 2545 -- Imprest Fund 2545 1 Nov-71 PM-226 2545 2 Mar-73 PM-226 Verification of Imprest Fund Request and Receipt for Cash Advance Sht A,B Set A,B 2550 -- Accounting and Financial Systems 2550 4 Dec-79 PM-226 Interoffice Transfer Voucher 2550 6 Mar-80 PM-226 Distribution of Payroll Charges 2550 8 Jul-81 PM-226 Report of Reimbursable Services Rendered 2550 9 Apr-74 PM-226 Commitment Notice 2550 10 Jul-80 PM-226 Miscellaneous Obligation Document 2550 11 Feb-81 PM-226 Document Control Register 2550 15 Dec-73 PM-226 Letter of Credit History 2550 19 Oct-85 PM-226 Project Officer Invoice Approval 2550 20 Jul-81 PM-226 Adjustment of Pay Status Codes in Financial Management Systems * 2550 21 Nov-88 PM-226 Project Officer’s Interagency Agreement Invoice Approval Set Set Set Sht Sht Sht Sht Set Set A,B A,B A,B A,B A,B A,B A,B D A,B 2560 -- Payroll 2560 1 Oct-71 2560 2 Nov-86 2560 4 Jul-81 2560 5 May-80 2560 7 Jun-74 Set D 8 12 15 16 17 18 21 22 23 25 28 28A Jan-75 Jul-74 Mar-77 Apr-75 Jul-75 Sep-77 Oct-78 Jul-81 Jul-81 Oct-88 Oct-86 Oct-86 PM -226 Timekeeper Signature Card Card PM-226 Payroll Error Notice Set PM-226 Authorization for Mailing Pay Checks Sht PM-226 Change in Fixed Account Number Sht PM-226 Request for and Authorization of Overtime Woit Set PM-226 Payroll Special Label Label PM-226 Time and Attendance Chargeout Card Card PM-226 Employee Statement of Leave Balances Sht PM-226 Leave Overpayment Remittance Request Sht PM-226 Payroll Commitment Adjustment Notice Sht PM-226 DIPS Payroll Master Input Data Sht PM-226 Emergency Salary Payment Voucher Sht PM-226 Cumulative Pay Adjustment Sht PM-226 Current Pay Adjustment Sht PM-226 Statement of Earnings and Leave Set PM-226 Payroll Distribution Time Sheet Set PM-226 Payroll Distribution Time Sheet (Continuation) Set 2560 2560 2560 2560 2560 2560 2560 2560 2560 * 2560 2560 2560 2565 -- 2565 2565 2565 A,B A,B A,B A,B A,B A,B C A,B C A A C C C A,C A,B A,B Time and 1 Jan-84 2 Jan-84 3 Jan-84 Attendance PM-226 Time and Attendance Card PM-226 Time and Attendance Card (Salmon) PM-226 Time and Attendance Card (Yellow) Card D Card A,B Card A,B 7 ------- Numerical List of EPA Forms Date of Con- Current smic- Stock Form No. Edition originator Title Lion Code 2570 -- Travel (Continued) 2570 4 Aug-76 PM-226 Payment Record Sht A,B 2570 6 Dec-80 PM-226 Treasury Financial Communication System Cant A,B (TFLS) Ticket 2600-2699 -- Travel and Transportation 2610 -- Authorization 2610 1 Oct-81 PM-226 Travel Authorization Set A,B 2610 2 Jan-83 PM-226 Notice of Leave To Be Charged While on Travel Set A,B 2620 - - Expenses 2620 1 Dec-86 PM-226 Employee Application for Reimbursement of Sht A,B Expenses * 2620 2 Dec-86 PM-226 Actual Subsistence Expenses While Occupying Sht A,B Temporary Quarters 2620 3 Jul-85 PM-226 Employee Acknowledgement of Diners Club Set C Credit Card Program 2635 -- Permanent Change of Station 2635 1 Nov-72 PM-226 Infonnation for Authority of Moving and Sht A,B Related Travel Expenses 2635 2 Aug-77 PM-226 Relocation Expenses Payment Record Set A,B 2660 - - Meetings 2660 2 Mar-85 WH-556F Registration Record Sht C 2700-2799 - - Audit Investigation Management 2720 -- Investigations 2720 1 Apr-80 A-109 Investigative Control and AssignmentRecord Set A 2720 2 May-83 A-109 Notice of Scheduled Investigation Sht A 2720 4 May-80 A-109 Office of Investigations Monthly Report Sht A * 2720 6 Mar-87 A-109 Evidence Custody Set A 2720 8 Mar-84 EN-329 Report of Interview Set A 2720 9 Mar-84 EN-329 Report of Investigation Set A 2720 10 Apr-82 EN-329 Reportofinformation Received Set C 2720 13 Apr-83 A-i® Investigative Report Cover A 2720 14 Nov-84 A-i® Report of Investigation-Narrative Sht A 2720 15 Nov-84 A-i® Report of Investigation Sht A 2720 16 Jul-83 A-i® Report of Investigation Sht A 2720 17 Nov-84 A-i® Investigation Cover Sheet Sht A 2720 18 Oct-84 A-i® Advice of Rights for a Federal Employee Sht C 2720 19 Oct-84 A-i® Notice to a Federal Employee: Duty To Sht C Respond to Questions 2720 20A Oct-84 A-i® Advice of Rights Sht C 2720 20B Oct-84 A-i® Advice of Rights Sht C * 2720 21 Jan-89 A-i® PATS Biweekly Time Distribution Report Set C 2800-2899 -- Data Processing Systems 2800 -- General 2800 i Mar-73 PM-2i8 80-Column Keypunch Code Sheet Sht C * Available in Electronic Format. Contact the Forms Office for details. 8 ------- Date of Current Form No. Edition Originator 2800 -- General (Continued) 2800 8 Dec-79 2800 9 Jan-80 2800 14 Apr-80 2800 15 Apr-80 2800 16 May-80 2800 17 May-80 2800 18 Sep-80 Numerical List of EPA Forms Application Receipt and Acceptance Program Change Facility - ID Update Maintenance Form Confidentiality Claim Facility Inventory Maintenance Form Waste Definition Maintenance Form Ad Hoc Report Request Hazardous Waste Data Management System 2800 22 Jun-81 PM-218 Approved Operating Plan 3100-3199 -- Human Resources Management 3100 -- General 3115 -- Promotion * 3115 3 Nov-86 3115 3A Oct-84 PM-212 Merit Promotion Announcement PM-212 Merit Promotion Vacancy Announcement (Upward Mobility) * 3115 3C Nov-86 PM-212 Temporary Vacancy Announcement * 3115 3D Nov-86 PM-224 Career Management System Vacancy Announcement 3115 4 Sep-84 PM-212 Staffing Requisition 3115 7 Sep-84 PM-212 Evaluation and Rating Worksheet 3115 8 Sep-84 PM-212 Merit Promotion Certificate 3115 8A Sep-84 PM-212 Merit Promotion Certificate (Continuation) 3115 8B Sep-84 PM-212 Nonstatus Candidate Referral List 3115 8C Sep-84 PM-212 Noncompetitive Candidate Referral Certificate 3115 8D Oct-84 PM-212 Certificate for Upward Mobility * 3115 8E Nov-86 PM-212 Candidate Referral Certificate: Temporary Position 3115 9 Sep-84 PM-212 Merit Promotion Information Record * Available in Electronic Format. Contact the Forms Office for details. Title OS-340 OS-340 OS-340 OS-340 OS-340 OS-340 OS-340 Con- struc- tion Sht Set Sht Sht Sht Sht Sht Stock Code C C C C C C C Sht C Set C Sht C Sht A Sht A,B Set D 3110 - - Enforcement Administration 3100 1 Feb-81 PM-212 Agreement To Remain in the Government Service 3100 13 Jan-78 PM-212 Medical Report 3100 14 May-80 PM-212 Volunteer Service Program Participation Agreement 3100 16 Jun-80 PM-212 Position Control Transmittal 3100 17 Jan-84 PM-212 Probationary Period Certification * 3110 1 Feb-88 PM-212 Employee Separation or Transfer Checklist Set 3110 11 Aug-72 PM-212 Service Computation Date Worksheet Sht 3110 15 Jan-73 PM-212 Expert or Consultant Supplemental Information Sht 3110 17 Aug-73 PM-212 Consultant Certificate Sht 3110 18 Aug-73 PM-212 ExpertCertificate Sht 3110 20 Sep-73 PM-212 Review of Employment of Experts and Sht Consultants 3110 21 Sep-73 PM-212 Summary of Review of Experts and Consultants Sht 3110 26 Oct-74 PM-212 Competitive Level Code Log Sht 3110 35 Oct-79 PM-224 Senior Executive Service Vacancy Sht Announcement 3110 38 May-84 PM-212 Vacancy Announcement Sht 3110 43 Jul-86 PM-212 Organization Code Sheet Sht A,B C A,B A,B A,B A,B A,B C C C A,B and Placement Sht A,B Sht C Sht A,B Sht A,B Sht Sht Sht Sht Sht Sht Sht Sht A,B A,B A,B A,B A,B A$ A,B Set A,B 9 ------- Numerical List of EPA Forms Date of Current Form No. Edition 3115 -- Promotion 3115 13 Sep-84 3115 14 Sep-84 3115 15 Sep-84 3115 16 Jun-75 3115 17 Oct-84 Originator and Placement (Continued) PM-212 PM-212 PM-212 PM-212 PM-212 Con- stnic- Lion A,C A B A,B C C C C A B A A,B A B A B A B Sht A,B 3140 -- Employee 3140 11 Jul-76 3140 18 Sep-78 3140 20 Sep-78 3140 24A Jul-83 3140 27 Feb-86 3140 28 Feb-86 * Available in Elecironic Format Contact the Forms Office for details. C C C D C C A Sht A,B Sht C Title Stock Code MPP Checklist Sht Merit Promotion Application Rating Sheet Sht Merit Promotion Rating Plan Specifications Sht Special Consideration Referral Sht Interview Rating Sheet for Upward Mobility Sht Positions 3115 18 Oct-84 PM-212 Job Element Rating Sheet for Upward Mobility Sht Positions 3115 20 Apr-77 PM-212 Merit Promotion Program Vacancy Sht Announcement Results 3115 21 Sep-79 PM-212 SES Staffing Request Sht 3115 22 Oct-84 PM-212 Appraisal of Other Characteristics Needed for Sht Upward Mobility * 3115 24 Aug-87 PM-212 Performance Agreement, Appraisal, and Pain Certification Job Analysis Record Sht Cumulative Merit Promotion Evaluation Sheet Sht Basic Qualifications Determination Worksheet Sht 3115 3115 3115 28 29 31 Sep-84 Sep-84 Sep-84 PM-212 PM-212 PM-212 Responsibilities and Conduct LE-131 Confidential Statement of Employment and Financial Interest 3120 -- Employee 3120 1 May-84 3130 -- Incentive 3130 1 Nov-83 3130 2 Dec-77 3130 3 Apr-74 3130 4 Jul-82 Awards PM-212 PM-212 PM-212 PM-212 PM-212 PM-212 PM-212 PM-212 PM-212 PM-212 PM-212 PM-212 3130 6 3130 7A 3130 7B 3130 7C 3130 7D 3130 8 3130 9 3130 10 Jan-73 Jul-86 Jul-86 Jul-86 Jul-86 Jan-88 Jan-88 Sep-88 Recommendation for Monetaiy Award Employee Suggestion Form Suggestion Record and Evaluation Certificate of Approval for Payment of Suggestion Award Certificate of Completion of Training Length of Service Certificate -10 Years Length of Service Certificate -20 Years Length of Service Certificate -30 Years Length of Service Certificate -40 Years Suggestion Award Certificate Certificate of Retirement Special Achievement Award Set Sht Set Sht Card Sht Sht Sht Sht Sht Sht Sht A,B A A A,B A,B A B A,B A$ A B A B Development and Training PM-212 Upward Mobility Trainee Evaluation Sht PM-212 Assignee’s Evaluation of Mobility Assignments Sht PM-212 Supervisor’s Evaluation of EPA’s WA Sht Personnel Exchange Program PM-214 Project Officer Certificate (Interim Appointment)Sht PM-214 Project Officer Certification Program (Contract Sht Administration Course) PM-214 Project Officer Certification Program (Basic Sht Course) * 3140 29 Jul-87 PM-224 Career Management System Pam 3150 -- Position and Compensation Classification * 3150 1 Feb-87 PM-212 Position Description 3150 3A Jan-77 PM-212 Position Classification Survey 10 ------- Numerical List of EPA Forms Date of Current Form No. Edition Originator Title 3150 -- Position and Compensation Classification (Continued) 3150 5 Sep-73 PM-212 Position Description Amendment Sht 3150 6 Dec-79 PM-212 Evaluation Statement for Supervisors of Two- Sht Grade-Interval Positions 3150 7 Sep-73 PM-212 Evaluation Statement for Supervisors of Sht Subprofessional Positions 3150 9 Sep-73 PM-212 Evaluation Statement Sht 3150 10 Sep-73 PM-212 DeskAuditReport Sht 3150 11 Sep-75 PM-212 Position Description for Regional Pam Nonsupervisory Professional Prograrn/Staff/ Technical Positions 3150 15 Dec-73 PM-212 GroupActionRequestList Sht 3150 16 Dec-79 PM-212 Position Description for Supervisors of Two- Pam Grade-Interval Positions 3150 21 Dec-77 PM-212 Factor Evaluation System Evaluation Statement Sht 3150 22 Aug-79 PM-212 Position Description (Factor Evaluation Pam System) 3150 26 Jun-81 PM-212 Classification Appeal Decision Sht 3150 27 Jan-84 PM-212 Position Description for Regional Pam Nonsupervisosy Two-Grade-Interval Program! Staff/Technical Positions 3150 28 May-84 PM-212 Position Description for Regional Pam Nonsupervisory Professional Program/S taff/ Technical Positions 3150 29 Feb-84 PM-212 Position Description for Regional Pam Nonsupervisory Nonprofessional Program/ Staff! Fechnical Positions 3155 -- Pay Administration 3155 1 Apr-77 LE-132 Request for Waiver of Claim for Erroneous Payment 3155 2 Apr-73 LE-132 Overpayment Investigation Report 3155 3 Jan-81 PM-212 Supplemental Pay for Non-Federal IPA Detailees 3160 -- Attendance and Leave 3300-3399 -- Legal * Available in Electronic Format. Contact the Forms Office for details. Sht A,B Sht A,B Set A Con- struc- tion Stock Code A,B A,B A A,B A,B A A,B A,B A A,B C A A A 3160 2 Oct-82 PM-212 Restoration of Forfeited Annual Leave Sht A,B 3160 3 Nov-76 PM-212 Request for Flexible Hours Sht B 3160 5 Apr-78 PM-212 Record of Excused Absence for Employee Sht A 3300 - - General 3300 1 Aug-77 LE-130 Application for Certification of Pollution Control Facility Set A 3300 2 Aug-77 LE-130 Notice of State Certificate Set A 3300 3 Aug-77 LE-130 Notice of Federal Certification Set A 3300 4 Mar-85 LE-130L Law Libraiy (Charge-Out) Card C 3300 6 Sep-82 LE-134 EPA Assistance Appeals Initiation and Update Pal C 3300 7 Jun-82 LE-134 Form 3 Consolidated Cases Pal C 3300 8 Jun-82 LE-134 Form 2 Events Pal C 3300 9 Jul-82 LE-134 Grant Appeal Checkout Sheet Card C * 3300 11 Nov-88 LE-133 Enforcement Case Data Sin C * 3300 12 Nov-88 LE-133 CERCLA Enforcement Case Data Sht C 11 ------- Numerical List of EPA Forms Date of Con- Current struc- Stock Form No. Edition Originator Title Lion Code 3320 -- Standards and Enforcement 3320 1 Oct-77 EN-336 Discharge Monitoring Report Set A 3320 IT Jan-87 EN-336 NPDES Discharge Monitoring Report Set A,]) 3340 -- Patents and Copyrights 3340 1 Aug-72 LE-132 Employee Report of Invention Set A,B 3340 2 Aug-72 LE-132 Invention Rights Questionnaire Set C 3500-3599 -- Enforcement 3500 -- General 3500 5 Dec-80 EN-397 Unleaded Gasoline Field Inspection Set A 3510 -- Permits 3510 1 Oct-80 EN-336 General Information Consolidated Permits Pam A Program (Form 1) 3510 2B Jun-80 EN-336 Application for Permit To Discharge Wastewater Sht A (Form 2B) 3510 2C Feb-85 EN-336 Application for Permit To Discharge Wastewater Pam A (Form 2C) 3510 21) Sep-86 EN-336 Application Form 2D-New Sources & New Pam A Dischargers: Application for Permit To Discharge Process Waste 3510 2E Sep-86 EN-336 Application Form 2E--Faciities Which Do Not Pam A Discharge Process Waslewater 3510 3 Jun-80 OS-320 Application for Hazardous WastePermit Pam A 3510 3A Dec-80 OS-340 Acknowledgement of Application for a Card C Hazardous Waste Permit 3510 3B May-80 OS-340 Acknowledgement of Application for a Env C Hazardous Waste Permit (Verification) 3520 -- Air * 3520 1 Sep-88 EN-340 Importation of Motor Vehicles and Motor Sht A,D Vehicle Engines Subject to Federal Air Pollution Regulations 3520 2 May-85 EN-397F Lead Additive Report forReflners Sht C 3520 3 May-76 EN-340 Lead Additive Report for Manufacturing Sht C Facility or Site 3520 5 May-85 EN-397F Lead Additi eReport for Gasoline Importer Sht C 3520 6A Jun-85 EN-397F Lead Additive Report Supplement A Sht C Constnictive Allocations 3520 May-85 EN-397F Lead Additive Report Supplement B: Sht C Transfers of Lead * 3520 7 Sep-87 EN-397F Notice of Violation of Section 211 of the Set C Clean Air Act * 3520 8 Jul-88 EN-340 Application for Final Admission of Sht C Nonconforming Imported Vehicle * 3520 8A Jul-88 EN-340 Continuation of Application for Final Sht C Admission of Nonconforming Imported Vehicle * 3520 9 Jul-88 EN-340 Application for Final Admission of a Catalytic Sht C Convener and Oxygen Sensor Equipped Vehicle 3540 - - Pesticides 3540 1 May-77 EN-342 Notice of Athval of Pesticides and Devices Set A 3540 2 Mar-77 EN-342 Notice of Inspection Set A * Available in Electronic Format. Contact the Forms Office for details. 12 ------- Numerical List of EPA Forms 3700-3799 -- Program Review and Reporting 3720 -- Program * 3720 10 Jul-87 3720 1OA Mar-79 * 3720 11 Jan-89 Reporting PM-223 PM-223 PM-223 Sht C Sht C Sht B 4500-4599 -- International Activities 4510 -- Communications with Foreign Organizations and Individuals 4510 2 Dec-77 A-106 International Visitor(s) Alert Sht C 4540 -- International Project Clearance 4540 1 Mar-82 A-106 Clearance of Foreign Research Award 4550 -- International Travel Plans 4550 1 Jul-79 A-106 International Trip Report 4550 5 Jun-81 A-106 International Travel Plan 4550 7 Nov-80 A-106 Passport Log * Available in Electronic Format. Contact the Forms Office for details. Sht A,B Set A,B Set A,B Card C Con- struc- Stock lion Code Set Folder Set Set Set A A A A C Date of Current Form No. Edition Originator Title 3540 -- Pesticides (Continued) 3540 3 Aug-75 EN-342 Receipt for Samples 3540 4 Aug-74 EN-342 Sample Record Jacket 3540 5 May-76 EN-342 Report of Analysis 3540 5A Oct-75 EN-342 Report of Analysis Continuation * 3540 8 Nov-88 EN-342 Application for Registration of Pesticide- Producing Establishment * 3540 8A Nov-88 EN-342 Notification of Registration of Pesticide- Producing Establishments 3540 9 Nov-77 EN-342 Authorization To Administer Oaths, Affidavits, and Affirmations 3540 11 Dec-76 EN-342 Affidavit 3540 13 Oct-73 EN-342 Copy of Invoice and Shipping Record 3540 16 Jan-85 EN-342 Pesticides Report for Pesticide-Producing Establishments 3540 17 Dec-73 EN-342 History of Official Sample 3540 20 Apr-75 EN-342 Use Investigation Report 3540 21 Apr-75 EN-342 Establishment Inspection Report 3540 22 Apr-75 EN-342 Corrective Action Report 3540 24 Apr-78 EN-342 EPA Inspector’s Credential 3540 25 Mar-77 EN-342 Notice of Pesticide Use/Misuse Inspection 3540 26 Mar-77 EN-342 Receipt for Pesticide Use/Misuse Inspection 3540 27 Mar-77 EN-342 Notice of Stop Sale, Use, or Removal Order 3540 28 Apr-78 EN-342 State Inspector’s Credential 3540 30 Dec-80 EN-342 Contractor’s Credential 3540 31 Oct-85 EN-342 Inspector’s Credential 3560 -- Water 3560 3 Mar-85 EN-338 Compliance Inspection Report 3560 4 Feb-80 EN-338 Deficiency Notice Sht C Sht A Sht A Pal A Set C Sht Set Set Set Card Set Set Label Card Card Car l A A A A C A A A C C C Sht A Set A Start Action Request Workgroup Membership Invitation Federalism Review 13 ------- 4700 -- General * 4700 4 Nov-86 A-lOS Numerical List of EPA Forms Preaward Compliance Review Report for Wastewater Treatment Construction Grants 4700 14 May-84 A-lOS EEO Complaint Invoice Con- siruc- Stock tion Code 4800-4899 -- Buildings, Facilities, Space, and Site Management 4850 -- Buildings 4850 1 May-81 4850 2 Aug-83 * 4850 3 Aug-87 Maintenance and Operation PM-215 Job Orders PM-215 Maintenance Job Order PM-215 Fume Hood Certification 4900-4999 -- Motor Vehicle and Aircraft Management 4920 -- Operation 4920 1 Sep-78 4920 3 Sep-84 4920 4 Sep-80 4920 5 Nov-83 4920 6 Nov-83 4920 7 Nov-83 4920 8 Nov-83 4920 9 Nov-83 4920 10 Nov-83 4920 11 Nov-83 4920 12 Feb-84 4920 13 Nov-83 4920 14 Nov-83 * 4920 15 May-88 PM-215 PM-215 PM-215 PM-215 PM-215 PM-215 PM-215 PM-215 PM-215 PM-215 PM-215 PM-215 PM-215 PM-215 A,B A,B C C C A,B C C C C C C C C 4940 -- Maintenance 4940 1 Jun-72 PM-215 4940 2 Oct-83 PM-215 Motor Vehicle Record Driver’s Daily and Weekly Preventive Maintenance Checklist Can! A,B Sht C 5000-5099 -- Telecommunications 5020 -- Telephone System * 5020 1 Jun-88 PM-21 iT Washington Telecommunications Service Request 5020 2 Sep-79 PM-211T Telephone Key System Worksheet 5040 -- Teletype and Facsimile System 5040 1 Nov-75 PM-21 iT Message Receipt Log Sht 5040 2 Nov-75 PM-211T Facsimile Log Sht 5040 3 Aug-79 PM-21 IT Originating Traffic Log Sht 5040 4 Nov-81 PM-211T Terminating Traffic Log Sht 5040 5 Dec-83 PM-21 iT Facsimile Transmission Request and Cover SheetSht 5040 8 Aj -78 PM-21 IT Message for Transmission Sht Date of Cuirent Form No. Edition Originator 4700-4799 -- Equal Opportunity Title Sht A Set C Sht Set Label C C B Application for Motor Vehicle Operator’s LicenseSht Daily Vehicle Utilization Report Sht Motor Pool Assignment Sht Accumulative Daily Request--Carrier Sht Accumulative Daily Requests--Dispatcher Sht Key and Credit CardLog Sht Request for EPA Driver Service Set Daily Schedule Chart Sht Accident Report Sht Monthly Vehicle Report Sht Procedure in Case of Theft or Accident Sht Passenger Message Slip Set Driver’s Log Sht Parking Violation Set Sht B Sht C A A,B A A,B B A B * Available in Electronic Fonnat. Contact the Forms Office for details. 14 ------- Numerical List of EPA Forms Date of Current Form No. Edition Originator Title 5040 -- Teletype and Facsimile System (Continued) * 5040 9 Feb-88 PM-21 iT Confirmation of Teleconference Schedule 5100-5199 -- Office Services 5100 -- General 5100 1 Sep-79 5100 2 Dec-80 5100 2A Dec-80 5100 4 Jun-81 5100 4A Aug-82 PM-215 PM-215 PM-215 PM-215 PM-215 5110 -- Employee 5110 1 May-73 Identification PM-215 EPA Identification Card Acknowledgement Cani A 5130 -- Self-Service Store 5130 1 Feb-79 PM-215 5130 2 Apr-80 PM-215 * 5130 3 Aug-87 PM-215 Procedures Self Service-Store Void Slip EPA Self-Service Stove Request/Sales Slip Application for EPA Supply Store Shopping Plate 5140 -- Maintenance and Repair Services 5140 1 Oct-73 PM-215 Office Equipment Repair Log 5160 -- Parking Permits 5160 1 Apr-77 PM-215 Parking Permit Application 5160 2 Apr-73 PM-215 Physician’s Statement in Support of Handicap Parking 5160 3 Apr-73 PM-215 Supervisor’s Report in Support of Handicap Parking Assignment Sht C 5180 -- Mail and 5180 1 Jun-72 5180 3 Jul-81 * 5180 4 Dec-87 * 5180 5 Dec-87 5180 8 May-76 5180 10 Apr-79 5180 11 May-79 5180 12 May-79 5180 13 May-79 5180 14 May-79 5180 15 May-79 5180 16 Jan-80 * 5180 17 Mar-87 Messenger Services PM-21 1D PM-215 PM-215 PM-215 PM-215 PM-215 PM-215 PM-215 PM-215 PM-215 PM-215 PM-215 PM-215 5200-5299 -- Legislative 5200 -- General 5200 2 May-83 5200 3 May-83 * Available in Electronic Format. 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Con- struc- Stock tion Code Set C Building Modification Services Request Labor Services Request Labor Services Request Receipt Log Relocation Worksheet Relocation Worksheet Set Set Sht Sht Sht A,B B B B C Set Set Card C B B Sht Sht A,B A,B Sht A,B Mail Control Schedule Record of Registered and Certified Mail Sampled Mail Report Supplemental Mail Report U.S. Government Shipment Label Express Mail Register Mail Label - First Class Mail Label - Third Class Special Fourth-Class Book Rate Mail Label - Fourth Class Mail Label - Third-Class Bulk Business Reply Label Daily Record of Postage Meter Register Readings * 5180 18 Aug-88 PM-215 Custom Designed Mail Special Envelope Set Sht Pam Pam Label Sht Label Label Label Label Label Label Sht A,B C C C A,B A,B B B B B B C C A-102 A-102 Legislative Alert Hearing Report Env A,B Sht C Sht C 15 ------- Numerical List of EPA Forms Date of Con- Current siruc- Stock Form No. Edition Originator Title Lion Code 5200 -- General (Continued) 5200 3A May-83 A-102 Hearing Report Sht C 5300-5399 - - Research and Development 5300 -- General * 5300 23 Aug-87 RD-674 Environmental Review for Extramural Projects Set A 5700-5799 -- Grants 5700 -- General 5700 lB May-87 PM-216 Application Kit for Assistance (Planning or Folder A Program Assistance) 5700 7C May-80 PM-216 Application Kit for Assistance (Fellowship) Folder A 5700 7D May-80 PM-216 Application Kit for Assistance (Training) Folder A 5700 7E Aug-80 PM.216 Application Kit for Assistance (Research) Folder A 5700 12 Apr-78 PM-216 Application for Federal Assistance Pam A 5700 14 Apr-84 PM-216 Assistance Funding Order Sht A,B 5700 20A May-82 PM-216 Assistance Agreement/Amendment Pam A, B 5700 20B Nov-86 PM-216 Assistance Amendment Sht A 5700 20C Feb-86 PM-216 EPA Assistance Agreement/Amendment Set A 5700 29 Jul-82 PM-216 Grant AuditRequest Sht A 5700 30 Nov-86 PM-216 Preapplication for Federal Assistance Pain A 5700 31 Oct-79 PM-216 Application for Federal Assistance (Short Pam A Form) 5700 33 Nov-86 PM-216 Application for Federal Assistance Pam A 5700 33A May-74 PM-216 Application for Federal Assistance, Narrative Sht A Statement 5700 333 May-74 PM-216 Application for Federal Assistance, Narrative Pam A Statement 5700 33F Jul-76 PM-216 Application for Federal Assistance, Narrative Sht A Statement 5700 336 Nov-75 PM-216 Application for Federal Assistance, Narrative Pam A Statement 5700 33H Aug-86 EN-342 Pesticide EnforcementCocperaiive Agreement Sht A 5700 33! Dec-79 PM-216 Application for Federal Assistance, Narrative Sht A Statement 5700 41 Apr-84 PM-216 Cost or Price Summary Pam A 5700 42 Feb-85 PM-216 Grant Record Adjustment Notice Set C 5700 48 May-84 PM-216 Procurement System Certification Sht A * 5700 49 Nov-88 PM-216 Certification Regarding Debannent, Pam A,B Suspension, and Other Responsibility Matters 5720 -- Construction * 5720 4 May-87 A-lOS labor Standards Provisions for Federal & Pam A,B Federally Assisted Contracts 5720 12 Sep-85 PM-216 Application for Federal Assistance (Construction Pain A Grants#Cooperaiive Agreements) 5770 -- Training and Fellowships 5770 2 Apr-78 PM-216 Fellowship Application Pam C 5770 3 Feb-77 PM-216 Fellowship Facilities and Commitment Sht C Statement * Available in Electmnic Format. Contact the Forms Office for details. 16 ------- 7500-7599 -- Water Quarterly MBEAVBE Consolidation Report Superfund Minority Contractors Utilization Report Superfund Minority Contractors Utilization Report--Part 2 7510 -- Wastewater Treatment 7510 1 Jun-81 WH-595 Estimate of Municipal Wastewater Treatment Facilities 7520 -- Underground Injection Control * 7520 1 Jan-88 WH-550E UIC Federal Reporting System Part I: Permit Review and Issuance/Wells in Area of Review Jan-88 WH-550E Part II: Compliance Evaluation Jan-88 WH-550E Part II: Compliance Evaluation/Significant Noncompliance * 7520 3 Jan-88 WH-SSOE Part Ill: Inspections/Mechanical Integrity Testing 4 Mar-88 WH-550E Part IV: Quarterly Exceptions List 5 Jan-88 WH-550E Part V: Summary of UIC Grant Utilization 6 Feb-84 WH-550 Underground Injection Control Permit Application 7520 7 Feb-84 WH-550 Application To Transfer Permit 7520 8 Nov-83 WH-550 Injection Well Monitoring Report * Available in Electronic Format. 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Numerical List of EPA Forms Date of Current Form No. Edition Originator Title 5770 -- Training and Fellowships (Continued) 5770 4 Feb-77 PM-216 Fellowship Applicant Qualifications Inquiry 5770 5 May-78 PM-216 Agency Fellowship Certificate 5770 6 Jun-73 PM-216 Fellowship Amendment 5770 7 Jun-73 PM-216 EPA Fellowship Activation Notice 5770 8 Jul-73 PM-216 Fellowship Agmement 5770 9 Jul-73 PM-216 EPA Fellowship Termination Notice 6000-6099 -- Minority and Women’s Business 6005 -- General 6005 2 Jun-84 A-149 * 6005 3 Sep-87 A-149 Con- struc- tion Sht Sht Sht Set Sht Sht Stock Code C C A A A A * 6005 3A Sep-87 A-149 Sht A Sht A Sht A 7500 -- General 7500 2 Jul-75 EN-342 Official Sample Seal Label 7500 8 Jul-80 WH-553 Report of Pollution-Caused Fish Kill Card 7500 22 Apr-77 WH-553 STORET User Handbook Error Discovery Notification Card 7500 35B 22-May TS-799 Postcard/Preliminary Assessment Information Card 7500 42 Dec-80 WH-550 Federal Reporting Data System -- Violations Sht 7500 43 May-78 WH-550 Federal Reporting Data System -- Variances and Exemption Sht 7500 48 Nov-79 WI{-550 Inventory of Injection Wells Sht 7500 52 Jun-80 OS-200 SPCC Inspection Summary Sheet Sht 7500 53 Sep-80 OS-200 SPCC Inspection Field Sheet Sht 7500 54 Sep-80 OS-200 Detailed SPCC Documentation Pam * 7500 55 Jan-89 EN-338 NPDES Laboratory Performance Evaluation Pam 7500 57 Feb-84 WH-556F Chain of Custody Record Set 7500 58 Feb-84 WH-556F Analysis Identification Tag Tag A C C C A A A A A A D C C D A * 7520 2A * 7520 2B * 7520 * 7520 7520 Sht Set Set A Set A Set A Set A Set A Sht A Sht A Sht A 17 ------- Numerical List of EPA Forms Date of Cuffem Form No. Edition Originator Title 7520 -- Underground Injection Control (Continued) 7520 9 Feb-84 WH-550 Completion Form for Class I Injection Wells 7520 10 Feb-84 WH-550 Completion Report for Brine Disposal, Hydrocaibon Storage 7520 11 Feb-84 WH-550 Annual Disposal/Injection Well Monitoring Report 7520 12 Feb-84 WH-550 Well Rework Record 7520 14 Mar-84 WH-550 Plugging and Abandonment Record 7530 -- Underground Storage Tanks 7530 1 Sep- 88 OS-420 Notification for Underground Storage Tanks Pam C 7550 -- Permits 7550 6 Jan-73 EN-336 NPDES--Application for Permit To Discharge (Form A) 7550 8 Mar-74 EN-336 NPDES Application for Permit To Discharge (Form C) 7550 9 May-73 EN-336 NPDES-Application for Permit To Discharge (Form D) 7550 22 Jul-73 EN-336 NPDES-Application for Permit To Discharge Wastewater (Form A) 7550 23 Jul-73 EN-336 NPDES-Application for Permit To Discharge Wastewater (Form C) 7700-7799 -- Toxic Substances 7710 -- General 7710 3C Nov-77 7710 3D Nov-77 7710 03E Feb-79 * 7710 9 Feb-88 7710 13 Sep-81 TS-788 TSCA Inventory Report Form C Set TS-788 TSCA Inventory Report Form D Set TS-793 Chemical Substance Inventory Report Form E Set H7502C Request for Word Processing Set TS-793 Federal Agency, Congress, and Federal Court Sht Sign-Out Log 7710 19 Sep-81 TS-793 Confidentiality Agreement--TSCA Contractor Sht Employee 7710 22 Nov-78 TS-793 Library Request Index Card 7710 23 Nov-78 TS-788 Meeting Registration Card Card 7710 30 Sep-79 H7502C Time Accounting Information System Record Set 7710 31 Oct-79 TS-793 Frozen Medical Specimen Label Label 7710 32 Nov-80 TS-793 Information Transmittal Card 7710 33 Oct-79 TS-793 Dry Ice/hazardous Material Label Label 7710 34 Sep-79 TS-793 Trade Name Product Identity Report Sht 7710 35 May-82 TS-778 Manufacturer’s Repoit Preliminary Assessment Sht Information 7710 45 Sep-81 TS-793 Destruction L.og Sht * 7710 48 Dec-87 TS-796 HERD Action Report Set 7730 -- Asbestos Control 7730 1 Jun-82 TS-794 7730 2 Jun-82 TS-794 7730 7730 3 4 Jun-82 Jan-85 TS-794 PM-273 Inspections for Friable Asbestos-Containing Mawx s A Guide for Reducing Asbestos Exposure Notice to School Employees Notice to EPA Employees * Available in Electronic Fonnat. Contact the Forms Office for details. Con- struc- Stock tion Code Sht A Sht A Sht A Sht A Sht A Sht Sht Sht Pam Pam A A A A A D D D C A C C B C C C C C A C Sht C Sht C Sht C Sht C 18 ------- Numerical List of EPA Forms Date of Con- Current stoic- Stock Form No. Edition Originator Title tion Code 7740 -- TSCA 7740 1 Dec-82 EN-342 TSCA Receipt for Samples and Documents Set A 7740 2 Dec-82 EN-342 TSCA Declaration of CBI Set A 7740 3 Dec-82 EN-342 TSCA Notice of Inspection Set A 7740 4 Dec-82 EN-342 TSCA Inspection Confidentiality Notice Set A 7740 5 Mar-83 EN-342 TSCA Investigation Summary Set A * 7740 6 May-88 TS-793 Federal TSCA CBI Access Request, Sht A Agreement, and Approval (Document & Computer) * 7740 6A Oct-88 TS-793 Federal TSCA CBI Access Request, Sht A,B Agreement, & Approval: Coniractor/ Subcontractor Employee 7740 8 Dec-85 TS-793 Partial Updating of TSCA Inventory Data Base: Set C Production and Site Report 7740 9 Oct-85 TS-793 TSCA Confidential Business Information Card A,B (Cover Sheet) 7740 10 Oct-85 TS-793 Receipt Log: TSCA CBI Sht A,B 7740 11 Oct-85 TS-793 Inventory Log: TSCA CBI Sht A,B 7740 12 Oct-85 TS-793 Memorandum of TSCA CBI Telephone Sht A,B Conversation 7740 13 Oct-85 TS-793 TSCA CBI Visitors Log Sht A,B 7740 14 Oct-85 TS-793 Temporary Loan Receipt for TSCA CBI Set A,B 7740 15 Oct-85 TS-793 TSCA CBI Meeting Sign-in Sheet Sht A,B 7740 16 Oct-85 TS-793 Confidentiality Agreement for US Employees Set A,B Upon Relinquishing TSCA CBI Access Authority 8500-8599 - - Pesticides 8500 -- General 8500 1 Jun-83 EN-342 Investigation Request Set A 8500 6 Nov-72 TS-768 Pesticide Sample Record Card A 8500 7 Feb-72 H7505C Enforcement Case Review Set C 8500 7A Feb-72 H7505C Enforcement Case Review Set C 8500 12 Apr-75 TS-768 Microbiological Laboratory Report Sht C 8500 14 Oct-77 TS-768 OPP Comment Acknowledgement Card C 8500 15 Aug-77 TS-768 ADP Support Service Request Set C 8500 21 Feb-87 H7505C Silvex/2,4,5-T Products: Claim for Pam C Indemnification, Request for Federal Disposal * 8500 22 Jan-89 H7502C Dinoseb Products: Claim for Indemnification, Pam C Request for Federal Disposal * 8500 23 May-88 H7502C Request for Document Center Services Set C * 8500 24 Feb-88 H7502C FIFRA Sensitive Information Transmittal Set C 8510 -- Human Health 8510 8A Nov-80 TS-793 Urine Pesticide Residue Analysis Report (MPM)Sht C 8510 8B Nov-80 TS-793 Urine Pesticide Residue Analysis Report Sht C (APM) 8510 10 Feb-82 TS-798 Patient Summary Report Sht C 8510 13 Aug-73 TS-768 Shipment of Specimens Card C 8510 14 Oct-76 TS-768 Biological Report of Analysis Set A 8550 5 Feb-79 TS-768 Pesticide Incident Report Sht A 8550 5A Feb-79 TS-769 Incident Report Update Sht A 8550 10 Jan-74 TS-793 Specimen Label Label C 8550 11 Apr-75 TS-768 Microbiological Laboratory Report Sht C * Available in Electronic Format. Contact the Forms Office for details. 19 ------- Numerical List of EPA Forms Date of Current Form No. Edition Originator Title 8570 -- Product Registration * 8570 1 Sep-88 H7505C Application for Pesticide Ainendment/ Registration 8570 4 Feb-85 H7505C Confidential Statement of Formula 8570 5 Apr-83 H7505C Application for Supplemental Registration of Distributor 8570 6 May-76 117505C Notice of Registration * 8570 13 Nov-88 H7505C Data Review Record * 8570 17 Feb-85 H7505C Application for an Expernnental Use Permit 8570 20 Jan-81 H7505C Data Reference Sheet * 8570 25 Dec-87 117505C Application for/Notification of State Registration of a Pesticide To Meet a Special Local Need 8570 27 Oct-86 117505C Formulator’s Exemption Statement 8570 28 Oct-86 H7505C Certification of Compliance with Data Gap Pmcedw 8570 29 Jul-86 H7505C Certification with Respect to Citation of Data * 8570 30 Jan-89 H7502C Pesticide Registration Maintenance Fee Filing 8580 -- FIFRA 8580 1 Oct-82 8580 3 Oct-82 * 8580 4 May-88 8580 6 Oct-82 FIFRA Section 3(CX2XB) Generic Data Exemption Statement Product Specific Data Report Certificate of Attempt To Enter into an Agreement with Other Registraths for Development of Data 8580 7 Mar-83 EN-342 FIFRA Investigation Summary 8700-8799 -- Solid Waste 8700 -- General 8700 11 Nov-79 8700 12 Nov-85 8700 12A Apr-80 Docket Control Slip Sht Notification of Hazardous Waste Activity Pam Acknowledgement of Notification of Hazardous Env Waste Activity Acknowledgement of Notification of Hazardous Set Waste Activity (Verification) Hazardous Waste Report Uniform Hazardous Waste Manifest Uniform Hazardous Waste Manifest (Continuation) 8710 -- RCRA 8710 1 Oct-82 8710 2 Oct-82 8710 4 Oct-82 OS-310 OS-340 OS-310 Con- struc- tion Stock Code Set C Set Set Set Set Set Set Set C C C C C C A Set C Set C H7505C H7505C H7505C 117505C Set Set Sht Sht Sht Sht C C C C C C OS-340 OS-340 OS-340 8700 12B Apr-80 OS-340 8700 13 8700 22 8700 22A Dec-87 Sep-86 Sep-86 Set A C A C C Pam D Sht C Sht C OS-320 OS-340 OS-340 Inventory Log (RCRA CBI) User Sign-Out Log (RCRA CBI) Federal Agency, Congress, and Federal Court Sign-Out Log (RCRA CBI) 8710 5 Oct-82 OS-3 10 Request for Approval of Conti tor Access to RCRA Confidential Business Information 8710 6 Oct-82 OS-3 10 RCRA Confidential Business Information Meeting Sign-in Sheet 8710 7 Oct-82 OS-3 10 Destruction Log (RCRA CBI) Sht Sht Sht C C C Sht C Sht C Sht C * Available in Electronic Format. Contact the Forms Office for details. 20 ------- Date of Current Form No. Edition Originator 8710 -- RCRA (Continued) 8710 9 Oct-82 OS-310 RCRA Contractor Employee Confidentiality Agreement 8710 10 Oct-82 OS-310 Confidentiality Agreement for US Employees Upon TerminatioWTransfer 8710 11 Oct-82 OS-310 Authorization for Access to RCRA CB1 8710 12 Oct-82 OS-310 Request for Approval of Temporary Employee for Access to RCRA CBI 8710 13 Oct-82 OS-3 10 RCRA Confidential Business Information 8710 14 Oct-82 OS-3 10 Confidentiality Agreement for Contractor Employees Upon TerminationiTransfer 9000-9999 - - Superfund 9100 -- Administrative * 9100 1 Feb-88 OS-510 Technical Enforcement Support at Hazardous Waste Sites 9310 -- Administration * 9310 1 Oct-87 OS-210 Application for Reimbursement to Local Governments for Emergency Response Pam A 9510 -- Community Right-To-Know * 9510 1 Jul-88 OS-120 Substantiation To Accompany Claims of Trade Secrecy: Emergency Planning! Community Right-To-Know Act * 9510 2 Dec-88 OS-120 SPMS and SCAP Report: Fiscal Year 1989 * Available in Electronic Format. Contact the Forms Office for details. Pam A,B Pam C Numerical List of EPA Forms Con- stnlc- Stock Title non Code Sht C Sht C Sht C Sht C Sht C Sht C Set C Set C Set C 9110 -- 9110 1 9110 2 Scientific Aug-88 OS-230 Inorganic Traffic Report Aug-88 OS-230A Organic Traffic Report 21 ------- Alphabetical List of EPA Forms Date of Current Form No. Edition Originator Title Con- struc- lion Sht Sht Sht Sht Card Sht Sht Sht Sht Sht Card Env Stock A,B C C C C C A,B A C C C C Env C Set C Card C Sht A,B Sht C Set A,B 1540 9 Oct-81 A-107 8 1/2 x 11 Layout Sheet 2800 1 Mar-73 PM-218 80-Column Keypunch Code Sheet 7730 2 Jun-82 TS-794 A Guide for Reducing Asbestos Exposure 1320 15 Mar-82 TS-799 AAjOPTS Routing and Transmittal Slip * 1480 55 May-88 EN-342 AARP Inspector’s Credential 4920 10 Nov-83 PM-215 Accident Report 2500 2 Nov-77 PM-226 Accounting Code Sheet 2500 5 Feb-80 PM-226 Accounts Receivable General Ledger Code Sheet 4920 5 Nov-83 PM-215 Accumulative Daily Request--Carrier 4920 3510 6 3A Nov-83 Dec-80 PM-215 OS-340 Accumulative Daily Requests—Dispatcher Acknowledgement of Application for a Hazardous Waste Permit 3510 3B May-80 OS-340 Acknowledgement of Application for a Hazardous Waste Permit (Verification) 8700 12A Apr-80 OS-340 Acknowledgement of Notification of Hazardous 8700 12B Apr-80 OS-340 Waste Activity Acknowledgement of Notification of Hazardous Waste Activity (Verification) 1550 4 Jul-81 A-101 Acknowledgement Receipt for FOl Appeal * 2620 2 Dec-86 PM-226 Actual Subsistence Expenses While Occupying Temporaiy Quarters 2800 18 Sep-80 OS-340 Ad Hoc Re rtRequest Hazardous Waste Data Management System 2550 20 Jul-81 PM-226 Adjustment of Pay Status Codes in Financial Management Systems 1740 13 Oct-73 PM-215 Adjustment Voucher 8500 15 Aug-77 TS-768 ADP Support Service Request 2500 4 Aug-73 PM-226 Advance Travel Code Sheet 2720 20A Oct-84 A-109 Advice of Rights 2720 20B Oct-84 A- 109 Advice of Rights 2720 18 Oct-84 A-109 Advice of Rights for a Federal Employee 3540 11 Dec-76 EN-342 Affidavit 5770 5 May-78 PM-216 Agency Fellowship Certificate 3100 1 Feb-81 PM-2l2 Agreement To Remain in the Government Service * 1480 50 Aug-87 PM-215 Alarm Monitor Log 7500 58 Feb-84 WH-556F Analysis Identification Tag 1900 60 Feb-84 PM-214 Announcement of Contract Award 7520 11 Feb-84 WH-550 Annual Disposal/Injection Well Monitoring Report * 8570 17 Feb-85 H7505C Application for an Experimental Use Permit 3300 1 Aug-77 LE-l30 Application for Certification of Pollution Control Facility 5130 3 Aug-87 PM-215 Application for EPA Supply Store Shopping Plate 5700 12 Apr-78 PM-216 Application for Federal Assistance 5700 33 Nov-86 PM-216 Application for Federal Assistance 5720 12 Sep-85 PM-216 Application for Federal Assistance (Construction GrantslCooperative Agreements) 5700 31 Oct-79 PM-216 Application for Federal Assistance (Short Form) 5700 33A May-74 PM-216 Application for Federal Assistance, Narrative Statement 5700 33B May-74 PM-216 Application for Federal Assistance, Narrative Statement 5700 33F Jul-76 PM-216 Application for Federal Assistance, Narrative Statement 5700 330 Nov-75 PM-216 Application for Federal Assistance, Narrative Statement * Form available in electronic format. Contact the Forms Office for more information. Sht Set Sht Sht Sht Sht Sht Sht Set Sht Tag Shi Sht Set Set Card Pam Pam Pam A,B C C C C C A C C C C A,B A C A B A A A Pam A Sht A Pam A Sht A Pam A 22 ------- Alphabetical List of EPA Forms Date of Con- Current struc- Form No. Edition Originator Title tion Stock 5700 331 Dec-79 PM-216 Application for Federal Assistance, Narrative SIn A Statement * 3520 9 Jul-88 EN-340 Application for Final Admission of a Catalytic Sht C Converter and Oxygen Sensor Equipped Vehicle * 3520 8 Jul-88 EN-340 Application for Final Admission of Nonconforming Sht C Imported Vehicle 3510 3 Jun-80 OS-320 Application for Hazardous Waste Permit Pam A 4920 1 Sep-78 PM-215 Application for Motor Vehicle Operator’s License Sht A,B 3510 2B Jun-80 EN-336 Application for Permit To Discharge Wastewater Sht A (Form 2B) 3510 2C Feb-85 EN-336 Application for Permit To Discharge Wastewater Pam A (Form 2C) * 8570 1 Sep-88 H7505C Application for Pesticide Amendment/Registration Set C * 3540 8 Nov-88 EN-342 Application for Registration of Pesticide-Producing Set C Establishment * 9310 1 Oct-87 OS-210 Application for Reimbursement to Local Pam A Governments for Emergency Response 8570 5 Apr-83 H7505C Application for Supplemental Registration Set C of Distributor * 8570 25 Dec-87 H7505C Application for/Notification of State Registration Set A of a Pesticide To Meet a Special Local Need 3510 2D Sep-86 EN-336 Application Form 2D-New Sources & New Pam A Dischargers:Application for Permit To Discharge Process Waste 3510 2E Sep-86 EN-336 Application Form 2E--Facilities Which Do Not Pam A Discharge Process Wastewater 5700 7C May-80 PM-216 Application Kit for Assistance (Fellowship) Folder A 5700 7B May-87 PM-216 Application Kit for Assistance (Planning or Folder A Program Assistance) 5700 7E Aug-80 PM-216 Application Kit for Assistance (Research) Folder A 5700 7D May-80 PM-216 Application Kit for Assistance (rraining) Folder A 2800 8 Dec-79 OS-340 Application Receipt and Acceptance Sht C 7520 7 Feb-84 WH-550 Application To Transfer Permit Sht A 3115 22 Oct-84 PM-212 Appraisal of Other Characteristics Needed for Sht A Upward Mobility 2800 22 Jun-81 PM-218 Approved Operating Plan Sht C 1900 4 Jun-71 PM-214 Assignee’s Assignment of Refunds, Rebates, Set A,B Credits,and Other Amounts 3140 18 Sep-78 PM-212 Assignee’s Evaluation of Mobility Assignments Sht C 1900 3 Jun-75 PM-214 Assignee’s Release Sht A,B 5700 20A May-82 PM-216 Assistance Agreement/Amendment Pam A,B 5700 20B Nov-86 PM-216 Assistance Amendment Sht A 5700 14 Apr-84 PM-216 AssistanceFundingOrder Sht A,B 1710 1 Sep-84 PM-215 Audio-Visual Equipment Loan Record Sht C 2350 2 Jul-84 A-107 Audiovisual Service Request Set C 1480 40 Feb-84 A-109 Authority for Release of Information Set A,B 8710 11 Oct-82 OS-310 AuthorizationforAccesstoRCRACBl Sht C 2560 4 Jul-81 PM-226 Authorization for Mailing Pay Checks Sht A,B 3540 9 Nov-77 EN-342 Authorization To Administer Oaths, Affidavits, Sht A and Affirmations 2560 6 Jun-74 PM-226 Authorized Compensatory Time Record Sht A,B 3115 31 Sep-84 PM-212 Basic Qualifications Determination Worksheet Sht A,B 2505 4 Sep-73 PM-226 Bill for Collection Set A,B 8510 14 Oct-76 TS-768 Biological Report of Analysis Set A 5100 1 Sep-79 PM-215 Building Modification Services Request Set A,B * Form available in electronic format. Contact the Forms Office for more information. 23 ------- Alphabetical List of EPA Forms Date of Con- current Struc- Form No. Edition Originator Title tion Stock 5180 16 Jan-80 PM-215 Business Reply Label Label C * 3115 8E Nov-86 PM-212 Candidate Referral Certificate: Temporary Position Sht A,B * 3140 29 Jul-87 PM-224 Career Management System Pam A * 3115 3D Nov-86 PM-224 Career Management System Vacancy Announcement Sht A,B * 3300 12 Nov-88 LE-133 CERCLA Enforcement Case Data Sht C 3115 8D Oct-84 PM-212 Certificate for Upward Mobility Sht A,B 3130 4 Jul-82 PM-212 Certificate of Approval for Payment of Suggestion Sht A,B A urd 8580 6 Oct-82 H7505C Certificate of Attempt To Enter into an Agreement Sht C with Other Registrants for Development of Data 3130 6 Jan-73 PM-212 Certificate of Completion of Training Cani A,B 3130 9 Jan-88 PM-212 Certificate of Retirement Sht A,B 8570 28 Oct-86 H7505C Certification of Compliance with Data Gap Set C Pmcedw * 5700 49 Nov-88 PM-216 Certification Regarding Debarment, Suspension, Pam A,B and Other Responsibility Matters 8570 29 Jul-86 H7505C Certification with Respect to Citation of Data Set C 7500 57 Feb-84 W11-556F Chain of Custody Record Set C 2560 5 May-80 PM-226 Change in Fixed Account Number Sht A,B 2410 20 Jul-82 PM-225 Change RequestlNotification-Funding Sht A,B 1315 4 Aug-86 PM-213 Checklist of EPA Transmittals Sht A,B 7710 3E Feb-79 TS-793 Chemical Substance Inventory Report Form E Set D 3150 26 Jun-81 PM-212 Classification Appeal Decision Sht C * 1325 4 Jan-87 PM-223 Clearance Control Set C 4540 1 Mar-82 A-106 Clearanceof Foreign Research Award Sht A,B 1300 2 Jun-71 PM-223 Clearance Record Sht A,B * 1315 16 Feb-89 PM-213 Clearance/Approval Record Sht A.B 1315 16A Dec-83 PM-213 Clearance/Approval Record (Continuation) Sht C 1300 13 Ajr-86 PM-21 1D Clerical Wait Request Sht A,B 2505 5 Mar-76 PM-226 Collection Officer Designation Card A,B 2550 9 Apr-74 PM-226 Commitment Notice Sht A,B 1130 4 Feb-84 PM-213 Committee Inventory Record Sht C 1550 10 May-81 H7502C Company Data Review in Response to P0! Request Set C 3110 26 Oct-74 PM-212 Competitive Level Code Log Sht C 7520 9 Feb-84 WH-550 Completion Form for Class I Injection Wells Sht A 7520 10 Feb-84 WH-550 Completion Report for Brine Disposal, Sht A Hydrocarbon Storage 3560 3 Mar-85 EN-338 Compliance Inspection Report Sht A 1320 1 ! -70 PM-211D Concurrence Sheet (OfficialFile Copy) Sht A,B 1320 1 Dec-70 PM-215 Concurrence Sheet (OfficialFile Copy) Set A,B 3120 1 May-84 LE-131 Confidential Statement of Employment and Sht A,B Financial Interest 8570 4 Feb-85 H7505C Confidential Statement of Formula Set C 8710 14 Oct-82 OS-310 Confidentiality Agreement for Contractor Sht C Employees Upon Termination / Transfer 7740 16 Oct-85 TS-793 Confidentiality Agreement for US Employees Upon Set Relinquishing TSCA CBI Access Authority 8710 10 Oct-82 OS-310 Confidentiality Agreement for US Employees Sht C Upon Termination/Transfer 7710 19 Sep-81 TS-793 Confidentiality Agreement--TSCA Contractor Sht Employee 2800 15 Apr-80 05-340 Confidentiality Claim Sht C * 5040 9 Feb-88 PM-211T Confirmation of Teleconference Schedule Set C 3110 17 Aug-73 PM-212 Consultant Certificate Sht A,B * Form available in electronic format Contact the Forms Office for more information. 24 ------- Alphabetical List of EPA Forms Date of Con- Current struc- Form No. Edition Originator Title tion Stock * 3520 8A Jul-88 EN-340 Continuation of Application for Final Admission of She C Nonconforming Imported Vehicle 1900 20 Apr-85 PM-214 Contract Checklist She A,B * 1480 44 May-87 PM-215 Contract Guard Duty Register She C * 1900 19 Aug-88 PM-214 Contract Memorandum of Transmittal and Checklist Card A,B 2410 9A Jun-83 PM-214 Contract Planning Submission Annual Plan She A,B 2410 9B Jun-83 PM-214 Contract Planning Submission Quarterly Plan She A,B 1900 26 Apr-85 PM-214 Contracting Office? s Evaluation of Contractor Set A,B Performance 1900 5 Jun-71 PM-214 Contractor’s Assignment of Refunds, Rebates, Set A,B and Credits 3540 30 Dec-80 EN-342 Contractor’s Credential Card C 1900 10 Nov-76 PM-214 Contractor’s Cumulative Claim and Reconciliation Sht A,B 1900 6 Feb-81 PM-214 Contractor’s Release Set A,B 3540 13 Oct-73 EN-342 Copy of Invoice and Shipping Record P J A 3540 22 Apr-75 EN-342 Corrective Action Report Set A 1320 2 Apr-77 A-1O1 Correspondence Signature Tab Card A,B 5700 41 Apr-84 PM-216 Cost or Price Summary Pam A 1900 41B Jun-79 PM-214 CPAF Contract Individual event Performance Sht A Observation 1900 41A Jun-79 PM-214 CPAF Contract Summary of Significant Sht A Performance Observation 1400 1 Feb-84 PM-215 Credential Acknowledgement Statement She A 3115 29 Sep-84 PM-212 Cumulative Merit Promotion Evaluation Sheet Sht A,B 2560 22 Jul-81 PM-226 Cumulative Pay Adjustment She C 2560 23 Jul-81 PM-226 Current Pay Adjustment She C * 5180 18 Aug-88 PM-215 Custom Designed Mail Special Envelope Env A,B * 5180 17 Mar-87 PM-2 15 Daily Record of Postage Meter Register Readings She C 4920 9 Nov-83 PM-215 Daily Schedule Chart She C 4920 3 Sep-84 PM-215 Daily Vehicle Utilization Report Sht A,B 8570 20 Jan-81 H7505C Data Reference Sheet Set C * 8570 13 Nov-88 H7505C Data Review Record Set C 3560 4 Feb-80 EN-338 Deficiency Notice Set A 1900 59 Nov-83 PM-214 Delivery Order for Emergency Response Set A 1900 65 Jun-85 PM-214 Designation & Appointment of Project Set A,B Officer/Work Assignment Manager/Delivery Order 3150 10 Sep-73 PM-212 Desk Audit Report Sht A,B 7710 45 Sep-81 TS-793 Destruction Log Sht A 8710 7 Oct-82 OS-310 Destruction Log (RCRA CBI) She C 7500 54 Sep-80 OS-200 Detailed SPCC Documentation Pam A 1900 57 Apr-84 PM-214 Determination and Findings: Method of Contracting She C 1900 62 Feb-84 PM-214 Determination and Findings: Authority To Use Sht C a Letter Contract 1900 53 Apr-84 PM-214 Detennination and Findings: Authorization To She C Use a Time and Materials Contract * 8500 22 Jan-89 H7502C Dinoseb Products: Claim for Indemnification, Pam C Request for Federal Disposal 2560 18 Sep-77 PM-226 DIPS Payroll Master Input Data She A 1315 10 Dec-79 PM-213 Directive Number Assignment Card C 1315 5 Jul-82 PM-213 Directives Processing Worksheet She A,B 3320 1 Oct-77 EN-336 Discharge Monitoring Report Set A 2550 6 Mar-80 PM-226 Distribution of Payroll Charges Set A,B 8700 11 Nov-79 OS-340 Docket Control Slip She C 1300 14 Nov-83 TS-799 Document Clearance Request She C 2550 11 Feb-81 PM-226 Document Control Register She A,B * Form available in electronic format. Contact the Forms Office for more information. 25 ------- Alphabetical List of EPA Forms Dale of Con- Current sUuc- Form No. Edition Originator Title tion Stock 4940 2 Oct-83 PM-215 Driver’s Daily and Weekly Preventive Sht C Maintenance Checklist 4920 14 Nov-83 PM-215 Driver’s Log Sht C 7710 33 Oct-79 TS-793 Dry Ice/Hazardous Material Label Label C 4700 14 May-84 A-lOS EEO Complaint Invoice Set C 1320 3B Feb-81 PM-215 EGD Contractor’s 4th Class Mailing Label Label C 2560 21 Oct-78 PM-226 Emergency Salary Payment Voucher Sht C 2620 3 Jul-85 PM-226 Employee Acknowledgement of Diners Club Credit Set C Card Pmgram * 2620 1 Dec-86 PM-226 Employee Application for Reimbwsement Sht A,B of Expenses 3340 1 Aug-72 LE-132 Employee Report of Invention Set A,B * 3110 1 Feb-88 PM-212 Employee Separation or Transfer Checklist Set A,B 2560 15 Mar-77 PM-226 Employee Statementof Leave Balances Sht A,B 3130 2 Dec-77 PM-212 Employee Suggestion Form Sht A * 3300 11 Nov-88 LE-133 EnfoivementCase Data Sht C 8500 7 Feb-72 H7505C Enforcement Case Review Set C 8500 7A Feb-72 H7505C Enforcement Case Review Set C * 5300 23 Aug-87 RD-674 Envimnmental Review for Extramural Projects Set A 5700 20C Feb-86 PM-216 EPA Assistance Agreement/Amendment Set A 3300 6 Sep-82 LE-134 EPA Assistance Appeals Initiation and Update Pal C 1480 36 Oct-83 PM-215 EPA Bomb Data Information Card C 5770 7 Jun-73 PM-216 EPA Fellowship Activation Notice Set A 5770 9 Jul-73 PM-216 EPA Fellowship Termination Notice Sht A * 1480 33 Feb-88 PM-215 EPA Headquarters Building Pass Card C 5110 1 May-73 PM-215 EPA Identification Card Acknowledgement Card A 3540 24 Apr-78 EN-342 EPA Inspector ’s Credential Card C 1550 5 May-79 A-107 EPA Journal Subscription Notice Sht C 1315 12A May-86 PM-213 EPAOider Shi A,B 1320 5A Jun-82 PM-215 EPA Postcard (Field Elements) Card A 1320 5 Jan-78 PM-215 EPA Postcard (Headqu ters) Can! C 5130 2 Apr-80 PM-215 EPA Self-Service Stove Request/Sales Slip Set B 1750 7 Sep-72 PM-215 Equipment MaintenanceReconi Card A,B 3540 21 Apr-75 EN-342 Establishment Inspection Report Set A 7510 1 Jun-81 Wll-595 Estimate of Municipal Wastewater Treatment Sht D Facilities 3115 7 Sep-84 PM-212 Evaluaün dRating Worksheet Sht A,B 3150 9 Sep-73 PM-212 Evaluation Statement Sht A,B 3150 7 Sep-73 PM-212 Evaluation Statement for Supervisors of Sht A Subprofessional Positions 3150 6 Dec-79 PM-212 Evaluation Statement for Supervisors of Sht A,B Two-Grade-Interval Positions * 2720 6 Mar-87 A-109 Evidence Custody Set A 1320 11 Jul-83 A-b! Executive Communications Transmittal Sht C 3110 18 Aug-73 PM-212 ExpeztCertificate Sht A,B 3110 15 Jan-73 PM-212 Expert or Consultant Supplemental Information Sht A,B 5180 10 Apr-79 PM-215 Express Mail Register Sht A,B 2800 14 Apr-80 OS-340 Facility - ID Update Maintenance Form Sht C 2800 16 May-80 OS-340 Facility Inventory Maintenance Form Sht C 5040 2 Nov-75 PM-211T Facsimile Log Sht A,B 5040 5 Dec-83 PM-21 IT Facsimile Transmission Request and Cover Sheet Sht B 3150 21 Dec-77 PM-212 Factor Evaluation System Evaluation Statement Sht A 1480 6 Jun-71 A- 109 FBI Record Check Request Sht C 7710 13 Sep-81 TS-793 Federal Agency, Congress, andFederal Court Sht A Sign-Out Log * Form available in electronic formaL Contact the Forms Office for more information. 26 ------- Alphabetical List of EPA Forms Date of Con- Cuffent Struc- Form No. Edition Originator Title tion Stock 8710 4 Oct-82 OS-310 Federal Agency, Congress, and Federal Court Sht C Sign-Out Log (RCRA CBI) 2340 15 Jan-81 PM-215 Federal Register Typesetting Request Set A,B 7500 43 May-78 WH-550 Federal Reporting Data System -- Variances Sht A and Exemption 7500 42 Dec-80 WH-550 Federal Reporting Data System -- Violations Sht A * 7740 6A Oct-88 TS-793 Federal TSCA CBI Access Request, Agreement, Sht A,B & Approval: Contractor/Subcontractor Employee * 7740 6 May-88 TS-793 Federal TSCA CR1 Access Request, Agreement, Sht A & Approval (Document & Computer) * 3720 11 Jan-89 PM-223 Federalism Review Sht B 5770 8 Jul-73 PM-216 Fellowship Agreement Sht A 5770 6 Jun-73 PM-216 Fellowship Amendment Sht A 5770 4 Feb-77 PM-216 Fellowship Applicant Qualifications Inquiry Sht C 5770 2 Apr-78 PM-216 Fellowship Application Pam C 5770 3 Feb-77 PM-216 Fellowship Facilities and Commitment Statement Sht C 8580 7 Mar-83 EN-342 PIFRA Investigation Summary Set A 8580 1 Oct-82 H7505C FJFRA Section 3(CX2)(B) Sht C * 8500 24 Feb-88 H7502C FIFRA Sensitive Information Transmittal Set C 1340 4 Nov-78 PM-211D Files Maintenance Plan Sht A,B 1550 6 Apr-80 117502C FOl Case Receipt Log Sht C 1550 7 Dec-80 H7502C FOl Case Status Report Card C 1550 11 May-81 H7502C P01 Invoice Set C * 1550 3 Jun-87 A-10l FOl Request Acknowledgement (Regions) Card A 1550 9A May-81 H7502C P01 Request Response Sht C * 1550 2 Apr-87 A-l0l FOIA Request Acknowledgement Card C 3300 8 Jun-82 LE-134 Form 2 Events Pal C 3300 7 Jun-82 LE-134 Form 3 Consolidated Cases Pal C 1335 1 Feb-85 PM-211D Form Action Request Sht A,B 1335 18 Sep-83 PM-21 1D Form Approval Pal C 1335 9 Sep-85 PM-211D Forms Distribution Guide Pam C 1335 4 Nov-80 PM-211D Forms Number Assignment Sheet Sht C 1335 17 Apr-83 PM-215 Forms/Publications Shipping Label Label C 8570 27 Oct-86 H7505C Formulator’s Exemption Statement Set C 1550 12 Sep-85 A- 101 Freedom of Information Request Log Sht A 1550 9 May-81 H7502C Freedom of Information Request Response Set C 7710 31 Oct-79 TS-793 Frozen Medical Specimen Label Label C * 4850 3 Aug-87 PM-215 Fume Hood Certification Label B 3510 1 Oct-80 EN-336 General Information Consolidated Permits Pam A Program (Form 1) 2500 3 Jul-73 PM-226 General Ledger Code Sheet Sht C 8580 3 Oct-82 H7505C Generic Data Exemption Statement Sht C 3300 9 Jul-82 LE-134 Grant Appeal Checkout Sheet Card C 5700 29 Jul-82 PM-216 Grant AuditRequest Sht A 5700 42 Feb-85 PM-216 Grant Record Adjustment Notice Set C 3150 15 Dec-73 PM-212 Group Action Request List Sht A,B * 1480 48 May-87 PM-215 Guard Inspection Report Pal C * 1480 49 Aug-87 PM-215 Guard Post Orders Sht C * 1480 49A Aug-87 PM-215 Guard Post Orders (Continuation Sheet) Sht C * 1480 49B Aug-87 PM-215 Guard Post Orders (Continuation Sheet Sht C Schedule of Activities) 1900 34A Apr-83 PM-214 Guide for Preparation of Contractor’s Claim Pam A,B 1900 34 Apr-83 PM-214 Guide for Preparation of Contractor’s Claims Pam A,B 1900 55 Jan-82 PM-214 Hazardous Substance Response Fund Set A 8700 13 Dec-87 OS-320 Hazardous Waste Report Pam D * Form available in electronic format. Contact the Forms Office for more information. 27 ------- Alphabetical List of EPA Forms Date of Con- Current struc- Form No. Edition Originator Title tion Stock 5200 3 May-83 A-102 Hearing Report Sht C 5200 3A May-83 A-102 Hearing Report Sht C * 7710 48 Dec-87 TS-796 HERD Action Report Set C 3540 17 Dec-73 EN-342 History of Official Sample Sht A * 3520 1 Sep-88 EN-340 Importation of Motor Vehicles and Motor Vehicle Sht A,D Engines Subject to Federal Air Pollution Regulations 8550 5A Feb-79 TS-769 Incident Report Update Sht A 2635 1 Nov-72 PM-226 Information for Authority of Moving and Related Sht A,B Travel Expenses 1320 20 Sep-86 TS-799 Information Transmittal Cant C 7710 32 Nov-80 TS-793 Information Transmittal Cani C 7520 8 Nov-83 WH-550 Injection Well Monitoring Report Slit A 9110 1 Aug-88 OS-230 Inorganic Traffic Report Set C 7730 1 Jun-82 TS-794 Inspections for Friable Asbestos-Containing Sht C Ma * 1480 43 May-88 EN-397F Inspector’s Credential Card C 3544) 31 Oct-85 EN-342 Inspector’s Credential Cani C * 1610 1 Oct-88 PM-216 Interagency Agreement Pam A,B 4550 5 Jun-81 A-106 International Travel Plan Set A,B 4550 1 Jul-79 A-106 International Trip Report Set A,B 4510 2 Dec-77 A-106 International Visitoi s) Alert Sht C 2550 4 Dec-79 PM-226 Interoffice Transfer Voucher Set A,B 3115 17 Oct-84 PM-212 Interview Rating Sheet for Upward Mobility Sht C Positions 3340 2 Aug-72 LE-132 Invention Rights Questionnaire Set C 8710 1 Oct-82 OS-310 Inventcxy Log (RCRA CBI) Sht C 7740 11 Oct-85 TS-793 Inventory Log: TSCA CBI Sht A,B 7500 48 Nov-79 WH-550 Inventory of Injection Wells Slit A 2720 17 Nov-84 A-109 Investigation Cover Sheet Slit A 8500 1 Jun-83 EN-342 Investigation Request Set A 2720 1 Apr-80 A-109 Investigative Contiol and AssignmentRecord Set A 2720 13 Apr-83 A-109 Investigative Report Cover A 1345 1 Mar-81 H7505C Jacket Locator Cant Cant C 3115 28 Sep-84 PM-212 Job Analysis Record Sht A,B 3115 18 Oct-84 PM-212 Job Element Rating Sheet for Upward Mobility Sht C Positions 4850 1 May-81 PM-215 Job Orders Sht C 4920 7 Nov-83 PM-215 Key and Credit Cant Log Sht A.B * 1480 51 Aug-87 PM-215 Key Issuance Register Sht C 5100 2 Dec-80 PM-215 Labor Services Request Set B 5100 2A Dec-80 PM-215 Labor Services Request Receipt Log Sht B * 5720 4 May-87 A-lOS LaborSlandardsPmvisionsforFederal&Fede(allY Pam A,B Assisted Contracts 3300 4 Mar-85 LE-130L Law Library (Charge-Out) Cant C 3520 5 May-85 EN-397F Lead Additive Rqxxt for Gasoline Importer Slit C 3520 3 May-76 EN-340 Lead Additive Report for Manufacturing Facility Sht C or Site 3520 2 May-85 EN-397F Lead Additive Report for Refiners Sht C 3520 6A Jun-85 EN-397F Lead Additive Report Supplement A: Sht C Constructive Allocations 3520 May-85 EN-397F Lead Additive Report Supplement B: Transfers Sht C of Lead 1540 14 Aug-79 A-107 Leaflet Grid Sht C 1740 15 Jan-81 PM-215 Leased Personal Property System Input Data Sht A,B * Form available in electronic formal Contact the Forms Office for more information. 28 ------- Alphabetical List of EPA Forms Date of Con- Current siruc- Form No. Edition Originator Title Lion Stock 2560 16 Apr-75 PM-226 Leave Overpayment Remittance Request Sht C 5200 2 May-83 A-102 Legislative Alert Sht C 3130 7A Jul-86 PM-212 Length of Service Certificate -- 10 Years Sht A,B 3130 7B Jul-86 PM-212 Length of Service Certificate --20 Years Sht A,B 3130 7C Jul-86 PM-212 Length of Service Certificate --30 Years Sht A,B 3130 7D Jul-86 PM-212 Length of Service Certificate --40 Years Sht A,B 1900 56 Apr-85 PM-214 Letter Contract for State/Local Government Pam C Response to Emergency Hazardous Substance Release 2550 15 Dec-73 PM-226 Letter of Credit History Sht A,B 7710 22 Nov-78 TS-793 Library Request Index Card C 5180 1 Jun-72 PM-211D Mail Control Schedule Set A,B 5180 11 May-79 PM-215 Mail Label - First Class Label B 5180 14 May-79 PM-215 Mail Label - Fourth Class Label B 5180 12 May-79 PM-215 Mail Label - Third Class Label B 5180 15 May-79 PM-215 Mail Label - Third-Class Bulk Label B 1320 3 Mar-84 PM-215 Mailing Label Label B 2200 3 Jan-85 A-107 Mailing List Update (OPA) Can! C 2200 4 Jan-85 OS-305 Mailing List Update (OSW) Card C 4850 2 Aug-83 PM-215 Maintenance Job Order Set C 7710 35 May-82 TS-778 Manufacturers Repoit Preliminary Assessment Sht C Information 3100 13 Jan-78 PM-212 MedicalReport Sht C 7710 23 Nov-78 TS-788 Meeting Registration Card Can! C 7740 12 Oct-85 TS-793 Memorandum of TSCA CBI Telephone ConversationSht A,B 1900 54 Apr-85 PM-214 Memorandum to the File: Synopsis Exemption Sht C * 3115 3 Nov-86 PM-212 Merit Promotion Announcement Sht A,B 3115 14 Sep-84 PM-212 Merit Promotion Application Rating Sheet Sht A,B 3115 8 Sep-84 PM-212 Merit Promotion Certificate Sht A,B 3115 8A Sep-84 PM-212 Merit Promotion Certificate (Continuation) Sht A,B 3115 9 Sep-84 PM-212 Merit Promotion Information Record Set A,B 3115 20 Apr-77 PM-212 Merit Promotion Program Vacancy Sht C Announcement Results 3115 15 Sep-84 PM-2 12 Merit Promotion Rating Plan Specifications Sht A,B 3115 3A Oct-84 PM-212 Merit Promotion Vacancy Announcement Sht C (Upward Mobility) 5040 8 Apr-78 PM-21 iT Message for Transmission Sht A,B 5040 1 Nov-75 PM-21 iT Message Receipt Log Sht A 8500 12 Apr-75 TS-768 Microbiological Laboratory Report Sht C 8550 11 Apr-75 TS-768 Microbiological Laboratory Report Sht C 2550 10 Jul-80 PM-226 Miscellaneous Obligation Document Sht A,B 1900 63 Apr-84 PM-214 Monthly Requisition and/or Receiving Report for Set A,B Blanket Pwvhase Orders 4920 11 Nov-83 PM-215 Monthly Vehicle Report Sht C 4920 4 Sep-80 PM-215 Motor Pool Assignment Sht C 4940 1 Jun-72 PM-215 Motor Vehicle Record Can! A,B 3115 13 Sep-84 PM-212 MPP Checklist Sht A,C 3115 8C Sep-84 PM-212 Noncompetitive Candidate Referral Certificate Sht A,B 3115 8B Sep-84 PM-212 Nonstatus Candidate Referral List Sht A,B 1315 11 May-86 PM-213 Notice Sht A,B 2500 1 Apr-77 PM-226 Notice of Administrative Exception Set A,B 3540 1 May-77 EN-342 Notice of Arrival of Pesticides and Devices Set A 3300 3 Aug-77 LE-130 Notice of Federal Certification Set A 3540 2 Mar-77 EN-342 Notice of Inspection Set A 2610 2 Jan-83 PM-226 Notice of Leave To Be Charged While on Travel Set A,B * Form available in electronic format. Contact the Forms Office for more information. 29 ------- Alphabetical List of EPA Forms Dale of Con- Current struc- Form No. Edition Originator Title Lion Stock 2340 17 Jul-84 PM-215 Notice of Pending Delivery/Shipment Set C 3540 25 Mar-77 EN-342 Notice of Pesticide Use/Misuse Inspection Set A 8570 6 May-76 H7505C Notice of Registration Set C 2720 2 May-83 A-109 Notice of Scheduled Investigation Slit A 3300 2 Aug-77 LE-130 Notice of State Certificate Set A 3540 27 Mar-77 EN-342 Notice of Stop Sale, Use, or Removal Order Label A * 3520 7 Sep-87 EN-397F Notice of Violation of Section 211 of the Clean Set C Air Act 1900 58 Apr-84 PM-214 Notice Regarding Work Stoppage Slit C 2720 19 Oct-84 A-109 Notice to a Federal Employee: Duty To Respond Sht C to Questions 7730 4 Jan-85 PM-273 Notice to EPA Employees Sht C 1900 49 Apr-85 PM-214 Notice To Proceed with Emergency Response to Pam C Hazardous Substance Release 7730 3 Jun-82 TS-794 Notice to School Employees Sht C 7530 1 Sep-88 OS-420 Notification for Underground Storage Tanks Pam C 1130 3 Jan-81 PM-213 Notification of Advisory Committee Meeting Set C 1700 1 Jun-81 PM-215 Notification of Designation of Shipping Officer Slit A,B 8700 12 Oct-88 OS-340 Notification of Hazardous Waste Activity Pam A * 3540 8A Nov-88 EN-342 Notification of Registration of Slit C Pesticide-Producing Establishments 7550 8 Mar-74 EN-336 NPDES Application for Permit To Discharge Sht A (Fonn C) 3320 iT Jan-87 EN-336 NPDES Discharge Monitoring Report Set A,D * 7500 55 Jan-89 EN-338 NPDES Laboratory Performance Evaluation Pam D 7550 6 Jan-73 EN-336 NPDES--Application for Permit To Discharge Sht A (Form A) 7550 9 May-73 EN-336 NPDES-Application for Permit To Discharge Sht A (Form D) 7550 22 Jul-73 EN-336 NPDES-Application for Permit To Discharge Pam A Wastewater (Form A) 7550 23 Jul-73 EN-336 NPDES-Application for Permit To Discharge Pam A Wastewatcr (Form C) 1320 9 Apr-74 A-101 OA Priority Correspondence Folder Folder C 1320 17 t -84 A-104 OFA Routing Slip/Assignment Form Set C 5140 1 Oct-73 PM-215 Office Equipment RepairLog Sht C 2720 4 May-80 A-109 Officeof Investigations Monthly Report Sht A * 1480 46 May-87 PM-215 Officer’s Operations Log Slit C 7500 2 Jul-75 EN-342 Official Sample Seal Label A 1305 4 Apr-72 PM-215 Official US Government Identification Card C 1480 39 Dec-82 PM-215 Official US Government Identification Cani C 1320 12 Jan-78 A-101 OL Priority Correspondence Folder Folder C 8500 14 Oct-77 TS-768 OPP Comment Acknowledgement Card C 1900 48 Apr-85 PM-214 OnlerforServices-EmergencyResponseto Pam C Hazardous Substance Release 9110 2 Aug-88 OS-230A Organic Traffic Report Set C 3110 43 Jul-86 PM-212 Organization Code Sheet Sht A,B 5040 3 Aug-79 PM-211T Originating Traffic Log Sht A * 1315 17 May-87 OS-100 OSWER Directive Initiation Request Sht C 1300 11 Apr-81 TS-793 011 Document Clearance Form Slit C 3155 2 Apr-73 LE-132 Overpayment Investigation Report Slit A,B 1740 9 Jun-79 PM-215 Owned Personal Property System Input Data Sht A 2550 5 Mar-fl PM-226 Paid Purchase Order Register Slit C 5160 1 Apr-77 PM-215 Parking Perntit Application Sht A,B * 4920 15 May-88 PM-215 Parking Violation Set C * Form available in electronic format. Contact the Forms Office for more information. 30 ------- Alphabetical List of EPA Forms Date of Con- Current Struc- Form No. Edition Oiiginator Title tion Stock * 7520 2A Jan-88 WH-550E Part II: Compliance Evaluation Set A * 7520 2B Jan-88 WH-550E Part II: Compliance Evaluation/Significant Set A Noncompliance * 7520 3 Jan-88 WH-550E Part ifi: Inspections/Mechanical Integrity Testing Set A * 7520 4 Mar-88 WH-550E Part IV: Quarterly Exceptions List Set A * 7520 5 Jan-88 WH-550E Part V: Summary of UIC Grant Utilization Set A 7740 8 Dec-85 TS-793 Partial Updating of TSCA Inventory Data Base: Set C Production and Site Report 4920 13 Nov-83 PM-215 Passenger Message Slip Set C 4550 7 Nov-80 A-106 Passport Log Cant C 8510 10 Feb-82 TS-798 Patient Summary Report Sht C * 2720 21 Jan-89 A-109 PATS Biweekly Time Distribution Report Set C 2570 4 Aug-76 PM-226 Payment Record Sht A,B 2560 17 Jul-75 PM-226 Payroll Commitment Adjustment Notice Sht A 2560 28 Oct-86 PM-226 Payroll Distribution Time Sheet Set A,B 2560 28A Oct-86 PM-226 Payroll Distribution Time Sheet (Continuation) Set A,B 2560 2 Nov-86 PM-226 Payroll Error Notice Set A,B 2560 8 Jan-75 PM-226 Payroll Special Label Label A,B * 3115 24 Aug-87 PM-2 12 Perfonnance Agreement, Appraisal, and Pam A,B Certification 1740 21 Aug-85 PM-215 Personal Property Custody Card Cant A,B 1700 2 Oct-72 PM-215 Personal Property Loan Agreement Sht A,B 1480 2 Jan-80 A-109 Personnel Security Action Request Sht A 5700 33H Aug-86 EN-342 Pesticide Enforcement Cooperative Agreement Sht A 8550 5 Feb-79 TS-768 Pesticide Incident Report Sht A * 8570 30 Jan-89 H7502C Pesticide Registration Maintenance Fee Filing Set C 8500 6 Nov-72 TS-768 Pesticide Sample Record Card A 3540 16 Jan-85 EN-342 Pesticides Report for Pesticide-Producing Set C Establishments 5160 2 Apr-73 PM-215 Physician’s Statement in Support of Handicap Sht A,B Parking 7520 14 Mar-84 WH-550 Plugging and Abandonment Record Sht A 3150 3A Jan-77 PM-212 Position Classification Survey Sht C 3100 16 Jun-80 PM-212 Position Control Transmittal Sht A,B * 3150 1 Feb-87 PM-212 Position Description Sht A,B 3150 22 Aug-79 PM-212 Position Description (Factor Evaluation System) Pam A,B 3150 5 Sep-73 PM-212 Position Description Amendment Sht A,B 3150 27 Jan-84 PM-212 Position Description for Regional Nonsupervisory Pam A 2-Grade-Interval Program/StaffiTechnical Positions 3150 29 Feb-84 PM-212 Position Description for Regional Nonsupervisory Pam A Nonprofessional Program/Stafffrechnical Positions 3150 11 Sep-75 PM-212 Position Description for Regional Nonsupervisory Pam A Professional Program/S tafffFechnical Positions 3150 28 May-84 PM-212 Position Description for Regional Nonsupervisory Pam A Professional Program/Staff [ Fechnical Positions 3150 16 Dec-79 PM-212 Position Description for Supervisors of Pam A,B 2-Grade-Interval Positions 1320 3A Feb-81 PM-215 Postal Card--Contractor’s 4th Class Card C 7500 35B 22-May TS-799 Postcard/Preliminary Assessment Information Card C 2070 12 Jul-81 OS-240 Potential Hazardous Waste Preliminary Assessment Pam C 2070 14 Jul-81 OS-240 Potential Hazardous Waste Site Current Disposition Pam C 2070 11 Jul-81 OS-240 Potential Hazardous Waste Site Identification Sht C 2070 13 Jul-81 OS-240 Potential Hazardous Waste Site--Site Inspection Pam C Report 5700 30 Nov-86 PM-216 Preapplication for Federal Assistance Pam A * Form available in electronic format. Contact the Forms Office for more information. 31 ------- Alphabetical List of EPA Forms Date of Con- Current struc- Form No. Edition Originator Title tion Stock * 4700 4 Nov-86 A-lOS Preaward Compliance Review Report for Slit A Wastewater Treatment Construction Grants 1335 5 Feb-71 PM-211D Printing Specification Sheet Sht C 3100 17 Jan-84 PM-212 Probationary Period Certification Set D 4920 12 Feb-84 PM-215 Procedure in Case of Theft or Accident Sht C 1900 8 Sep-86 PM-214 Procurement Request/Requisition Set A,B 1900 8A Apr-84 PM-214 Procurement Request/Requisition (Continuation) Set A,B 5700 48 May-84 PM-216 Procurement System Certification Sht A * 8580 4 May-88 H7505C Product Specific DataReport Sht C 1900 2 Dec-81 PM-214 Profit/Fee Objectives Sht A, B 2800 9 Jan-80 OS-340 Program Change Set C 3140 24A Jul-83 PM-214 Project Officer Certificate (Interim Appointment) Sht D 3140 28 Feb-86 PM-214 Project Officer Certification Program (Basic Course) Sht C 3140 27 Feb-86 PM-214 tOfficer Certification Program Sht C (Contract Administration Course) 2550 19 Oct-85 PM-226 Project Officer Invoice Approval Set D 1900 27 Apr-84 PM-214 Project Officers Evaluation of Contractor Set A,B Performance * 2550 21 Nov-88 PM-226 Project Officers Interagency Agreement Invoice Set D Approval 1740 10 Aug-72 PM-215 Property Action Request and Memorandum Receipt Set A,B 1700 9 Jun-84 PM-215 Property Pass Set C 1700 7 Oct-74 PM-215 Property Receipt and Transfer Document Set A$ 1900 61 Feb-84 PM-2 14 Proposal Technical Evaluation Sht A,B 2340 1 Apr-84 PM-215 Publication Review/Printing Request Set A,B 2360 2 Dec-73 PM-215 Publications Distribution Reconl Slit C 1540 12 Aug-79 A-107 Publications Grid for 4 x 9 Slit C 1540 13 Aug-79 A-107 Publications Grid for 5-5/8 x 8-3/4 Sht C 2360 1 Feb-84 PM-215 Publications/Forms Request Set A,B 1900 66 Sep-86 PM-214 PuithaseOrderRecord (Small Purchases) Sht C 1900 44 Feb-79 PM-214 Purchase Order Register Sht C 1900 67 Sep-86 PM-214 PuithaseOrder/8ubcontmctRecord Sht C 6005 2 Jun-84 A-149 Quarterly MBE/WBE Consolidation Report Sht A 8710 13 Oct-82 OS-310 RCRA Confidential Business Information Slit C 8710 6 Oct-82 OS-310 RCRA Confidential Business Information Meeting Slit C Sign-in Sheet 8710 9 Oct-82 OS-310 RCRA Contractor Employee Confidentiality Sht C Agreement 3540 26 Mar-77 EN-342 Receipt for Pesticide Use/Misuse Inspection Set A 3540 3 Aug-75 EN-342 Receipt for Samples Set A 7740 10 Oct-85 TS-793 Receipt Log: TSCA CS! Sht A,B 1700 6 Jun-74 PM-215 Receiving Report Set A,B 3130 1 Nov-83 PM-2l2 Recommendation for Monetary Award Set A,B 1480 41 Jan-86 A-109 Record of Communication (Records Sht C Ch 3160 5 Apr-78 PM-212 Record of Excused Absence for Employee Sht A * 1480 47 May-87 PM-215 Record of Keys Issued Sht C 1900 37 Apr-85 PM-214 RecordofProcuitmentRequestReview Set A,B 2505 2 May-81 PM-226 Record of Public Funds Received Set A,B 5180 3 Jul-81 PM-215 Record of Registered and Certified Mail Sht C 1340 7 Feb-88 PM-21 1D Records Control Schedules Sht C 2410 23 Apr-80 PM-fl5 Regional Decision Unit Program Contract 4 &irant Sht A,B Dollar Allocations 2410 24 Apr-80 PM-225 Regional Decision Unit Work YearPmposal Sht A,B 2505 1 Jan-72 PM-226 Register of Collections Sht A,B * Form available in electronic format. Contact the Forms Office for more information. 32 ------- Alphabetical List of EPA Forms Date of Con- Current struc- Form No. Edition Originator Title tion Stock 2660 2 Mar-85 WH-556F Registration Record Sht C 2635 2 Aug-77 PM-226 Relocation Expenses Payment Record Set A,B 5100 4 Jun-81 PM-215 Relocation Worksheet Sht B 5100 4A Aug-82 PM-215 Relocation Worksheet Sht C 3540 5 May-76 EN-342 Report of Analysis Set A 3540 5A Oct-75 EN-342 Report of Analysis Continuation Set A 2720 10 Apr-82 EN-329 Report of Information Received Set C 2720 8 Mar-84 EN-329 Report of Interview Set A 2720 9 Mar-84 EN-329 Report of Investigation Set A 2720 15 Nov-84 A-109 Report of Investigation Sht A 2720 16 Jul-83 A-109 Report of Investigation Sht A 2720 14 Nov-84 A-109 Report of Investigation-Narrative Sht A 1480 38 Jul-81 PM-215 Report of Loss or Theft Set A,B * 1730 1 Sep-88 PM-215 Report of Nonexpendable Government Property Sht C Acquimd by Contractor 7500 8 Jul-80 WH-553 Report of Pollution-Caused Fish Kill Card C 2550 8 Jul-81 PM-226 Report of Reimbursable Services Rendered Set A,B 1740 12 Dec-82 PM-215 Reportof Survey Sht A,B 1440 6 Jun-84 PM-273 Report of Unhealthful or Unsafe Conditions Set A,B 2545 2 Mar-73 PM-226 Request and Receipt for Cash Advance Set A,B 2560 7 Jun-74 PM-226 Request for and Authorization of Overtime Work Set A,B 8710 5 Oct-82 OS-310 Request for Approval of Contractor Access to Sht C RCRA Confidential Business Information 1130 1 Nov-72 PM-213 Request for Approval of Nominees for Public Sht C Advisory Committees 8710 12 Oct-82 OS-3 10 Request for Approval of Temporary Employee for Sht C Access to RCRA CBI 1110 1 Jul-83 PM-213 Request for Change in Organization Structure Sht A,B 1900 7 Apr-85 PM-214 Request for Cost Analysis Sht A,B * 8500 23 May-88 H7502C Request for Document Center Services Set C 4920 8 Nov-83 PM-215 Request for EPA Driver Service Set C 1540 10 Jul-79 A-107 Request forEPA-Produced Videotape Sht C 1900 35 Jul-84 PM-214 Request f c c Equal Opportunity Clearance of Sht A,B Contract Award 3160 3 Nov-76 PM-212 Request for Flexible Hours Sht B * 1480 53 Dec-87 PM-2 15 Request for Lock Work Set C 1540 11 Jul-79 A-107 RequestforNon-EPA-Produced Videotape Sht C 1300 5 Jun-87 PM-211D Request for Reprint of Article Card A,B 1700 4 Nov-72 PM-215 Request for Shipping Service Set A,B 3155 1 Apr-77 LE-132 Request for Waiver of Claim for Erroneous Payment Sht A,B * 7710 9 Feb-88 H7502C Request for Word Processing Set C 1335 8 Aug-83 PM-211D Request/Receipt of Accountable Forms Set A,B * 2170 6 Feb-88 PM-21 1D Response to Request for Publication Card C 3160 2 Oct-82 PM-212 Restoration of Forfeited Annual Leave Sht A,B 3110 20 Sep-73 PM-212 Review of Employment of Experts and Consultants Sin A,B 2340 18 Mar-84 PM-215 Revised Estimate Can! C 3540 4 Aug-74 EN-342 Sample Record Jacket Folder A * 5180 4 Dec-87 PM-215 Sampled Mail Report Pam C 2505 3 Jan-72 PM-226 Schedule of Collections Sht A,B 1640 1 Jan-75 A-104 Section 309 Action Log Sht A,B 1480 7 Mar-80 A-109 Security File Review Sht C 1480 27 Feb-85 A-109 Security Investigation Review/Analysis Sht C 1480 19 Feb-74 A-109 Security Termination Statement Sht A,B 5130 1 Feb-79 PM-215 Self Service-Store Void Slip Set C 3110 35 Oct-79 PM-224 Senior Executive Service Vacancy Announcement Sht C * Form available in electronic format. Contact the Forms Office for more information. 33 ------- Alphabetical List of EPA Forms Date of Con- Current stoic- Form No. Edition Originator Title Lion Stock 3110 11 Aug-72 PM-212 Service Computation Date Worksheet Sht C 3115 21 Sep-79 PM-212 SES Staffing Request Sht A,B 8510 13 Aug-73 TS-768 Shipment of Specimens Cant C 1740 19 Apr-79 PM-215 Shipping and Receiving Record Cant C 8500 21 Feb-87 H7505C Silvex!2,4,5-T Products: Claim for Pam C Indemnification, Request for Federal Disposal 1740 18 Mar-77 PM-215 Simplified Stock Record Card A,B 7500 53 Sep-80 OS-200 SPCC Inspection Field Sheet Sht A 7500 52 Jun-80 OS-200 SPCC Inspection Summary Sheet Sht A 3130 10 Sep-88 PM-212 Special Achievement Award Sht A,B 1320 19 Feb-83 PM-215 Special Communications Env C 3115 16 Jun-75 PM-212 Special Consideration Referral Sht C 5180 13 May-79 PM-215 Special Fourth-Class Book Rate Label B 1320 8 Apr-73 PM-213 Special Mail Label Label A,B * 1480 52 Aug-87 PM-215 Special Order Sht C 8550 10 Jan-74 TS-793 Specimen Label Label C * 9510 2 Dec-88 05-120 SPMS and SCAP Report Fiscal Year 1989 Pam C 3115 4 Sep-84 PM-212 Staffing Requisition Sht A,B * 3720 10 Jul-87 PM-223 Start Action Request Sht C 3540 28 Apr-78 EN-342 State Inspector’s Credential Cant C * 2560 25 Oct-88 PM-226 Statement of EamingsandLeave Set A,C 1315 14 Aug-78 PM-213 Status of Pending Directives Sht C 1740 16 Feb-79 PM-215 Stock Recent Card B 1300 1 May-71 PM-211D Stock Reorder Notice Sht A,B 1700 3 Nov-73 PM-215 Storeroom Request and Issue Record Sht A,B 7500 22 Apr-77 WH-553 STORET User Handbook Error Discovery Card C Notification * 9510 1 Jul-88 OS-120 Substantiation To Accompany Claims of Trade Pam A,B Secrecy: Emergency Planning/Community Right-To-Know Act 2570 3 Dec-71 PM-226 Substitute Memorandum of US Transportation Cant A,B Request 3130 8 Jan-88 PM-212 Suggestion Award Certificate Sht A,B 3130 3 Apr-74 PM-212 Suggestion Record and Evaluation Set A 3110 21 Sep-73 PM-212 Summary of Review of Experts and Consultants Sht A,B * 6005 3 Sep-87 A-149 Superfund Minority Contractors Utilization Report Sht A * 6005 3A Sep-87 A-149 Supeifund Minority Contractors Utilization Sht A Report—Part 2 3140 20 Sep-78 PM-212 Supervisor’s Evaluation of EPA’s IPA Personnel Sht C Exchange Program 5160 3 Apr-73 PM-215 Supervisor’s Report in Support of Handicap Sht A,B Parking Assignment 1440 9 Jan-82 PM-273 Supervisor’s Report of Accident/illness Set A,B * 5180 5 Dec-87 PM-215 Supplemental Mail Report Pam C 3155 3 Jan-81 PM-212 Su lemental Pay for Non-Federal IPA Detailees Set A * 9100 1 Feb-88 OS-510 Technical Enforcement SupportatHazardous Set C Waste Sites 2220 1 Apr-77 PM-21 1D Technical Report Data Sht A,B 5020 2 Sep-79 PM-21 IT Telephone Key System Worksheet Sht C 7740 14 Oct-85 TS-793 Temporary Loan Receipt for TSCA CBI Set A,B * 3115 3C Nov-86 PM-212 Temporary Vacancy Announcement Sht A,B 5040 4 Nov-81 PM-21 iT Terminating Traffic Log Sht A,B 1900 64 Jul-84 PM-214 Termination Settlement Memorandum of Cant C Transmittal and Checklist 1300 19 Feb-83 PM-2111) ThingsToDoToday Sht A,B * Form available in electronic format Cont t the Forms Office for more information. 34 ------- Alphabetical List of EPA Forms Date of Con- Current struc- Form No. Edition Originator Title tion Stock 7710 30 Sep-79 H7502C Time Accounting Information System Record Set B 2565 1 Jan-84 PM-226 Time and Attendance Card Card D 2565 2 Jan-84 PM-226 Time and Attendance Card (Salmon) Card A,B 2565 3 Jan-84 PM-226 Time and Attendance Card (Yellow) Can! A,B 2560 12 Jul-74 PM-226 Time and Attendance Chargeout Card Card C 2560 1 Oct-71 PM-226 Timekeeper Signature Card Can! A,B 7710 34 Sep-79 TS-793 Trade Name Product Identity Report Sht C 2130 1 Oct-77 PM-211D Translation Service Request Sht A,B 1315 12 Jul-82 PM-213 Transmittal Sht A 2610 1 Oct-81 PM-226 Travel Authorization Set A,B 2570 6 Dec-80 PM-226 Treasury Financial Communication System Card A,B (TFLS) Ticket 7740 15 Oct-85 TS-793 TSCA CBI Meeting Sign-in Sheet Sht A,B 7740 13 Oct-85 TS-793 TSCA CBI Visitors Log Sht A,B 7740 9 Oct-85 TS-793 TSCA Confidential Business Information Can! A,B (Cover Sheet) 7740 2 Dec-82 EN-342 TSCA Declaration of CBI Set A 7740 4 Dec-82 EN-342 TSCA Inspection Confidentiality Notice Set A 7710 3C Nov-77 TS-788 TSCA Inventory Report Form C Set D 7710 3D Nov-77 TS-788 TSCA Inventory Report Form D Set D 7740 5 Mar-83 EN-342 TSCA Investigation Summary Set A 7740 3 Dec-82 EN-342 TSCA Notice of Inspection Set A 7740 1 Dec-82 EN-342 TSCA Receipt for Samples and Documents Set A 1320 18 Feb-83 LE-131 Typing Instruction Sheet Sht C 5180 8 May-76 PM-215 U.S. Government Shipment Label Label A,B * 7520 1 Jan-88 WH-550E UIC Federal Reporting System Part I: Permit Set A Review and Issuance /Wells in Area of Review 7520 6 Feb-84 WH-550 Underground Injection Control Permit Application Sht A 8700 22 Sep-86 OS-340 Uniform Hazardous Waste Manifest Sht C 8700 22A Sep-86 OS-340 Uniform Hazardous Waste Manifest (Continuation) Sht C 3500 5 Dec-80 EN-397 Unleaded Gasoline Field Inspection Set A 3140 11 Jul-76 PM-212 Upward Mobility Trainee Evaluation Sht C 8510 88 Nov-80 TS-793 Urine Pesticide Residue Analysis Report (APM) Sht C 8510 8A Nov-80 TS-793 Urine Pesticide Residue Analysis Report (MPM) Sht C 3540 20 Apr-75 EN-342 Use Investigation Report Set A 8710 2 Oct-82 OS-340 User Sign-Out Log (RCRA CBI) Sht C 3110 38 May-84 PM-212 Vacancy Announcement Sht C 1300 24 Mar-85 PM-21 1D Vacation and Training Schedule Sht A,B 2545 1 Nov-71 PM-226 Verification of Imprest Fund Sht A,B 1710 3A Jun-77 A-107 Videotape Label (30 Minutes) Label C 1710 3B Jun-77 A-107 Videotape Label (60 Minutes) Label C * 1480 45 May-87 PM-215 Visitor and Employee Sign-in Register Sht C 1340 1 Mar-82 PM-211D Vital Records Transmittal Sht A,B 3100 14 May-80 PM-212 Volunteer Service Program Participation Agreement Sht A 1700 8 Nov-80 A-135 Voucher for Payment and Release Sht C 1740 17 Aug-81 PM-215 Voucher Register Sht A,B * 5020 1 Jun-88 PM-21 iT Washington Telecommunications Service Request Sht B 2800 17 May-80 OS-340 Waste Definition Maintenance Form Sht C 1900 41C Dec-78 PM-218 WCC Quarterly Performance Report Sht C 7520 12 Feb-84 WH-550 Well Rework Record Sht A 3720 1OA Mar-79 PM-223 Workgnup Membership Invitation Sht C 1900 51 Apr-85 PM-214 Worksheet for Order for Services Sht C 1900 13 Apr-85 PM-214 Worksheet for Small Purchases Sht A,B * Form available in electronic format. Contact the Forms Office for more information. 35 ------- List of EPA Forms by Function Con- struc- Form No. Edition Originator Title tion Advise 2720 2720 2720 Sht C Sht C Sht C 20B Nov-86 PM-216 6 Jun-73 PM-216 1 Dec-86 PM-226 3300 1 Aug-77 LE-130 Assistance Amendment Fellowship Amendment Employee Application for Reimbursement of Expenses Application for Certification of Pollution Control Facility Shi A Sht A Sht A,B Set A * These fonns are available in electronic format. Contact the Forms Office for more information. Date of Current Stock 5110 8500 8700 I May-73 14 Oct-77 12A Apr-80 18 Oct-84 20A Oct-84 20B Oct-84 PM-215 TS-768 OS-340 A-109 A- 109 A-109 Agree * 1610 1700 3100 1 2 1 Oct-88 Oct-72 Feb-81 PM-216 PM-215 PM-212 Acknowledge 1400 1 Feb-84 PM-215 Credential Acknowledgement Statement Sht A * 1550 2 Apr-87 A-1O1 FOIA Request Acknowledgement Card C * 1550 3 Jun-87 A-101 FOl Request Acknowledgement (Regions) Card A 1550 4 Jul-81 A-101 Acknowledgement Receipt for FOl Appeal Card C 2620 3 Jul-85 PM-226 Employee Acknowledgement of Diners Club Credit Card Program Set C 3510 3A Dec-80 OS-340 Acknowledgement of Application for a Hazardous Waste Permit EPA Identification Card Acknowledgement OPP Comment Acknowledgement Acknowledgement of Notification of Hazardous Waste Activity Card Card Card Env C A C C Advice of Rights for a Federal Employee Advice of Rights Advice of Rights Interagency Agreement Personal Property Loan Agreement Agreement To Remain in the Government Service Pain Sht Set A,B A,B C Sht A * 3115 24 Aug-87 PM-212 Pam A,B 5700 20A May-82 PM-216 Pam A,B 5700 20C Feb-86 PM-216 Set A 5700 33H Aug-86 EN-342 Sht A 5770 8 Jul-73 PM-216 Shi A 7710 19 Sep-81 TS-793 Sht A,B Sht A,B Set A,B Shi C Sht C Sht C 3100 14 May-80 PM-212 Volunteer Service Program Participation Agreement Performance Agreement, Appraisal, and Certification Assistance Agreement/Amendment EPA Assistance Agreement/Amendment Pesticide Enforcement Cooperative Agreement Fellowship Agreement Confidentiality Agreement--TSCA Contractor Employee * 7740 6A Oct-88 TS-793 Federal TSCA CBI Access Request, Agreement, & Approval: Contractor/ Subcontractor Employee 7740 16 Oct-85 TS-793 Confidentiality Agreement for US Employees Upon Relinquishing TSCA CBI Access Authority 8710 9 Oct-82 OS-310 RCRA Contractor Employee Confidentiality Agreement 8710 10 Oct-82 OS-310 Confidentiality Agreement for US Employees Upon Terminationlrransfer 8710 14 Oct-82 OS-310 Confidentiality Agreement for Contractor Employees Upon Termination/Transfer Amend 5700 5770 Apply * 2620 36 ------- List of EPA Forms by Function Date of Con- Current struc- Form No. Edition Originator Title lion Stock Apply (Continued) 3510 1 Oct-80 EN-336 General Information Consolidated Permits Pam A Program (Form 1) 3510 2B Jun-80 EN-336 Application for Permit To Discharge Sht A Wastewaler (Form 2B) 3510 2C Feb-85 EN-336 Application for Permit To Discharge Pam A Wastewater (Form 2C) 3510 2D Sep-86 EN-336 Application Form 2D-New Sources & New Pam A Dischargers: Application for Permit To Discharge Process Waste 3510 2E Sep-86 EN-336 Application Fonn 2E--Faciities Which Do Not Pam A Discharge Process Wastewater 3510 3 Jun-80 OS-320 Application for Hazardous Waste Permit Pam A * 3520 1 Sep-88 EN-340 Importation of Motor Vehicles and Motor Sht A,D Vehicle Engines Subject to Federal Air Pollution Regulations * 3520 8 Jul-88 EN-340 Application for Final Admission of Sht C Nonconforming Imported Vehicle * 3520 8A Jul-88 EN-MO Continuation of Application for Final Sht C Admission of Nonconforming Imported Vehicle * 3520 9 Jul-88 EN-MO Application for Final Admission of a Catalytic Sht C Converter and Oxygen Sensor Equipped Vehicle * 3540 8 Nov-88 EN-342 Application for Registration of Pesticide- Set C Producing Establishment 4920 1 Sep-78 PM-215 Application for Motor Vehicle Operator’s Sht A,B License * 5130 3 Aug-87 PM-215 Application for EPA Supply Store Shopping Card B Plate 5160 1 Apr-77 PM-215 Parking Permit Application Sht A,B 5700 7B May-87 PM-216 Application Kit for Assistance (Planning or Folder A Program Assistance) 5700 7C May-80 PM-216 Application Kit for Assistance (Fellowship) Folder A 5700 7D May-80 PM-216 Application Kit for Assistance (Training) Folder A 5700 7E Aug-80 PM-216 Application Kit for Assistance (Research) Folder A 5700 12 Apr-78 PM-216 Application for Federal Assistance Pam A 5700 30 Nov-86 PM-216 Preapplication for Federal Assistance Pam A 5700 31 Oct-79 PM-2l6 Application for Federal Assistance (Short Form) Pam A 5700 33 Nov-86 PM-216 Application for Federal Assistance Pam A 5720 12 Sep-85 PM-216 Application for Federal Assistance Pam A (Construction Grant (Cooperative Agreements) 5770 2 Apr-78 PM-216 Fellowship Application Pam C 7520 6 Feb-84 WH-550 Underground Injection Control Permit Sht A Application 7520 7 Feb-84 WH-550 Application To Transfer Permit Sht A 7550 6 Jan-73 EN-336 NPDES--Application for Permit To Discharge Sht A (Form A) 7550 8 Mar-74 EN-336 NPDES Application for Permit To Sht A Discharge (Form C) 7550 9 May-73 EN-336 NPDES-Application for Permit To Sht A Discharge (Form D) 7550 22 Jul-73 EN-336 NPDES-Application for Permit To Discharge Pam A Wastewater (Form A) 7550 23 Jul-73 EN-336 NPDES -Application for Permit To Discharge Pam A Wastewater (Form C) * 8570 1 Sep-88 H7505C Application for Pesticide Set C AmendmentlRegistration * These forms are available in electronic format. Contact the Forms Office for more information. 37 ------- List of EPA Forms by Function Date of Current Form No. Edition Originator Title H7505C Application for Supplemental Registration of Distributor Application for an Experimental Use Permit Application for/Notification of State Registration of a Pesticide To Meet a Special Local Need Application for Reimbursement to Local Governments for Emergency Response Assign 1900 4 Jun-71 PM-214 1900 5 Jun-71 PM-214 2720 1 Apr-80 A-109 4920 4 Sep-80 PM-215 Assignee’s Assignment of Refunds, Rebates, Credits, and Other Amounts Contractor’s Assignment of Refunds, Rebates, and Credits Investigative Control and Assignment Record Motor Pool Assignment Set A,B Set A,B Set A Sht C Apply (Continued) 8570 5 Apr-83 * 8570 17 * 8570 25 Feb-85 H7505C Dec-87 H7505C * 9310 1 Oct-87 OS-210 Approve 1480 40 2550 19 * 2550 21 2560 4 2610 1 3540 9 Feb-84 Oct-85 Nov-88 Jul-81 Oct-81 Nov-77 Con- struc- tion Stock Set C Set C Set A Pam A Set A,B Set D Set D Sht A,B Set A,B Sht A Sht A,B Sht C A-109 PM-226 PM-226 PM-226 PM-226 EN-342 Authority for Release of Information Project Officer Invoice Approval Project Officer’s interagency Agreement Invoice Approval Authorization for Mailing Pay Checks Travel Authorization Authorization To Administer Oaths, Affidavits, and Affirmations Clearance of Foreign Researeh Award Authorization for Access to RCRA CBI 4540 1 Mar-82 A-106 8710 11 Oct-82 OS-310 Bill 1550 11 May-81 H7502C FOl Invoice Set C 2505 4 Sep-73 PM-226 Bill for Collection Set A,B 4700 14 May-84 A-lOS EEO Complaint Invoice Set C Certify 3100 17 Jan-84 PM-212 Probationary Period Certification Set D 3110 17 Aug-73 PM-212 Consultant Certificate Sht A,B 3110 18 Aug-73 PM-212 ExpeitCertificate Sht A,B 3115 8 Sep-84 PM-212 Merit Promotion Certificate Sht A,B 3115 8A Sep-84 PM-212 Merit Promotion Certificate (Continuation) Sht A,B 3115 8C Sep-84 PM-212 Noncomperitive Candidate Referral Certificate Sht A,B 3115 8D Oct-84 PM-212 Certificate for Upward Mobility Sht A,B * 3115 8E Nov-86 PM-212 Candidate Referral Certificate: Temporary Position Sht A,B 3130 4 Jul-82 PM-212 CeilificateofApproval for Payment of Suggestion Award Certificate of Completion of Training Length of Service Certificate --10 Years Length of Service Certificate— 20 Years Length of Service Certificate --30 Years Length of Service Certificate --40 Years Suggestion Award Certificate Certificate of Retirement Special Achievement Award Sht A,B A,B A,B AB A,B A$ A,B A ,B A,B * These forms are available in electronic format. Cont t the Forms Office for more information. 3130 6 3130 7A 3130 lB 3130 7C 3130 7D 3130 8 3130 9 3130 10 Jan-73 Jul-86 Jul-86 Jul-86 Jul-86 Jan-88 Jan-88 SepS PM-212 PM-212 PM-212 PM-212 PM-212 PM-212 PM-212 PM-212 Card Sht Sht Sht Sht Sht Sht Sht 38 ------- List of EPA Forms by Function Date of Con- Current struc- Form No. Edition Originator Title tion Stock Certify (Continued) 3140 24A Jul-83 PM-214 Project Officer Certificate (Interim Sht D Appointment) 3140 27 Feb-86 PM-214 Project Officer Certification Program (Contract Sht C Administration Course) 3140 28 Feb-86 PM-214 Project Officer Certification Program Sht C (Basic Course) 3160 2 Oct-82 PM-212 Restoration of Forfeited Annual Leave Sht A,B 3540 11 Dec-76 EN-342 Affidavit Sht A 5700 48 May-84 PM-216 Procurement System Certification Sht A * 5700 49 Nov-88 PM-216 Certification Regarding Debarment, Pam A$ Suspension, and Other Responsibility Matters 5770 5 May-78 PM-216 Agency Fellowship Certificate Sht C 8570 28 Oct-86 H7505C Certification of Compliance with Data Gap Set C Pmcedmts 8570 29 Jul-86 H7505C Certification with Respect to Citation of Data Set C 8580 6 Oct-82 H7505C Certificate of Attempt To Enter into an Sht C Agreement with Other Registrants for Development of Data Claim 1900 10 Nov-76 PM-214 Contractor’s Cumulative Claim and Sht A,B Reconciliation 2800 15 Apr-80 OS-340 Confidentiality Claim Sht C 8500 21 Feb-87 H7505C Silvex/2,4,5-T Products: Claim for Pam C Indemnification, Request for Federal Disposal * 8500 22 Jan-89 H7502C Dinoseb Products: Claim for Indemnification, Pam C Request for Federal Disposal Confirm * 5040 9 Feb-88 PM-21 IT Confirmation of Teleconference Schedule Set C Contract 1900 56 Apr-85 PM-214 Letter Contract for State/Local Government Pam C Response to Emergency Hazardous Substance Release Cover 7740 9 Oct-85 TS-793 TSCA Confidential Business Information Card A,.B (Cover Sheet) Declare 7740 2 Dec-82 EN-342 TSCA Declaration of CBI Set A 8570 27 Oct-86 H7505C Formulator’s Exemption Statement Set C Describe * 3150 1 Feb-87 PM-212 Position Description Sht A,B 3150 11 Sep-75 PM-212 Position Description for Regional Pam A Nonsupervisory Professional Program/Staff! Technical Positions 3150 16 Dec-79 PM-212 Position Description for Supervisors of Pam A,B Two-Grade-Interval Positions 3150 22 Aug-79 PM-212 Position Description (Factor Evaluation Pam A$ System) * These forms are available in electronic format. Contact the Forms Office for more information. 39 ------- List of EPA Forms by Function Date of Con- Current struc- Form No. Edition Originator Title lion Stock Describe (Continued) 3150 27 Jan-84 PM-212 Position Description for Regional Pam A Nonsupervisory 2-Grade-Interval Program/ StaffiTechmcal Positions 3150 28 May-84 PM-212 Position Description for Regional Pam A Nonsupervisory Professional PmgranilStaff/ Technical Positions 3150 29 Feb-84 PM-212 Position Description for Regional Pam A Nonsupervisory Nonprofessional Program! StaWFechnical Positions Designate 1900 65 Jun-85 PM-214 Designation & Appointment of Project Set A,B Officer/Work Assignment Manager/Delivery 2505 5 Mar-76 PM-226 Collection Officer Designation Cani A$ Determine 1900 53 Apr-84 PM-214 Determination and Findings: Authorization Sht C To Use a Time and Materials Contract 1900 57 Apr-84 PM-214 Determination and Findings: Method of Sht C Contracting 1900 62 Feb-84 PM-214 Determination and Findings: Authority Sht C To Use a Letter Contract 3115 31 Sep-84 PM-212 Basic Qualifications Determination Worksheet Sht A,B Display 1320 3 Mar-84 PM-215 Mailing Label Label B 1320 3A Feb-81 PM-215 PostalCard--Contractor ’s4th Class Cani C 1320 3B Feb-Si PM-215 EGD Contractor’s 4th Class Mailing Label Label C 1320 5 Jan-78 PM-215 EPA Postcard (Headquarteis) Card C 1320 5A Jun-82 PM-215 EPA Postcard (Field Elements) Card A 1320 8 Apr-73 PM-213 Special Mail Label Label A$ 5180 8 May-76 PM-215 U.S. Government Shipment Label Label A,B 5180 11 May-79 PM-215 Mail Label - First Class Label B 5180 12 May-79 PM-215 Mail Label - Third Class Label B 5180 13 May-79 PM-215 Special Fourth-Class Book Rate Label B 5180 14 May-79 PM-215 Mail Label - Fourth Class Label B 5180 15 May-79 PM-215 Mail Label - Third-Class Bulk Label B 5180 16 Jan-80 PM-215 Business Reply Label Label C Distribute 2550 6 Mar-80 PM-226 Distribution of Payroll Charges Set A,B Estimate 7510 1 Jun-81 WH-595 Estimate of Municipal Waslewater Treatment Sht D Facilities Evaluate 1900 26 Apr-85 PM-214 ContractingOfficer ’sEvaluationofContractor Set A,B Peifonnance 2070 12 Jul-81 OS-240 PoientialHazardousWastePreliininary Pam C Assessment 3115 14 Sep-84 PM-212 Merit Promotion Application Rating Sheet Sht A ,B 3115 17 Oct-84 PM-212 Interview Rating Sheet for Upward Mobility Sht C Positions * These forms are available in electronic format Contact the Forms Office for more infonnation. 40 ------- List of EPA Forms by Function Date of Con- Current struc- Form No. Edition Originator Title tion Stock Evaluate (Continued) 3115 18 Oct-84 PM-212 Job Element Rating Sheet for Upward Sht C Mobility Positions 3115 22 Oct-84 PM-212 Appraisal of Other Characteristics Needed for Sht A Upward Mobility 3115 29 Sep-84 PM-212 Cumulative Merit Promotion Evaluation Sheet Sht A,B * 7500 55 Jan-89 EN-338 NPDES Laboratory Performance Evaluation Pam D * 7520 2A Jan-88 WH-550E Part II: Compliance Evaluation Set A Guide 1320 2 Apr-77 A-101 Correspondence Signature Tab Card A,B 1540 9 Oct-81 A-107 8 1/2 X 11 Layout Sheet Sht A,B 1540 12 Aug-79 A-107 Publications Grid for4X9 Sht C 1540 13 Aug-79 A-107 Publications Grid for 5-5/8 X 8-3/4 Sht C 1540 14 Aug-79 A-107 LeafletGrid Sht C 1900 34 Apr-83 PM-2 14 Guide for Preparation of Contractor’s Claims Pam A,B 1900 34A Apr-83 PM-214 Guide for Preparation of Contractor’s Claim Pam A,B Identify 1305 4 Apr-72 PM-215 Official US Government Identification Card C 1320 9 Apr-74 A-l01 OA Priority Correspondence Folder Folder C 1335 17 Apr-83 PM-215 Forms/Publications Shipping Label Label C 1345 1 Mar-81 H7505C Jacket Locator Card Card C * 1480 33 Feb-88 PM-215 EPA Headquarters Building Pass Card C 1480 39 Dec-82 PM-215 Official US Government Identification Card C * 1480 43 May-88 EN-397F Inspector’s Credential Card C * 1480 55 May-88 EN-342 AARP Inspector’s Credential Card C 1700 9 Jun-84 PM-215 Property Pass Set C 1710 3A Jun-77 A-107 VideotapeLabel (30 Minutes) Label C 1710 3B Jun-77 A-107 Videotape Label (60 Minutes) Label C 2070 11 Jul-81 OS-240 Potential Hazardous Waste Site Identification Sht C 2720 17 Nov-84 A-109 Investigation Cover Sheet Sht A 3540 24 Apr-78 EN-342 EPA Inspector’s Credential Card C 3540 28 Apr-78 EN-342 State Inspector’s Credential Card C 3540 30 Dec-80 EN-342 Contractor’s Credential Cani C 3540 31 Oct-85 EN-342 Inspector’s Credential Card C 5040 8 Apr-78 PM-211T Message for Transmission Sht A,B 7500 2 Jul-75 EN-342 Official Sample Seal Label A 7500 58 Feb-84 WH-556F Analysis Identification Tag Tag C 7710 31 Oct-79 TS-793 Frozen Medical Specimen Label Label C 7710 33 Oct-79 TS-793 Dry Ice/Hazardous Material Label Label C 8510 13 Aug-73 TS-768 Shipment of Specimens Cant C 8550 10 Jan-74 TS-793 Specimen Label Label C 8710 13 Oct-82 OS-310 RCRA Confidential Business Information Sht C Index 7710 22 Nov-78 TS-793 Library Request Index Can! C Initiate * 9100 1 Feb-88 OS-510 Technical Enfoivement Support at Hazardous Set C Waste Sites Inquire 3150 3A Jan-77 PM-212 Position Classification Survey Sht C 3340 2 Aug-72 LE-132 Invention Rights Questionaire Set C 5770 4 Feb-77 PM-216 Fellowship Applicant Qualifications Inquiry Sht C * These forms are available in electronic format. Contact the Forms Office for more information. 41 ------- * These forms are available in electronic format. Contact the Forms Office for more information. Title List of EPA Forms by Function Date of Current Form No. Edition Originator Invite 3720 IOA Mar-79 PM-223 Workgroup Membership Invitation Mail * 5180 18 Aug-88 PM-215 Custom Designed Mail Special Envelope Notify 1315 12 Jul-82 PM-213 Transmittal 1130 3 Jan-81 PM-213 Notification of Advisory Committee Meeting 1300 1 May-71 PM-21 1D Stock Reorder Notice 1315 11 May-86 1315 12A May-86 * 1480 52 Aug-87 1550 5 May-79 1700 1 Jun-81 1900 49 Apr-85 Con- struc- tion Stock Sht C Env A,B Sht A Set C Sht A,B PM-213 PM-213 PM-215 A-107 PM-215 PM-214 PM-214 PM-214 PM-215 PM-215 PM-225 PM-226 PM-226 PM-226 PM-226 PM-226 PM-226 PM-226 PM-226 A-109 A-109 1900 58 190060 2340 17 2340 18 2410 23 25001 2550 9 2560 2 2560 8 2560 12 2560 17 * 2560 25 2610 2 2720 2 2720 19 Apr-84 Feb-84 Jul-84 Mar-84 A pr-80 Apr-77 Apr-74 Nov-86 Jan-75 jul-74 Jul-75 Oct-88 Jan-83 May-83 Oct-84 Sht Sht Sht Sht Sht Pam Sht Sht Set Cad Sht Set Sht Set Labul Cad Sht Set Set Sht Sht A B C C A B C C A,B C C A A B A B A,B A B C A A,C A C 3110 35 Oct-79 PM-224 Notice EPA Order S Order EPA Journal Subscription Notice Notification of Designation of Shipping Officer Notice To Proceed with Emergency Response to Hamrdous Substance Release Notice Reganling Work Stoppage Announcement of Contract Award Notice of Pending Delivery/Shipment Revised Estimate Regional Decision Unit Program Contract/ Grant Dollar Allocations Notice of Administrative Exception Commitment Notice Payroll Error Notice Payroll Special Label Time and Attendance Chargeout Card Payroll Commitment Adjustment Notice Statement of Earnings and Leave Notice of Leave To Be Charged While on Travel Notice of Scheduled Investigation Notice to a Federal Employee: Duty To Respond to Questions Senior Executive Service Vacancy Announcement Vacancy Announcement Merit Promotion Announcement Merit Promotion Vacancy Announcement (Upward Mobility) Temporary Vacancy Announcement Career Management System Vacancy Announcement Nonstatus Candidate Referral List Special Consideration Referral Merit Promotion Program Vacancy Announcement Results Classification Appeal Decision Notice of State Certificate Notice of Federal Certification Notice of Violation of Section 211 of the Clean Air Act Notice of Arrival of Pesticides and Devices Notice of Inspection 3110 38 * 3115 3 3115 3A May-84 Nov-86 Oct-84 PM-212 PM-212 PM-212 * 3115 3C Nov-86 PM-212 * 3115 3D Nov-86 PM-224 3115 SB 3115 16 3115 20 3150 26 3300 2 3300 3 * 3520 7 Sht C Sht C Sht A,B Stit C Sht A,B Sht A,B Sht A, B Sht C Stir C Sep4 Jun-75 Apr-77 Jun-81 Aug-77 Aug-77 Sep- Wi PM-212 PM-212 PM-2l2 PM-212 LE-130 LE-130 EN-397F 3540 1 May-77 EN-342 3540 2 Mar-77 EN-342 Sht Set Set Set C A A C Set A Set A 42 ------- List of EPA Forms by Function Date of Con- Current struc- Form No. Edition Originator Title tion Stock Notify (Continued) * 3540 8A Nov-88 EN-342 Notification of Registration of Pesticide- Sht C Producing Establishments 3540 25 Mar-77 EN-342 Notice of Pesticide Use/Misuse Inspection Set A 3540 27 Mar-77 EN-342 Notice of Stop Sale, Use, or Removal Order Label A 3560 4 Feb-80 EN-338 Deficiency Notice Set A 4510 2 Dec-77 A-106 International Visitor(s) Aiert Sht C * 4850 3 Aug-87 PM-215 Fume Hood Certification Label B 4920 12 Feb-84 PM-215 Procedure in Case of Theft or Accident Sht C * 4920 15 May-88 PM-215 Parking Violation Set C 5200 2 May-83 A-1Q2 Legislative Alert Sht C 5700 42 Feb-85 PM-216 Grant Record Adjustment Notice Set C * 5720 4 May-87 A-lOS Labor Standards Provisions for Federal & Pam A,B Federally Assisted Contracts 5770 7 Jun-73 PM-216 EPA Fellowship Activation Notice Set A 5770 9 Jul-73 PM-216 EPA Fellowship Termination Notice Sht A 7500 22 Apr-77 WH-553 STORET User Handbook Error Discovery Cant C Notification 7530 1 Sep-88 OS-420 Notification for Underground Storage Tanks Pam C 7730 2 Jun-82 TS-794 A Guide for Reducing Asbestos Exposure Sht C 7730 3 Jun-82 TS-794 Notice to School Employees Sht C 7730 4 Jan-85 PM-273 Notice to EPA Employees Sht C 7740 3 Dec-82 EN-342 TSCA Notice of Inspection Set A 7740 4 Dec-82 EN-342 TSCA Inspection Confidentiality Notice Set A 8570 6 May-76 H7505C Notice of Registration Set C 8700 12 Oct-88 OS-340 Notification of Hazardous Waste Activity Pam A Obligate 2550 10 Jul-80 PM-226 Miscellaneous Obligation Document Sht A,B Plan 2410 9A Jun-83 PM-214 Contract Planning Submission Annual Plan Sht A,B * 3140 29 Jul-87 PM-224 Career Management System Pam A 4550 5 Jun-81 A-106 International Travel Plan Set A$ 5100 4 Jun-81 PM-215 Relocation Worksheet Sht B Receipt 1550 6 Apr-80 H7502C FOl Case Receipt Log Sht C 1700 7 Oct-74 PM-215 Property Receipt and Transfer Document Set A,B 2800 8 Dec-79 OS-340 Application Receiptand Acceptance Sht C 3540 3 Aug-75 EN-342 Receipt for Samples Set A 3540 26 Mar-77 EN-342 Receipt for Pesticide Use/Misuse Inspection Set A 7740 1 Dec-82 EN-342 TSCA Receipt for Samples and Documents Set A 7740 14 Oct-85 TS-793 Temporary Loan Receipt for TSCA CBI Set A$ Recommend 2410 24 Apr-80 PM-225 Regional Decision Unit Work Year Proposal Sht A,B 3130 1 Nov-83 PM-212 Recommendation for Monetary Award Set A,B 3130 2 Dec-77 PM-212 Employee Suggestion Form Sht A Record 2550 5 Mar-72 PM-226 Paid Purchase Order Register Sht C 2560 6 Jun-74 PM-226 Authorized Compensatory Time Record Sht A,B 1130 4 Feb-84 PM-213 Committee Inventory Record Sht C 1300 2 Jun-71 PM-223 Clearance Record Sht A,B 1300 11 Apr-81 TS-793 011 Document Clearance Form Sht C * These forms are available in electronic format. Contact the Forms Office for more information. 43 ------- List of EPA Forms by Function Date of Current Form No. Edition Originator Title Con- struc- tion Sin Sht Sht Card Sht Sht Sin Sht Set sin Set Slit Sht Pam Pad Sht Slit Slit Card Sht Slit Sin Slit Pad Sht Sht Sht Sin Sin Slit Sht Sht Slit Sin Slit Card Sin Card cad Card Sht Sht Set Sht Set Sht Stock A,B A$ C C A$ C A B C C C C C C A,$ C C C C C C C C C C C C C A A B C C A A,B B A,B A,B C A B A,B A B A B A B A,B A B A Record (Continued) 1300 19 Feb-83 PM-211D Things To Do Today 1300 1315 24 Mar-85 4 Aug-86 PM-211D PM-213 Vacation andTraining Schedule Checklist of EPA Transmittals 1315 10 Dec-79 PM-213 Directive Number Assignment 1315 14 Aug-78 PM-213 States of Pending Directives 1315 1315 1320 1320 1320 16 Feb-89 16A Dec-83 1 Dec-70 1 Dec-70 11 Jul-83 PM-213 PM-213 PM-211D PM-215 A-101 Clearance/Approval Record Clearance/Approval Record (Continuation) Concurrence Sheet (Official File Copy) Concurrence Sheet (Official File Copy) Executive Communications Transmittal * 1325 4 Jan-87 PM-223 Clearance Control 1335 4 Nov-80 PM-211D Forms Number Assignment Sheet 1335 1335 5 Feb-71 9 Sep-85 PM-21 1D PM-211D Printing Specification Sheet Forms Distribution Guide 1335 18 Sep-83 PM-211D Form Approval 1340 4 Nov-78 PM-211D Files Maintenance Plan 1340 7 Feb-88 PM-21 1D Records Control Schedules * 1480 46 May-87 PM-215 Officer’s Operations Log 1480 36 Oct-83 PM-215 EPA Bomb Data Information 1480 41 Jan-86 A-109 Record of Communication (Records Checks.Oearances) * 1480 44 May-87 PM-215 Contract Guard Duty Register * 1480 45 May-87 PM-215 Visitor and Employee Sign-in Register * 1480 47 May-87 PM-215 Record of Keys Issued * 1480 48 May-87 PM-215 Guard Inspection Report * 1480 49 Aug-87 PM-215 Guard Post Orders * 1480 49A Aug-87 PM-215 Guard Post Orders (Continuation Sheet) * 1480 49B Aug-87 PM-215 Guard Post Orders (Continuation Sheet Schedule of Activities) * 1480 50 Aug-87 PM-215 Alarm Monitor Log * 1480 1550 51 Aug-87 12 Sep-85 PM-215 A-101 Key Issuance Register Freedom of Information Request Log 1640 1 Jan-75 A-104 Section 309 Action Log 1700 1710 1740 8 Nov-80 1 Sep-84 9 Jun-79 A-135 PM-215 PM-215 Voucher for Payment and Release Audio-Visual Equipment Loan Record Owned Personal Property System Input Data 1740 13 Oct-73 PM-215 Adjusirnent Voucher 1740 16 Feb-79 PM-215 Stock Record 1740 17 Aug-81 PM-215 Voucher Register 1740 1740 1740 1750 18 Mar-77 19 Apr-79 21 Aug-85 7 Sep-72 PM-215 PM-215 PM-215 PM-215 Simplified Stock Record Shipping and Receiving Record Personal Property Custody Card Equipment Maintenance Record 1900 2 Dec-81 PM-214 Profit/Fee Objectives 1900 3 Jun-75 PM-214 Assignee’s Release 1900 6 Feb-81 PM-214 Contractor’s Release 1900 20 Apr-85 PM-214 Contract Checklist 1900 37 Apr-85 PM-214 Record of Procurement Request Review 1900 41A Jun-79 PM-214 CPAF Contract Summary of Significant Performance Observation 1900 44 Feb-79 PM-214 Purchase OrderRegister 1900 54 Apr-85 PM-214 Memorandum to the File: Synopsis Exemption Termination Seulement Memorandum of Transmittal and Checklist * These forms are available in electronic format. Contact the Forms Office for more information. 1900 64 Jul-84 PM-214 Slit C Sht C Card C 44 ------- List of EPA Forms by Function Date of Current Form No. Edition Originator Title Con- Struc- tion Stock Record (Continued) 1900 66 1900 67 Sep-86 Sep-86 PM-214 PM-214 Purchase Order Record (Small Purchases) PuithaseOrder/SubcontractReconl Sht Sht C C 2360 2 Dec-73 PM-215 Publications Distribution Record Sht C 2500 2 Nov-77 PM-226 Accounting Code Sheet Sht A,B 2500 3 Jul-73 PM-226 General Ledger Code Sheet Sht C 2500 4 Aug-73 PM-226 Advance Travel Code Sheet Sht C 2500 5 Feb-80 PM-226 Accounts Receivable General Ledger Code Sheet Sht A 2505 1 Jan-72 PM-226 Register of Collections Sht A,B 2505 2 May-81 PM-226 Record of Public Funds Received Set A,B 2505 3 Jan-72 PM-226 Schedule of Collections Sht A,B 2550 4 Dec-79 PM-226 Interoffice Trarufer Voucher Set A,B 2550 11 Feb-81 PM-226 Document Control Register Sht A,B 2550 15 Dec-73 PM-226 Letter of Credit History Sht A,B 2550 20 Jul-81 PM-226 Adjustment of Pay Status Codes in Financial Management Systems Set A,B 2560 1 Oct-71 PM-226 Timekeeper Signature Card Card A,B 2560 5 May-80 PM-226 Change in Fixed Account Number Sht A,B 2560 18 Sep-77 PM-226 DIPS Payroll Master Input Data Sht A 2560 21 Oct-78 PM-226 Emergency Salary Payment Voucher Sht C 2560 22 Jul-81 PM-226 Cumulative Pay Adjustment Sht C 2560 23 Jul-81 PM-226 Current Pay Adjustment Sht C 2560 28 Oct-86 PM-226 Payroll Distribution Time Sheet Set A,B 2560 28A Oct-86 PM-226 Payroll Distribution Time Sheet (Continuation) Set A,B 2565 1 Jan-84 PM-226 Time and Attendance Card Can! D 2565 2 Jan-84 PM-226 Time and Attendance Card (Salmon) Cant A,B 2565 3 Jan-84 PM-226 Time and Attendance Can! (Yellow) Can! A,B 2570 4 Aug-76 PM-226 Payment Record Sht A,B 2570 6 Dec-80 PM-226 Treasury Financial Communication System (TFLS) Ticket Can! A,B * 2620 2 Dec-86 PM-226 Actual Subsistence Expenses While Occupying Temporary Quarters Sht A,B 2635 1 Nov-72 PM-226 Information for Authority of Moving and Related Travel Expenses Sht A,B 2635 2 Aug-77 PM-226 Relocation Expenses Payment Record Set A,B 2660 2 Mar-85 WH-556F Registration Record Sht C * 2720 6 Mar-87 A-109 Evidence Custody Set A 2800 1 Mar-73 PM-218 80-Column Keypunch Code Sheet Sht C 2800 9 Jan-80 OS-340 Program Change Set C 2800 14 Apr-80 OS-340 Facility - ID Update Maintenance Form Sht C 2800 16 May-80 OS-340 Facility Inventory Maintenance Fonn Sht C 2800 17 May-80 OS-340 Waste Definition Maintenance Form Sht C 2800 22 Jun-81 PM-218 Approved Operating Plan Sht C 3100 13 Jan-78 PM-212 MedicalReport Sht C 3110 11 Aug-72 PM-212 Service Comuptation Date Worksheet Sht C 3110 15 Jan-73 PM-212 Expert or Consultant Supplemental Information Sht A,B 3110 26 Oct-74 PM-212 Competitive Level Code Log Sht C 3110 43 Jul-86 PM-212 Organization Code Sheet Sht A,B 3115 7 Sep-84 PM-212 Evaluation and Rating Worksheet Sht A,B 3115 9 Sep-84 PM-212 Merit Promotion Information Record Set A,B 3115 28 Sep-84 PM-212 Job Analysis Record Sht A,B 3130 3 Apr-74 PM-212 Suggestion Record and Evaluation Set A 3150 10 Sep-73 PM-212 Desk AuditReport Sht A,B 3155 3 Jan-81 PM-212 Supplemental Pay for Non-Federal IPA Detailees Set A 3160 5 Apr-78 PM-212 Record of Excused Absence for Employee Sht A * These forms are available in electronic format. Contact the Forms Office for more information. 45 ------- Title Record (Continued) 3300 4 Mar-85 3300 6 Sep-82 3300 7 Jun-82 3300 8 Jun-82 3300 9 Jul-82 * 3300 11 Nov-88 * 3300 12 Nov-88 3540 4 Aug-74 3540 13 Oct-73 3540 17 Dec-73 4550 7 Nov-80 4850 1 May-81 4920 5 Nov-83 4920 6 Nov-83 4920 7 Nov-83 4920 9 Nov-83 4920 13 Nov-83 4920 14 Nov-83 4940 1 Jun-72 5020 2 Sep-79 5040 1 Nov-75 5040 2 Nov-75 5040 3 Aug-79 5040 4 Nov-81 5100 2A Dec-80 5100 4A Aug-82 5140 1 Oct-73 5180 1 Jun-72 5180 3 Jul-81 5180 10 Apr-79 * 5180 17 Mar-87 7500 35B May-22 7500 42 Dec-80 7500 43 May-78 LE-130L LE-134 LE-134 LE-134 LE-134 LE-133 LE-133 EN-342 EN-342 EN-342 A-106 PM-215 PM-215 PM-215 PM-215 PM-215 PM-215 PM-215 PM-215 PM-21 iT PM-21 iT PM-21 iT PM-211T PM-21 iT PM-215 PM-215 PM-215 PM-21 1D PM-215 PM-215 PM-215 Con- struc- Lion Card Pad Pad Pad cad Sht Sht Folder Pad Sht Card Sht Sht Sht Sht Sht Set Sht cad Sht Sht Sht Sht Sht Sht Sht Sht Set Sht Sht Sht Stock C C C C C C C A A A C C C C A,B C C C A,B C A A,B A A B C C A C C List of EPA Forms by Function Date of Cmvent Form No. Edition Originator Law Library (Charge-Out) EPA Assistance Appeals Initiation and Update Form 3 Consolidated Cases Form 2 Events Grant Appeal Checkout Sheet Enforcement Case Data CERCLA Enforcement Case Data Sample Record Jacket Copy of Invoice and Shipping Record History of Official Sample Passport Log Job Orders Accumulative Daily Request—Carrier Accumulative Daily Requests--Dispatcher Key and Credit Card Log Daily Schedule Chart Passenger Message Slip Driver’s Log Motor Vehicle Record Telephone Key System Worksheet Message Receipt Log Facsimile Log Originating Traffic Log Terminating Traffic Log Labor Services Request Receipt Log Relocation Worksheet Office Equipment Repair Log Mail Control Schedule Record of Registered and Certified Mail Express Mail Register Daily Record of Postage Meter Register Readings PostcarcWreliminary Assessment Information Federal Reporting Data System -- Violations Federal Reporting Data System -- Variances and Exemption Inventory of Injection Wells SPCC Inspection Summary Sheet SPCC Inspection Field Sheet Detailed SPCC Documentation Chain of Custody Record Completion Form for Class I Injection Wells Well Rework Record Plugging and Abandonment Record Federal Agency, Congress, and Federal Court Sign-Out Log Meeting Registration Cant Time Accounting Information System Record Destruction Log TSCA Investigation Summary Receipt Log: TSCA CBI Inventory Log: TSCA CBI Memorandum of TSCA CBI Telephone Conversation 7740 13 Oct-85 TS-793 TSCA CBI Visitors Log TS-799 WH-550 WH-550 Nov-79 Jun-80 S p-80 Sep0 Feb4 F M Feb-84 Mar-84 Sep-81 Can! C Sht A Sht A WH-550 OS-200 OS-200 OS-200 WH-556F WH-550 WH-550 WH-550 TS-793 7500 48 7500 52 7500 53 7500 54 7500 57 7520 9 7520 12 7520 14 7710 13 7710 23 7710 30 7710 45 7740 5 7740 10 774011 7740 12 Nov-78 Sep-79 Sep-Si Mar-83 Oct-85 Oct-85 Oct-85 TS-788 H7502C TS-793 EN-342 TS-793 TS-793 TS-793 Sht Sht Sht Pam Set Sht Sht Sht Sht Cad Set Sht Set Sht Sht Sht A A A A C A A A A C B A A * These forms e available in electronic fonnat. Cont t the Forms Office for more infonnation. Sht A,B 46 ------- List of EPA Forms by Function Date of Current Form No. Edition Originator Title Record (Continued) 7740 15 Oct-85 TS-793 8500 6 Nov-72 TS-768 * 8570 13 Nov-88 H7505C 8570 20 Jan-81 H7505C 8580 1 Oct-82 H7505C 8580 7 Mar-83 EN-342 8700 11 Nov-79 OS -340 8710 1 Oct-82 OS-310 8710 2 Oct-82 OS-340 8710 4 Oct-82 OS-3 10 Con- Struc- tion Sht Card Set Set Slit Set Sht Slit Sht Sht TSCA CBI Meeting Sign-in Sheet Pesticide Sample Record Data Review Record Data Reference Sheet FIFRA Section 3(C)(2)(B) FIFRA Investigation Summary Docket Control Slip Inventory Log (RCRA CBI) User Sign-Out Log (RCRA CBI) Federal Agency, Congress, and Federal Cowl Sign-Out Log (RCRA CBI) 8710 6 Oct-82 OS-310 RCRA Confidential Business information Meeting Sign-in Sheet 8710 7 Oct-82 OS-310 Destruction Log (RCRA CBI) Stock A,B A C C C A C C C C Jun-84 Jan-82 Jul-81 Dec-80 Jun-74 Sep-88 Report 1440 6 1440 9 1480 38 1550 7 1700 6 * 1730 1 1740 12 1900 55 1900 63 ShE C Sht C PM-273 PM-273 PM-215 H7502C PM-215 PM-215 Set Set Set Card Set Sht A,B A,B A,B C A,B C Sht A,B Set A Set A,B Pam C Pam C Report of Unhealthful or Unsafe Conditions Supervisor’s Report of Accident/illness Report of Loss or Theft FOL Case Status Report Receiving Report Report of Nonexpendable Government Property Acquired by Contractor Dec-82 PM-215 Report of Survey Jan-82 PM-214 Hazardous Substance Response Fund Apr-84 PM-214 Monthly Requisition and/or Receiving Report for Blanket Purehase Orders 2070 13 Jul-81 OS-240 Potential Hazardous Waste Site--Site Inspection Report 2070 14 Jul-81 OS-240 Potential Hazardous Waste Site Current Disposition PM-211D Technical Report Data PM-214 Contract Planning Submission Quarterly Plan PM-226 Report of Reimbursable Services Rendered A- 109 Office of Investigations Monthly Report EN-329 Report of Interview EN -329 Report of Investigation EN-329 Report of information Received A-109 Investigative Report A-109 Report of Investigation-Narrative A- 109 Report of Investigation A-l09 Report of Investigation A-109 PATS Biweekly Time Distribution Report LE-132 Overpayment Investigation Report EN-336 Discharge Monitoring Report EN-336 NPDES Discharge Monitoring Report LE-132 Employee Report of Invention EN-397 Unleaded Gasoline Field Inspection EN-397F Lead Additive Report for Refiners EN-340 Lead Additive Report for Manufacturing Facility or Site Lead Additive Report for Gasoline Importer Lead Additive Report Supplement A: Constructive Allocations 2220 2410 2550 2720 2720 2720 2720 2720 2720 2720 2720 * 2720 3155 3320 3320 3340 3500 3520 3520 1 9B 8 4 8 9 10 13 14 15 16 21 2 1 iT 1 5 2 3 Apr-77 Jun-83 Jul-81 May-80 Mar-84 Mar-84 Apr-82 Apr-83 Nov-84 Nov-84 Jul-83 Jan-89 Apr-73 Oct-77 Jan-87 Aug-72 Dec- SO May-85 May-76 Sht Sht Set Sht Set Set Set Cover Sht ShE Sht Set Sht Set Set Set Set Sht Sht A,B A,B A A A C A A A A C A,B A A,D A,B A C C 3520 5 May-85 EN-397F 3520 6A Jun-85 EN-397F * These forms are available in electronic format. Contact the Forms Office for more information. Sht C Sht C 47 ------- List of EPA Forms by Function Dateof Con- Current stiuc- Form No. Edition Originator Title tion Stock Report (Continued) 3520 t 3 May-85 EN-397F Lead Additive Report Supplement B: Sht C Transfers of Lead 3540 5 May-76 EN-342 Report of Analysis Set A 3540 SA ( t-75 EN-342 Report of Analysis Continuation Set A 3540 16 Jan-85 EN-342 Pesticides Report for Pesticide-Producing Set C Establishments 3540 20 Apr-75 EN-342 Use Investigation Report Set A 3540 21 Apr-75 EN-342 Establishment Inspection Report Set A 3540 22 Apr-75 EN-342 Corrective Action Report Set A 3560 3 Mar-85 EN-338 Compliance Inspection Report Sht A 4550 1 Jul-79 A-106 International Trip Report Set A,B * 4700 4 Nov-86 A-lOS Preaward Compliance Review Report for Sht A Wastewater Treatment Construction Grants 4920 3 Sep-84 PM-215 Daily Vehicle Utilization Report Sht A,B 4920 10 Nov-83 PM-215 Accident Report Sht C 4920 11 Nov-83 PM-215 Monthly Vehicle Report Sht C * 5180 4 Dec-87 PM-215 Sampled Mail Report Pam C * 5180 S Dec-87 PM-215 Supplemental Mail Report Pam C 5200 3 May-83 A-1a2 Hearing Report Sht C 5200 3A May-83 A-102 Hearing Report Sht C 5700 41 Apr-84 PM-216 Cost or Price Summary Pam A 6005 2 Jun-84 A-149 Quarterly MBE/WBE Consolidation Report Sht A * 6005 3 Sep-87 A-149 Superfund Minority Contractors Utilization Sht A Report * 6005 3A Sep-87 A-149 Superfund Minority Contractors Utilization Sht A Report—Part 2 7500 8 Jul-80 WH-553 Report of Pollution-Caused Fish Kill Cant C * 7520 2.8 Jan-88 WH-550E Part II: Compliance Evaluation/Significant Set A Noncompliance * 7520 3 Jan-88 WH-550E Part ifi: lnspection ’Mechanical Integrity Set A Testing * 7520 4 Mar-88 WH-550E Part IV: Quarterly Exceptions List Set A * 7520 5 Jan-88 WH-550E Part V: Summary of UIC Grant Utilization Set A 7520 8 Nov-83 WH-550 Injection Well Monitoring Report Sht A 7520 10 Feb-84 WH-550 Completion Report for Brine Disposal, Sht A Hydrocarbon Storage 7520 11 Feb-84 WH-550 Annual Disposal/Injection Well Monitoring Sht A Report 7710 3C Nov-77 TS-788 TSCA Inventory Report Form C Set D 7710 3D Nov-77 TS-788 TSCA Inventory Report Form D Set D 7710 3E Feb-79 TS-793 Chemical Substance Inventory Report Form E Set D 7710 34 Sep-79 TS-793 Trade Name Product Identity Report Sht C 7710 35 May-82 TS-778 Manufacturefs Report: Preliminary Sht C Assessment Information * 7710 48 Dec-87 TS-796 HERD Action Report Set C 7730 1 Jun-82 TS-794 Inspections for Friable Asbestos-Containing Sht C Materials 7740 8 Dec-85 TS-793 Partial Updating of TSCA Inventory Data Set C Base: Production and Site Report 8500 12 Apr-75 TS-768 Microbiological Laboratory Report Sht C 8510 8A Nov-80 TS-793 Urine Pesticide Residue Analysis Report Sht C (MPM) 8510 8B Nov-80 TS-793 UrinePesticideResidue Analysis Report Sht C (APM) 8510 10 Feb-82 TS-798 Patient Summary Report Sht C * These forms are available in elecironic format. Contact the Forms Office for more information. 48 ------- List of EPA Forms by Function * These forms are available in elecu onic format. Contact the Forms Office for more information. Date of Current Form No. Edition Originator Title Report (Continued) 8510 14 Oct-76 8550 5 Feb-79 8550 5A Feb-79 8550 11 Apr-75 * 8570 30 Jan-89 * 8580 4 May-88 8700 13 Dec-87 8700 22 Sep-86 8700 22A Sep-86 TS-768 TS-768 TS-769 TS-768 H7502C H7505C OS-320 OS-340 OS-340 OS-230 OS-230A OS- 120 Con- struc- tion Set Sht S ht Sht Set Sht Pam Sht Sht Stock A A A C C C D C C Biological Report of Analysis Pesticide Incident Report Incident Report Update Microbiological Laboratory Report Pesticide Registration Maintenance Fee Filing Product Specific Data Report Hazardous Waste Report Uniform Hazardous Waste Manifest Uniform Hazardous Waste Manifest (Continuation) Inorganic Traffic Report Organic Traffic Report SPMS and SCAP Report: Fiscal Year 1989 Aug-88 Aug-88 Dec-88 Jul-83 PM-213 Nov-72 PM-21 3 Set C Set C Pam C Sht A,B Sht C 9110 1 9110 2 * 9510 2 Request 1110 1 1130 1 1300 5 1300 13 1300 14 * 1315 17 1320 18 1335 1 1335 8 1480 2 1480 6 * 1480 53 1540 10 1540 11 1550 9A 1700 3 1700 4 1740 10 1900 7 1900 8 1900 8A Jun-87 Apr-86 Nov-83 May-87 Feb-83 Feb-85 Aug-83 Jan-80 Jun-71 Dec-87 Jul-79 Jul-79 May-81 Nov-73 Nov-72 Aug-72 Apr-85 Sep-86 Apr-84 PM-2 11 D PM-211D TS-799 OS-100 LE-131 PM-21 1D PM-21 1D A-109 A-109 PM-215 A-107 A-107 H7502C PM-215 PM-215 PM-215 PM-214 PM-214 PM-2 14 Card Sht Sht Sht S ht Sht Set Sht Sht Set Sht Sht Sht Sht Set Set A,B A,B C C C A,B A,B A C C C C C A,B A,B A,B Request for Change in Organization Structure Request for Approval of Nominees for Public Advisory Committees Request for Reprint of Article Clerical Work Request Document Clearance Request OSWER Directive Initiation Request Typing Instruction Sheet Form Action Request Request/Receipt of Accountable Forms Personnel Security Action Request FBI Record Check Request Request for Lock Work Request for EPA-Produced Videotape Request for Non-EPA-Produced Videotape FOl Request Response Storeroom Request and Issue Record Request for Shipping Service Property Action Request and Memorandum Receipt Request for Cost Analysis Procurement Request/Requisition Procurement Request/Requisition (Continuation) 1900 35 Jul-84 PM-214 Request for Equal Oppoutunity Clearance of Contract Award 1900 48 Apr-85 PM-214 Order for Services-Emergency Response to Hazardous Substance Release Delivery Order for Emergency Response Translation Service Request Publication Review/Printing Request Federal Register Typesetting Request Audiovisual Service Request Publications/Forms Request Change Request/Notification-Funding Request and Receipt for Cash Advance Request for and Authorization of Overtime Work Leave Overpayment Remittance Request Sht A$ Set A B Set A,B Sht A,B Pam C 1900 59 Nov-83 2130 1 Oct-77 2340 1 Apr-84 2340 15 Jan-81 2350 2 Jul-84 2360 1 Feb-84 2410 20 Jul-82 2545 2 Mar-73 2560 7 Jun-74 PM-214 PM-21 ID PM-215 PM-215 A-107 PM-215 PM-225 PM-226 PM-226 2560 16 Apr-75 PM-226 Set Sht Set Set Set Set Sht Set Set A A,B A A B C A B A,B A B Sht C 49 ------- List of EPA Forms by Function Date of Con- Current siruc- Form No. Edition Originator Title tion Stock Request (Continued) 2570 3 Dec-71 PM-226 Substitute Memorandum of US Transportation Cani A B Request 2800 18 Sep-80 OS-340 Ad Hoc Report Request Hazardous Waste Data Sht C Management System 3115 4 Sep-84 PM-212 Staffmg Requisition Sht A,B 3115 21 Sep-79 PM-212 SES Staffing Request Sht A,B 3150 15 l -73 PM-212 Group Action Request List Sht A,B 3155 1 Apr-77 LE-132 Request for Waiver of Claim for Erroneous Sht A,B Payment 3160 3 Nov-76 PM-212 Request for Flexible Hours Sht B * 3720 10 Jul-87 PM-223 Start Action Request Sht C 4850 2 Aug-83 PM-215 MaintenanceJob Order Set C 4920 8 Nov-83 PM-215 Request for EPA Driver Service Set C * 5020 1 Jun-88 PM-21 iT Washington Telecommunications Service Sht B Request 5040 5 1 -83 PM-21 iT Facsimile Transmission Request and Cover Sht B Sheet 5100 1 Sep-79 PM-215 Building Modification Services Request Set A,B 5100 2 Dec-80 PM-215 Labor Services Request Set B 5130 2 Apr-80 PM-215 EPA Self-Service Stove Request/Sales Slip Set B 5700 14 Apr-84 PM-216 Assistance Funding Order Sht A,B 5700 29 Jul-82 PM-216 Grant Audit Request Sht A * 7710 9 Feb-88 H7502C RequestforWordProcessing Set C * 7744) 6 May-88 TS-793 Federal ThCA CBI Access Request, Agreement, Sht A and Appmval (Document & Computer) 8500 1 Jun-83 EN-342 Investigation Request Set A 8500 15 Aug-77 TS-768 ADP Support Service Request Set C * 8500 23 May-88 H7502C Request for Document Center Services Set C 8710 5 Oct-82 OS-310 RequestforApprovalofCornnictorAccessto Sht C RCRA Confidential Business Information 8710 12 Oct-82 OS-310 Request for Approval of Temporary Employee Sht C for Access to RCRA CBI Respond 1550 9 May-81 H7502C FreedomoflnformationRequestResponse Set C * 2170 6 Feb-88 PM-211D Response to Request for Publication Card C Review 1480 7 Mar-80 A-109 Security File Review Sht C 1480 27 Feb-85 A-109 Security Investigation Review/Analysis Sht C 1550 10 May-81 H7502C Company Data Review in Response to FOl Set C Request 1900 27 Apr-84 PM-214 Project Officers Evaluation of Contractor Set A,B Performance 1900 41B Jun-79 PM-214 CPAF Contract Individual event Performance Sht A Ob on 1900 41C Dec-78 PM-218 WCC Quarterly Performance Report Sht C 1900 61 Feb-84 PM-214 Proposal Technical Evaluation Sht A,B 3110 20 Sep-73 PM-212 Review of Employment of Experts and Sht A,B Consultants 3110 21 Sep-73 PM-212 Summary of Review of Experts and Sht A,B Consultants 3140 11 Jul-76 PM-212 UpwardMobilityTraineeEvalualion Sht C 3140 18 Sep-78 PM-212 Assignee’s Evaluation of Mobility Assignments Sht C * These forms e available in e1ecu onic format. Contact the Forms Office for more information. 50 ------- List of EPA Forms by Function Date of Con- Current struc- Form No. Edition Originator Title lion Stock Review (Continued) 3140 20 Sep-78 PM-212 Supervisor’s Evaluation of EPA’S IPA Sht C Personnel Exchange Pmgram * 3720 11 Jan-89 PM-223 Federalism Review Sht B * 5300 23 Aug-87 RD-674 Environmental Review for Extramural Projects Set A * 7520 1 Jan-88 WH-550E UIC Federal Reporting System Part I: Permit Set A Review and Issuance/Wells in Area of Review 8500 7 Feb-72 H7505C Enforcement Case Review Set C 8500 7A Feb-72 H7505C Enforcement Case Review Set C State 1480 19 Feb-74 A-109 Security Termination Statement Sht A,B 2560 15 Mar-77 PM-226 Employee Statement of Leave Balances Sht A,B 3115 15 Sep-84 PM-212 Merit Promotion Rating Plan Specifications Sht A,B 3120 1 May-84 LE-131 Confidential Statement of Employment and Sht A,B Financial Interest 3150 6 Dec-79 PM-212 Evaluation Statement for Supervisors of Sht A,B Two-Grade-Interval Positions 3150 7 Sep-73 PM-212 Evaluation Statement for Supervisors of Sht A Subprofessional Positions 3150 9 Sep-73 PM-212 Evaluation Statement Sht A,B 3150 21 Dec-77 PM-212 Factor Evaluation System Evaluation Sht A Statement 5700 33A May-74 PM-216 Application for Federal Assistance, Narrative Sht A Statement 5700 33B May-74 PM-216 Application for Federal Assistance, Narrative Pam A Statement 5700 33F Jul-76 PM-216 Application for Federal Assistance, Narrative Sht A Statement 5700 33G Nov-75 PM-216 Application for Federal Assistance, Narrative Pam A Statement 5700 331 Dec-79 PM-216 Application for Federal Assistance, Narrative Sht A Statement 5770 3 Feb-77 PM-216 Fellowship Facilities and Commitment Sht C Statement 8570 4 Feb-85 H7505C Confidential Statement of Formula Set C 8580 3 Oct-82 H7505C Generic Data Exemption Statement Sht C Support * 9510 1 Jul 88 OS-120 Substantiation To Accompany Claims of Trade Pam A,B Secrecy: Emergency Planning/Community Right-To-Know Act Transcribe 1740 15 Jan-81 PM-215 Leased Personal Property System Input Data Sht A,B Transmit 1320 12 Jan-78 A-101 OL Priority Correspondence Folder Folder C 1320 15 Mar-82 TS-799 AA/OPTS Routing and Transmittal Slip Sht C 1320 17 Dec-84 A-104 OFA Routing Slip/Assignment Form Set C 1320 19 Feb-83 PM-215 Special Communications Env C 1320 20 Sep-86 TS-799 Information Transmittal Card C 1340 1 Mar-82 PM-211D VitalRecords Transmittal Sht A,B * 1900 19 Aug-88 PM-214 Contract Memorandum of Transmittal and Can! A,B Checklist * These forms are available in electronic format. Contact the Forms Office for more information. 51 ------- List of EPA Forms by Function Date of Con- Current siruc- Form No. Edition Originator Title tion Stock Transmit (Continued) 3100 16 Jun-80 PM-212 Position Control Transmittal Sht A,B 7710 32 Nov-80 TS-793 Information Transmittal Card C * 8500 24 Feb-88 H7502C FIFRA Sensitive Information Transmittal Set C Update 2200 3 Jan-85 A-107 Mailing List Update (OPA) Card C 2200 4 Jan-85 OS-305 Mailing List Update (OSW) Card C Verify 2545 1 Nov-71 PM-226 Verification of Imprest Fund Sht A,B * 3110 1 Feb-88 PM-212 Employee Separation or Transfe Checklist Set A,B 3115 13 Sep-84 PM-212 MPP Checklist Sht A,C 3150 5 Sep-73 PM-212 Position Description Amendment Sht A,B 3510 3B May-80 OS-340 Acknowledgement of Application for a Env C Hazardous Waste Permit (Verification) 4940 2 Oct-83 PM-215 Driver’s Daily and Weekly Preventive Sht C Maintenance Checklist 5160 2 Apr-73 PM-215 Physician’s Statement in Support of Handicap Sht A,B Parking 5160 3 Apr-73 PM -215 Supervisor’s Report in Support of Handicap Sht A,B Parking Assignment 8700 128 Apr-80 OS-340 AcknowledgementofNoiiflcationofHazardous Set C Waste Activity (Verification) Void 5130 1 Feb-79 PM-215 Self Service-Store Void Slip Set C Worksheet 1315 5 Jul-82 PM-213 Directives Processing Worksheet Sht A,B 1900 13 Apr-85 PM-214 Worksheet for Small Purchases Sht A,B 1900 51 Apr-85 PM-214 WorksheetfcrOrderforServices Sht C * These forms &e available in electronic format. Cont& t the Forms Office for more information. 52 ------- List of EPA Forms Available in Electronic Format Date of Current Form No. Edition Originator Title Con- struc- tion S ht S ht Set Sht Card Card Sht S ht Sht Pad Sht S ht S ht Sht Sht Sht Set Card Card Card Pam S ht Stock A,B C C C C C C C C C C C C C C C C C C A A,B C * 1315 16 Feb-89 PM-213 Clea nce/Approval Record 1315 17 May-87 OS-100 OSWER Directive Initiation Request * 1325 4 Jan-87 PM-223 Clearance Control * 1480 46 May-87 PM-215 Officer’s Operations Log * 1480 33 Feb-88 PM-215 EPA Headquarters Building Pass * 1480 43 May-88 EN-397F Inspectors Credential * 1480 44 May-87 PM-215 Contract Guard Duty Register * 1480 45 May-87 PM-215 Visitor and Employee Sign-in Register * 1480 47 May-87 PM-215 Record of Keys Issued * 1480 48 May-87 PM-215 Guard Inspection Report * 1480 49 Aug-87 PM-215 Guard Post Orders 1480 49A Aug-87 PM-215 Guard Post Orders (Continuation Sheet) * 1480 49B Aug-87 PM-215 Guard Post Orders (Continuation Sheet Schedule of Activities) * 1480 50 Aug-87 PM-215 Alarm Monitor Log * 1480 51 Aug-87 PM-215 Key Issuance Register * 1480 52 Aug-87 PM-215 Special Order * 1480 53 Dec-87 PM-215 Request for Lock Work * 1480 55 May-88 EN-342 AARP Inspector’s Credential * 1550 2 Apr-87 A-101 FOIA Request Acknowledgement * 1550 3 Jun-87 A-101 FOl Request Acknowledgement (Regions) * 1610 1 Oct-88 PM-216 Interagency Agreement * 1730 1 Sep-88 PM-215 Report of Nonexpendable Government Property Acquired by Contractor * 1900 19 Aug-88 PM-214 Contract Memorandum of Transmittal and Checklist * 2170 6 Feb-88 PM-211D Response to Request for Publication * 2550 21 Nov-88 PM-226 Project Officer’s Interagency Agreement Invoice Approval * 2560 25 Oct-88 PM-226 Statement of Earnings and Leave * 2620 2 Dec-86 PM-226 Actual Subsistence Expenses While Occupying Temporary Quarters * 2720 6 Mar-87 A-109 Evidence Custody * 2720 21 Jan-89 A-109 PATS Biweekly Time Distribution Report * 3110 1 Feb-88 PM-212 Employee Separation or Transfer Checklist * 3115 3 Nov-86 PM-212 Merit Promotion Announcement * 3115 3C Nov-86 PM-212 Temporary Vacancy Announcement * 3115 3D Nov-86 PM-224 Career Management System Vacancy Announcement * 3115 8E Nov-86 PM-212 Candidate Referral Certificate: Temporary Position * 3115 24 Aug-87 PM-212 Performance Agreement, Appraisal, and Certification * 3140 29 Jul-87 PM-224 Career Management System * 3150 1 Feb-87 PM-212 Position Description * 3300 11 Nov-88 LE-133 Enforcement Case Data * 3300 12 Nov-88 LE-133 CERCLA Enforcement Case Data * 3520 1 Sep-88 EN-340 Importation of Motor Vehicles and Motor Vehicle Engines Subject to Federal Air Pollution Regulations * 3520 7 Sep-87 EN-397F Notice of Violation of SEction 211 of the Clean Air Act * 3520 8 Jul-88 EN-340 Application for Final Admission of Nonconfonning Imported Vehicle These fonns are available in electronic format. Contact the Forms Office for further information. Card A,B Card C Set D Set A,C Shi A,B Set Set Set Sht Sht Sht A C A,B A,B A,B A,B Sht A,B Pam A,B Pam Sht Sht Sht Sht A A,B C C A,D Set C Sht C E-1 ------- List of EPA Forms Available in Electronic Format Dale of Cuffent Form No. Edition Originator Title * 5040 9 Feb-88 PM-211T * 5130 3 Aug-87 PM-215 S 5180 4 r -8i PM-215 * 5180 5 Dec-87 PM-215 5180 17 Mar-87 PM-215 * 5180 18 Aug-88 PM-215 530() 23 Aug-87 RD-674 * 5700 49 Nov-88 PM-216 Continuation of Application for Final Admission of Nonconforming Imported Vehicle Application for Final Admission of a Catalytic Convener and Oxygen Sensor Equipped Vehicle Application for Registration of Pesticide- Producing Establishment Notification of Registration of Pesticide-Producing Establishments Start Action Request Federalism Review Preaward Compliance Review Report for Wastewater Treatment Construction Grants Fume Hood Certification Parking Violation Washington Telecommunications Service Request Confirmation of Teleconference Schedule Application for EPA Supply Store Shopping Plate Sampled Mail Report Supplemental Mail Report Daily Record of Postage Meter Register Readings Custom Designed Mail Special Envelope Environmental Review for Extramural Projects Certification Regarding Debarment, Suspension, and Other Responsibility Matters Labor Standards Provisions for Federal & Federally Assisted Contracts Supeifund Minority Contractors Utilization Report Superfund Minority Contractors Utilization Report-Part 2 NPDES Laboratory Performance Evaluation UIC Federal Reporting System Part L Permit Review and Issuance/Wells in Area of Review Part II: Compliance Evaluation Part II: Compliance EvaluationiSigniflcant Noncompliance Part III: Inspections/Mechanical Integrity Testing Part IV: Quarterly Exceptions List Part V: Summary of UIC Grant Utilization Request for Word Processing HERD Action Report Federal TSCA CBI Access Request, Agreement, and Appoval (Document & Computer) Federal TSCA CBI Access Request, Agreement, & Appoval: Contractor/Subcontractor Employee Dinoseb Products: Claim for Indemnification, Request for Federal Disposal Request for Document Center Services FIFRA Sensitive Information Transmiual Env A,B Set A Pam A Pam A B Sht A Sht A Pam D Set A Set A Set A Set A Set A Set A Set C Set C Sht A Sht A,B Pam C Set C Set C These forms ere available in electronic format. Contact the Forms Office for further information. * 3520 8A Jul-88 EN-340 * 3520 9 Jul-88 EN-340 Nov-88 EN-342 Nov-88 EN-342 * 3540 8 * 35408A * 3720 10 * 3720 11 * 4700 4 * 4850 3 * 4920 15 * 5020 1 Con- stnic- tion Stock Sht C Sht C Set C Sht C Sht C Sht B Sht A Jul-87 Jan-89 Nov-86 Aug-87 May-88 Jun-88 PM-223 PM-223 A-105 PM-215 PM-215 PM-21 iT Label Set Sht B C B Set C cad B Pam Pam Sht C C C * 5720 4 May-87 A-lOS * 6005 3 Sep-87 A-149 * 6005 3A Sep-87 A-149 7500 55 * 7520 1 * 7520 2A * 7520 2B Jan-89 EN-338 Jan-88 WH-550E Jan-88 WH-550E Jan-88 WH-550E * 7520 3 Jan-88 WH-550E * 7520 4 • 75 2() 5 * 7710 9 * 7710 48 * 7740 6 Mar-88 Jan-88 Feb-88 Dec-87 May-88 WH-550E WH-550€ H7502C TS-796 TS-793 * 7740 6A ( t-88 TS-793 • 8500 22 Jan-89 H7502C * 8500 23 * 8500 24 May-88 R7502C Feb-88 H7502C E-2 ------- List of EPA Forms Available in Electronic Format Date of Con- Current struc- Form No. Edition Originator Title tion Stock * 8570 1 Sep-88 H7505C Application for Pesticide Amendment/ Set C Registration * 8570 13 Nov-88 H7505C Data Review Record Set C * 8570 17 Feb-85 H7505C Application for an Experimental Use Permit Set C * 8570 25 Dec-87 H7505C Application for/Notification of State Set A Registration of a Pesticide To Meet a Special Local Need * 8570 30 Jan-89 1{7502C Pesticide Registration Maintenance Fee Filing Set C * 8580 4 May-88 H7505C Product Specific Data Report Sht C * 9100 1 Feb-88 OS-5 10 Technical Enforcement Support at Hazardous Set C Waste Sites * 9310 1 Oct-87 OS-210 Application for Reimbursement to Local Pam A Governments for Emergency Response * 9510 1 Jul-88 OS-120 Substantiation To Accompany Claims of Trade Pam A,B Secrecy: Emergency PlanningAommunity Right-To-Know Act * 9510 2 Dec-88 OS-120 SPMS and SCAP Report: Fiscal Year 1989 Pam C These forms are available in elecironic format. Contact the Forms Office for further information. E-3 ------- List of New EPA Forms (Created since September 1, 1984) Date of Con- Current struc- Form No. Edition Title tion Stock Replacing 1300 24 Mar-85 Vacation and Training Schedule Sht A,B 1315 11 May-86 Notice Sht A,B 1315 12A May-86 EPA Order Sht A,B * 1315 17 May-87 OSWER Directive Initiation Request Sht C * 1325 4 Jan-87 Clearance Control Set C 1340 7 Feb-88 Records Control Schedules Sht C * 1480 46 May-87 Officer’s Operations Log Sht C GSA 1103 1480 41 Jan-86 Record of Communication (Records Checks/ Sht C Clearances) * 1480 43 May-88 Inspector’s Credential Card C * 1480 44 May-87 Contract Guard Duty Register Sht C GSA 139 * 1480 45 May-87 Visitor and Employee Sign-in Register Sht C GSA 139 * 1480 47 May-87 RecordofKeys Issued Sht C GSA 138 * 1480 48 May-87 Guard Inspection Report Pad C * 1480 49 Aug-87 Guard Post Orders Sht C * 1480 49A Aug-87 Guard Post Orders (Continuation Sheet) Sht C * 1480 49B Aug-87 Guard Post Orders (Continuation Sheet Schedule Sht C of Activities) * 1480 50 Aug-87 Alarm Monitor Log Sht C * 1480 51 Aug-87 Key Issuance Register Sht C * 1480 52 Aug-87 Special Order Sht C * 1480 53 Dec-87 Request for Lock Work Set C * 1480 55 May-88 AARP Inspector’s Credential Card C 1550 12 Sep-85 Freedom of Information Request Log Sht A 1900 48 Apr-85 Order for Services-Emergency Response to Hazardous Pam C Substance Release 1900 49 Apr-85 Notice To Proceed with Emergency Response to Pam C Hazardous Substance Release 1900 51 Apr-85 Worksheet for Order for Services Sht C 1900 54 Apr-85 Memorandum to the File: Synopsis Exemption Sht C 1900 56 Apr-85 Letter Contract for State/Local Government Response Pam C to Emergency Hazardous Substance Release 1900 65 Jun-85 Designation & Appointment of Project Officer/Work Set A,B Assignment Manager/Delivery Order 1900 66 Sep-86 Purchase Order Record (Small Purchases) Sht C 1900 67 Sep-86 Purchase Order/S ubcontra t Record Sht C * 2170 06 Feb-88 Response to Request for Publication Card C 2200 03 Jan-85 Mailing List Update (OPA) Card C 2200 04 Jan-85 Mailing List Update (OSW) Card C * 2550 21 Nov-88 Project Officer’s Interagency Agreement Invoice Set D Approval 2560 28 Oct-86 Payroll Distribution Time Sheet Set A,B 2560 28A Oct-86 Payroll Distribution Time Sheet (Continuation) Set A,B 2620 3 Jul-85 Employee Acknowledgement of Diners Club Credit Set C Card Program 2720 18 Oct-84 Advice of Rights for a Federal Employee Sht C 2720 19 Oct-84 Notice to a Federal Employee: Duty To Respond Sht C to Questions 2720 20A Oct-84 Advice of Rights Sht C 2720 20B Oct-84 Advice of Rights Sht C * 2720 21 Jan-89 PATS Biweekly Time Distribution Report Set C 3115 22 Oct-84 Appraisal of Other Characteristics Needed for S ht A Upward Mobility 3115 28 Sep-84 Job Analysis Record Sht A,B 3115 29 Sep-84 Cumulative Merit Promotion Evaluation Sheet Sht A,B * Form available in electronic format. Contact the Forms Office for details. New-i ------- List of New EPA Forms (Created since September 1, 1984) Date of Con- Current struc- Form No. Edition Title tion Stock Replacing 3115 31 Sep-84 Basic Qualifications Determination Worksheet Sht A,B * 3115 3C Nov-86 Temporary Vacancy Announcement Sht A,B * 3115 3D Nov-86 Career Management System Vacancy Announcement Sht A,B 3115 8A Sep-84 Merit Promotion Certificate (Continuation) Sht A,B 3115 8B Sep-84 Nonstatus Candidate Referral List Sht A,B 3115 8C Sep-84 Noncompetitive Candidate Referral Certificate Sht A B 3115 8D Oct-84 Certificate for Upward Mobility Sht A,B * 3115 8E Nov-86 Candidate Referral Certificate: Temporary Position Sht A,B 3130 8 Jan-88 Suggestion Award Certificate Sht A$ 3130 9 Jan-88 Certificate of Retirement Sht A,B 3130 10 Sep-88 Special Achievement Award Sht A,B 3130 7A Jul-86 Length of Service Certificate —10 Years Sht A, B 3130 7B Jul-86 Length of Service Certificate —20 Years Sht A$ 3130 7C Jul-86 Length of Service Certificate —30 Years Sht A,B 3130 7D Jul-86 Length of Service Certificate— 40 Years Sht A,B 3140 27 Feb-86 ProjectOfficerCertification Program (Contract Sht C Administration Course) 3140 28 Feb-86 Project Officer Certification Program (Basic Course) Sht C * 3140 29 Jul-87 Career Management System Pam A * 3300 11 Nov-88 Enforcement Case Data Shi C * 3300 12 Nov-88 CERCLA Enforcement Case Data Sht C 3320 iT Jan-87 NPDES Discharge Monitoring Report Set A,D 3510 2D Sep-86 Application Form 2D-New Sources & New Pam A Dischargers: Application for Permit To Discharge Process Waste 3510 2E Sep-86 Application Form 2E--Facilities Which Do Not Pam A Discharge Process Wastewater * 3520 7 Sep-87 Notice of Violation of Section 211 of the Clean Set C Air Act * 3520 8 Jul-88 Application for Final Admission of Nonconforming Sht C Imported Vehicle * 3520 9 Jul-88 Application for Final Admission of a Catalytic S ht C Convener and Oxygen Sensor Equipped Vehicle * 3520 8A Jul-88 Continuation of Application for Final Admission of Sht C Nonconforming Imported Vehicle * 3720 11 Jan-89 Federalism Review Sht B * 4850 3 Aug-87 Fume Hood Certification Label B * 4920 15 May-88 Parking Violation Set C * 5040 9 Feb-88 Confumation of Teleconference Schedule Set C * 5180 17 Mar-87 Daily Record of Postage Meter Register Readings Sht C * 5180 18 Aug-88 Custom Designed Mail Special Envelope Env A,B * 5700 49 Nov-88 Certification Regarding Debarment, Suspension, and Pam A,B Other Responsibility Mauers 5720 12 Sep-85 Application for Federal Assistance (Construction Pam A GrantstCooperative Agreemenis) * 6005 3 Sep-87 Superfund Minority Contractors Utilization Report Sht A * 6005 3A Sep-Si Superfund Minority Contractors Utilization Sht A Report—Part 2 * 7520 5 Jan-88 Part V: Summary of UTC Grant Utilization Set A * 7520 2B Jan-88 Part H: Compliance Evaluation/Significant Set A Noncompliance 7530 1 Sep-88 Notification for Underground Storage Tanks Pam C 7730 4 Jan-85 Notice to EPA Employees Sht C 7740 8 Dec-85 Partial Updating of TSCA Inventory Data Base: Set C 7710-3B Production and Site Report * Form available in electronic format. Contact the Forms Office for details. New-2 ------- List of New EPA Forms (Created since September 1, 1984) Date of Con- Current struc- Form No. Edition Title tion Stock Replacing 7740 9 Oct-85 TSCA Confidential Business Information Cani A,B 7710-6 (Cover Sheet) 7740 10 Oct-85 Receipt Log: TSCA CBI Sht A,B 7740 11 Oct-85 Inventory Log: TSCA CBI Sht A,B 7740 12 Oct-85 Memorandum of TSCA CBI Telephone Conversation Sht A,B 7740 13 Oct-85 TSCA CBI Visitors Log Sht A,B 7740 14 Oct-85 Temporary Loan Receipt for TSCA CBI Set A,B 7740 15 Oct-85 TSCA CBI Mecung Sign-in Sheet Sht A,B 7740 16 Oct-85 Confidentiality Agreement for US Employees Upon Set A,B Relinquishing TSCA CBI Access Authority * 7740 6A Oct-88 Federal TSCA CBI Access Request, Agreement, Sht A,B & Approval: Contractor/S ubconiractor Employee 8500 21 Feb-87 Silvex/2,4,5-T Products: Claim for Indemnification, Pam C Request for Federal Disposal * 8500 22 Jan-89 Dinoseb Products: Claim for Indemnification, Pam C Request forFederal Disposal * 8500 23 May-88 Request for Document Center Services Set C * 8500 24 Feb-88 FIFRA Sensitive Information Transmiual Set C * 8570 25 Dec-87 Application for/Notification of State Registration Set A of a Pesticide To Meet a Special Local Need 8570 27 Oct-86 Formulator’s Exemption Statement Set C 8570 28 Oct-86 Certification of Compliance with Data Gap Set C Pmcedtuts 8570 29 Jul-86 Certification with Respect to Citation of Data Set C * 8570 30 Jan-89 Pesticide Registration Maintenance Fee Filing Set C * 9100 1 Feb-88 Technical Enforcement Support at Hazardous Set C Waste Sites 9110 1 Aug-88 Inorganic Traffic Report Set C 2075-6 9110 2 Aug-88 Organic Traffic Report Set C 2075-7 * 9310 1 Oct-87 Application for Reimbursement to Local Pam A Governments for Emergency Response * 9510 1 Jul-88 Substantiation To Accompany Claims of Trade Pam A,B Secrecy: Emergency Planning/Community Right-To-Know Act * 9510 2 Dec-88 SPMS and SCAP Report: Fiscal Year 1989 Pam C * Form available in electronic format. Contact the Forms Office for details. New-3 ------- List of EPA Forms Revised Since September 1, 1984 Date of Con- Current struc- Form No. Edition Title tion Stock 1300 5 Jun-87 Request for Reprint of Article Card A,B 1300 13 Apr-86 Clencal Work Request Sht A,B 1315 4 Aug-86 Checklist of EPA Transmiuals Sht A,B * 1315 16 Feb-89 Clearance/Approval Record Sht A,B * 1315 17 May-87 OSWER Directive Initiation Request Sht C 1320 17 Dec-84 OFA Routing Slip/Assignment Form Set C 1320 20 Sep-86 Information Transmittal Can! C 1335 1 Feb-85 Form Action Request Shi A,B 1335 9 Sep-85 Forms Distribution Guide Pam C 1480 27 Feb-85 Security Investigation Review/Analysis Sht C * 1480 33 Feb-88 EPA Headquarters Building Pass Can! C * 1480 43 May-88 Inspector’s Credential Can! C * 1550 2 Apr-87 FOlARequest Acknowledgement Card C * 1550 3 Jun-87 FOl Request Acknowledgement (Regions) Can! A * 1610 1 Oct-88 Interagency Agreement Pam A,B 1710 1 Sep-84 Audio-Visual Equipment Loan Record Sht C * 1730 1 Sep-88 Report of Nonexpendable Government Property Acquired by Sht C Contractor 1740 21 Aug-85 Personal Property Custody Card Can! A,B 1900 7 Apr-85 Request for Cost Analysis Shi A,B 1900 8 Sep-86 Procurement Request/Requisition Set A,B 1900 13 Apr-85 Worksheet for Small Purchases Sht A,B * 1900 19 Aug-88 Contract Memorandum of Transmittal and Checklist Can! A,B 1900 20 Apr-85 Contract Checklist Sht A,B 1900 26 Apr-85 Contracting Officer’s Evaluation of Contractor Performance Set A,B 1900 37 Apr-85 Record of Procurement Request Review Set A,B 1900 66 Sep-86 Puithase OrderRecord (Small Purchases) Sht C 1900 67 Sep-86 Purchase Order/Subcontract Record Sht C 2550 19 Oct-85 Project Officer Invoice Approval Set D 2560 02 Nov-86 Payroll Error Notice Set A,B * 2560 25 Oct-88 Statement of Earnings and Leave Set A,C 2620 1 l)ec-86 Employee Application forReimbursement of Expenses Sht A,B * 2620 2 Dec-86 Actual Subsistence Expenses While Occupying Temporary Sht A,B 2660 2 Mar-85 Registration Record Sht C * 2720 6 Mar-87 Evidence Custody Set A 2720 14 Nov-84 Report of Investigation-Narrative Sht A 2720 15 Nov-84 Report of Investigation Sht A 2720 17 Nov-84 Investigation Cover Sheet Sht A * 3110 1 Feb-88 Employee Separation or Transfer Checklist Set A,B 3110 43 Jul-86 Organization Code Sheet Sht A,B * 3115 3 Nov-86 Merit Promotion Announcement Sht A,B 3115 4 Sep-84 Staffing Requisition Sht A,B 3115 7 Sep-84 Evaluation and Rating Worksheet Sht A,B 3115 8 Sep-84 Merit Promotion Certificate Sht A,B 3115 9 Sep-84 Merit Promotion Information Record Set A,B 3115 13 Sep-84 MPP Checklist Sht A,C 3115 14 Sep-84 Merit Promotion Application Rating Sheet Sht A,B 3115 15 Sep-84 Merit Promotion Rating Plan Specifications Sht A,B 3115 17 Oct-84 Interview Rating Sheet for Upward Mobility Positions Sht C 3115 18 Oct-84 Job Element Rating Sheet for Upward Mobility Positions Sht C * 3115 24 Aug-87 Performance Agreement, Appraisal, and Certification Pam A,B 3115 3A Oct-84 Merit Promotion Vacancy Announcement (Upward Mobility) Sht C * 3150 1 Feb-87 Position Description Sht A,B *F available in electronic format. Contact the Forms Office for details. Revised-i ------- List of EPA Forms Revised Since September 1, 1984 Date of Con- Current struc- Form No. Edition Title tion Stock 3300 4 Mar-85 Law Library (Charge-Out) Can! C 3510 2C Feb-85 Application for Permit To Discharge Wastewater (Form 2C) Pam A * 3520 1 Sep-88 Importation of Motor Vehicles and Motor Vehicle Engines Sht A,D Subject to Federal Air Pollution Regulations 3520 2 May-85 Lead Additive Report for Refiners Sht C 3520 5 May-85 Lead Additive Report for Gasoline Importer SM C 3520 6A Jun-85 Lead Additive Report Supplement A: Constructive Allocations Sht C 3520 68 May-85 Lead Additive Report Supplement B: Transfers of Lead S ht C * 3540 8 Nov-88 Application for Registration of Pesticide-Producing Set C Establishment 3540 16 Jan-85 Pesticides Report for Pesticide-Producing Establishments Set C 3540 31 Oct-85 Inspector ’s Credential Card C * 3540 8A Nov-88 Notification of Registration of Pestocide-Producing Sht C Establishments 3560 3 Mar-85 Compliance Inspection Report Sht A * 3720 10 Jul-87 Start Action Request Sht C * 4700 4 Nov-86 Preaward Compliance Review Report for Wastewater Treatment Sht A Construction Grants 4920 3 Sep-84 Daily Vehicle Utilization Report Sht A,B * 4920 15 May-88 Parking Violation Set C * 5020 1 Jun-88 Washington Telecommunications Service Request Sht B * 5130 3 Aug-87 Application for EPA Supply Store Shopping Plate Card B * 5180 4 Dec-87 Sampled Mail Report Pam C * 5180 5 Dec-87 Supplemental Mail Report Pam C * 5300 23 Aug-87 Environmental Review for Extramural Projects Set A 5700 2DB Nov-86 Assistance Amendment Sht A 5700 20C Feb-86 EPA Assistance Agreement/Amendment Set A 5700 30 Nov-86 Preapplication for Federal Assistance Pam A 5700 33 Nov-86 Application for Federal Assistance Pam A 5700 33H Aug-86 Pesticide Enforcement Cooperative Agreement Sht A 5700 42 Feb-85 Grant Record Adjustment Notice Set C 5700 78 May-87 Application Kit for Assistance (Planning or Program Folder A Assistance) * 5720 4 May-87 Labor Standards Provisions for Federal & Federally Assisted Pam A,B Contracts * 7500 55 Jan-89 NPDES Laboratory Performance Evaluation Pam D * 7520 1 Jan-88 UIC Federal Reporting System Part I: Permit Review and Set A Issuance/Wells in Area of Review * 7520 3 Jan-88 Part 111: Inspections/Mechanical Integrity Testing Set A * 7520 4 Mar-88 Part IV: Quarterly Exceptions List Set A * 7520 2A Jan-88 Part II: Compliance Evaluation Set A 7530 1 Sep-88 Notification for Underground Storage Tanks Pam C * 7710 9 Feb-88 Request for Word Processing Set C * 7710 48 Dec-87 HERD Action Report Set C * 7740 6 May-88 Federal TSCA CBI Access Request, Agreement, and Approval Sht A (Document & Computer) * 7740 6A Oct-88 Federal TSCA CBI Access Request, Agreement, & Approval: Sht A,B Contractor/Subcontractor Employee * 8500 22 Jan-89 Dinoseb Products: Claim for Indemnification, Request for Pam C Federal Disposal * 8570 1 Sep-88 Application for Pesticide Amendment/Registration Set C 8570 4 Feb-85 Confidential Statement of Formula Set C * 8570 13 Nov-88 Data Review Record Set C * 8570 17 Feb-85 Application for an Experimental Use Permit Set C * Form available in electronic format. Contact the Forms Office for details. Revised-2 ------- List of EPA Forms Revised Since September 1, 1984 Date of Con- Current struc- Form No. Edition Title tion Stock * 8580 4 May-88 Product Specific Data Report Sht C 8700 12 Oct-88 Notification of Hazardous Waste Activity Pam A 8700 13 Dec-87 Hazardous Waste Report Pam D 8700 22 Sep-86 Uniform Hazardous Waste Manifest Sht C 8700 22A Sep-86 Uniform Hazardous Waste Manifest (Continuation) Sht C * Form available in electronic format. Contact the Forms Office for details. Revised-3 ------- List of EPA Forms Declared Obsolete Since September 1, 1984 Date Replaced Form No. Title Obsolete by 1130 2 Report of Vacancy on Public Advisory Committees Mar-87 1300 7 Tabbed Separator Jul-88 1300 8 Typing Log Mar-87 1300 9 Project Timesheet Jun-85 1300 12 Case Docketing Sheet Jul-88 Survey 1300 15 OA Personnel Action Request Routing Slip Jun-85 1300 16 Red Border Action Request Jul-88 1300 17 Weekly Summary Report Mar-87 1300 18 Daily Contact Log Mar-87 1300 20 Recusal Form Jun-85 1300 23 Program Record of Clearance/Approval Mar-87 1300 25 Projects for Automation and Efficiency Mar-87 1300 26 Tickler File Card Jul-88 1315 9 Standard 25% Reduction Sheet Jun-85 1315 13 Manual Index Sep-84 1320 4 Mailing Label (Regions and Field) Jun-85 1320-3 1320 7 Correspondence Log Sep-88 Survey 1320 13 Information Request Response Mar-87 1320 13A Information Transmittal Sep-88 1320 l3B Information Transmittal Sep-88 1320 13C Information Transmittal Sep-88 1320 16 Office of Administration Transmittal Mar-87 1335 12 EPA Forms Survey Jun-86 Computer 1335 14 EPA Forms Survey Control Sheet Jul-88 1335 19 Hold Jun-87 1340 2 Certificate of Destruction Jul-88 Survey 1340 5 Federal Records Center Box Label Mar-87 1340 6 Report of Records Holding Jul-88 1440 2 Health and Safety Inspection Checklist Jul-88 1440 10 Fire and Safety Recommendation Mar-87 1440 11 Employee Injury Mar-87 1480 3 Security Acknowledgement Statement Jul-88 Survey 1480 5 Custodian of Security Container Jun-86 SF 700 1480 8 Confidential Cover Jun-86 SF 705 1480 10 Secret Cover Jun-86 SF 704 1480 12 Safe/Cabinet Security Check Sheet Jun-86 SF 703 1480 13 Classified Material Receipt Mar-87 1480 15 Confidential and Secret Security Information Log Mar-87 1480 17 Safe Combination Record Jun-86 SF 703 1480 21 Privileged Information Control Record Mar-87 1480 22 Inventory of Secret Material Mar-87 1480 25 Security Computer Control Data Jul- 88 Survey 1480 31 Investigation Cover Jul-88 Survey 1480 35 Routine Use Disclosure Under Privacy Act of 1974 Jul-88 Survey 1480 37 Statement of Personal History (Contractor Employees) Mar-87 1740 14 Leased ADPE Personal Property System Input Jul-88 Survey 1740 20 Owned ADPE Personal Property System Input Jul-88 Survey 1800 1 Quarterly Report of EPA Direct Training Activities Jul-88 Survey 1900 40 RFB/IFB Control Mar-87 1970 1 Contract Award Schedule (Competitive) Mar-87 1970 2 Contract Award Schedule (Noncompetitive) Mar-87 2070 1 Potential Hazardous Waste Site Log Jun-85 2070 1-6 Instructions for Preparing Site Tracking Forms Jun-85 2070 2 Identification and Preliminary Assessment Jun-85 2070 3 Site Inspection Report Jun-85 2070 3A Land Farm Site Inspection Report Jun-85 Obsolete - 1 ------- List of EPA Forms Declared Obsolete Since September 1, 1984 Date Replaced Form No. Title Obsolete by 2070 3B Incinerators Inspection Report Jun-85 2070 3C Surface Impoundments Site Inspection Report Jun-85 2070 3D Storage Facilities Site Inspection Report Jun-85 2070 3E Landfills Site Inspection Report Jun-85 2070 4 Tentative Disposition Jun-85 2070 5 Final Strategy Determination Jun-85 2070 6 Monthly Statistical Summary Jun-85 2075 6 Inorganic Traffic Report Aug-88 2075 7 Organic Traffic Report Aug-88 2100 3 Source Registration Mar-87 2170 4 IRSB Computer Search Request Mar-87 2170 5 On-Line Literature Search Evaluation Mar-87 2200 2 Pesticides Abstracts Subscription Jul-88 Survey 2260 1 Publications Request Reply -- OSW Jul-88 2260 1A Request for Publications Jul-88 2340 2 Daily Camera Production Report Jul-88 Survey 2340 3 Daily Binding and Mailing Production Report Jul-88 Survey 2340 4 Daily Press Production Report Jul-88 Survey 2340 5 Weeldy Production Report Mar-87 2340 9 Printing Requisition Log Mar-87 2340 11 Production Control Record Jul-88 Survey 2340 14 Quarterly Copying Machine Usage Report Jul-88 Survey 2340 16 Copying Machine Production Graph Mar-87 2340 19 Reprint Articles and Page Changes -- JCP Reporting Form Mar-87 2410 26 Regional EIS Preparation Mar-87 2430 1 Advice of Allowance Mar-87 2430 2 Operating Plan Mar-87 2430 3 Allotment Notice Mar-87 2550 5 Paid Purchase Order Register Aug-88 Survey 2550 14 Leuer of Credit Register Aug-88 Survey 2560 6 Authorized Compensatory Time Record Aug-88 Survey 2560 19 Employee’s Pay Record Flextiine Report Mar-87 2560 24 Fact Findings and Information Sheet for Form ES-391 Aug-88 Survey 2560 27 Composite Check List Aug-88 Survey 2625 1A Teletype Ticketing Listing Sep-88 2700 2 Audit Services Order Jun-85 2720 3 Office of Investigations Daily Report Mar-87 2720 5 Monthly Case Studies Report Mar-87 2720 7 Report of Investigations Jul-88 Survey 3100 6 Physical Fitness Laboratory Report Dec-85 3100 8 Personnel Master Input Data Dec-85 3110 24 RIFW0II(sheet Mar-87 3110 25 RIF Control Mar-87 3110 27 Limited Appointment Record of Time Worked Aug-88 Survey 3110 36 SummerEmploymentRecruitment Index Dec-85 3110 41 Skills Inventory Information Sheet Mar-87 3115 12 Vacancy AnnouncementRoster Mar-87 3140 8 Supervisory Training Needs Plan Mar-87 3140 10 Executive and Management Development Worksheet Dec-85 3140 12 Special Evaluation, Long-Term Graduate Training Program Mar-87 3140 13 Individual Rating Sheet--Long-Term Training Program Mar-87 3140 17 Individual Development Planning Knowledges and Abilities Dec-85 Inventory 3140 19 Course Evaluation Report Dec-85 3140 22 Daily Individual Learning Center Schedule Mar-87 3140 23 Individual Rating Guide Mar-87 Obsolete - 2 ------- List of EPA Forms Declared Obsolete Since September 1, 1984 Date Replaced Form No. Title Obsolete by 3140 24 Project Officer Certificate Jan-86 3140 26 OIG Career Development Record Jul-88 Survey 3150 2 Secretary Position Description Mar-87 3150 3 Position Description Survey Mar-87 3150 8 Position Description for Headquarters Nonsupervisory Mar-87 Professional Program/Staff/Technical Position 3150 8A Position Description for Two-Grade Interval Program/S taff/ Mar-87 Technical Position 3150 19 Position Description Review Mar-87 3150 25 Merit Pay Documentation Mar-87 3150-1 3170 1 PEP Quality Sampling Sheet Mar-87 3170 2 PEP Center Hours and Requests Mar-87 3170 3 PEP Code Sheet Mar-87 3170 4 PEP Center Budget Transaction Volume Exceptions Mar-87 3170 5 PEP Center Task Standards Mar-87 3170 6 PEP Center Budget Information Mar-87 3170 7 PEP Center Constants and Calendar Exceptions Mar-87 3170 8 PEP Center Labor Transfer Mar-87 3170 8A PEP Center Labor Transfer Mar-87 3170 9 PEP Daily Backlog Flash Mar-87 3170 10 Employee File Maintenance Mar-87 3170 11 Employee Production Batch Header Mar-87 3170 12 Employee Payroll Exceptions Mar-87 3170 13 Employee Master Mar-87 3170 14A PEP Daily Activity Sheet Jul-88 Survey 3170 14B PEP Daily Activity Sheet Mar-87 3300 10 Chronological Record of Investigations Sep-85 3340 3 Contractor’s or Grantee’s Invention Disclosure Jul-88 Survey 3340 4 Summary Report of Inventions and Subagreements or Subcontracts Jun-85 3500 7 Federal Agency Pollution Abatement Plan - Project Report Nov-88 Survey 3500 8 Library Reference Grid Sep-88 3540 15 Poison Dec-85 3540 23 Pesticides Field Weight Record Nov-88 Survey 3700 1 EPA Information Clearinghouse Inventory Sep-88 Survey 3700 1A Models Survey Sep-88 Survey 3710 1 Resources Schedule Mar-87 4520 1 Payment Authorization Aug-88 4520 2 Special Foreign Currency Program Fiscal Report Aug-88 4700 6 Workforce Profile Mar-87 4700 7 Ultimate Goal Formula Mar-87 4700 8 Assessment of Underrepresentation Mar-87 4700 9 Annual Goal Mar-87 4700 10 Prorating Annual Goals Mar-87 4700 12 Affirmative Action Plan Summary Mar-87 4700 13 Action Plan for Prevention of Sexual Harassment in the Workplace Mar-87 4800 1 Report of Daily Inspection Mar-87 4810 1 Blueprint Label Jul-88 Survey 5040 7 Sent/Received Message Label Sep-88 5100 3 Status of Work Order Jul-88 Survey 5150 2 Contractor Shipping and Receiving Activity Jul-88 Survey 5180 9 Application for Contractor Use of EPA Official Mail Mar-87 5300 19 Office of Environmental Engineering and Technology - Action Oct-84 Assignment 5700 7A Application Kit for Grant (Construction) Mar-87 5700 8 Grant Application/Proposal Receipt (Headquarters) Mar-87 5700 8A Grant Application/Proposal Receipt Mar-87 Obsolete - 3 ------- List of EPA Forms Declared Obsolete Since September 1, 1984 Date Replaced Form No. Tide Obsolete by 5700 19 Unsolicited Proposals Mar-87 5700 22 Grants Received Refeiml Log Mar-87 5700 28 State Priority Certification Mar-87 5700 32 Application for Federal Assistance (Construction) Mar-87 5700 33E Application for Federal Assistance Mar-87 5700 38 Grant Closeout Checklist Mar-87 5700 47 Grants Mailing List Verification Mar-87 5760 2 Preapplication Acknowledgement Mar-87 5760 3 Record of Grant Application Jul-88 5760 3A Record of Grant Application Jul-88 6005 1 Minority and Women’s Business Utilization Report Aug-87 SF 334 7500 8A Acknowledgement Card for Form 7500-8 Mar-87 7500 21 Construction Grants Program Mailing List Application Jun-85 7500 24 STORET Water Quality File Station Location Storage Oct-88 Survey 7500 27 WQCS Violations File Record Creation and Maintenance Mar-87 7500 28 WQCS Violations File Record Creation and Maintenance Mar-87 7500 29 Chemical or Radiological Analysis Input Mar-87 7500 30 Bacteriological or Turbidity Analysis Input Mar-87 7500 31 Bacteriological or Turbidity Summary Analysis Input System Mar-87 7500 32 EAS Record Creation and Maintenance Mar-87 7500 33 EAS Record Creation and Maintenance - Violation Information Mar-87 7500 34 EAS Record Creation and Maintenance - Cast Abstract Mar-87 7500 35 EAS Record Creation and Maintenance - Milestone Information Mar-87 7500 36 VES Record Creation and Maintenance Mar-87 7500 37 VES Record Creation and Maintenance - Milestones Mar-87 7500 38 VES Record Creation and Maintenance - CARE Abstract Mar-87 7500 39 VMS Record Creation and Maintenance Mar-87 7500 46 Underground Injection Control Program Comment Mar-87 Acknowledgement 7500 49 Innovative and Alternative Technology Project Clearinghouse Mar-87 Rea 7500 50 Confidential Coversheet Aug-88 Survey 7710 2 Toxic Substances Acknowledgement Postcard Jul-88 7710 3A TSCA Inventory Report Form A Aug-86 7740-8 7710 3B TSCA Inventory Report Form B Aug-86 7740-8 7710 10 Inventory Log (TSCA-CBI) Jul-88 7740-10 7710 11 Sign Out Log - User Copy Jul-88 Survey 7710 12 Sign Out Log - Contractor/Subcontractor Jul-88 Survey 7710 14 Loan Receipt for TSCA Confidential Business Information Jul-88 7740-14 7710 iSA Request for Approval of Contractor Access to TSCA CBI Jul-88 7740-6A 7710 17 Confidentiality Agreement for U.S. Employees Upon Jul-88 7740-16 Termination or Transfer 7710 18 Confidentiality Agreement - TSCA Federal Non- EPA Employee Jul-88 Survey 7710 21 Codex MRL Acceptance Jul-88 Survey 7710 36 Reporting Commercial and Industrial Uses of Asbestos Jul-88 Survey 7710 37 Reporting Secondary Processing and Importation of Asbestos Jul-88 Mixtares 7710 41 Green Border Review Comments Jul-88 7710 43 Confidentiality Agreement for Contractor Employees Upon Jul-88 7740-18 Termination or Transfer 7710 44 TSCA Confidential Business Information Meeting Sign-in Sheet Jul-88 7740-15 7710 46 Request for Approval of Temporary Employees for Access to Jul-88 Survey TSCA CBI 7710 50 Claim for Reimbursement for Interrupted Operation of Jul-88 Survey Underground Motor Vehicle Fuel Storage Tanks Obsolete - 4 ------- List of EPA Forms Declared Obsolete Since September 1, 1984 Date Replaced Form No. Title Obsolete by 7740 7 Request, Review, Approval, and Registration for TSCA CBI May-88 7740-6 Computer Access 8500 8 Product Registration Record Jul-88 8500 17 Pesticide Application Certification Sep-88 8500 18 Pesticide Cerlification Examination Answer Sheet Sep-88 8500 19 In-House Route Slip Jul-88 8500 20 EDB Products: Claim for Indemnification Jul-88 8510 8C Urine Pesticide Residue Analysis Report (CM) Jul-88 Survey 8510 8D Urine Pesticide Residue Analysis Report (MM) Jul-88 Survey 8510 9 Tissue Pesticide Residue Analysis Report Jul-88 Survey 8520 4 Inspector’s Credential Nov-88 Survey 8560 1 Pesticide Chemical Lab Coded Jul-88 8560 2 Pesticides Incoming Sample Log Jul-88 8560 3 Pesticides Outgoing Sample Log Jul-88 8560 4 Pesticides Sample Record Jul-88 8570 9 Disinfectants Efficacy Data Summary Jul-88 8570 15 Experimental Permits Record Jul-88 8570 21 Certification Statement Jun-85 8570 22 Offer To Pay Statement (Combined) Jul-88 8570 23 Offer To Pay Statement (Cite-All) Jun-85 8570 24 Offer To Pay Statement (Alternate) Jun-85 8580 2 Data Compensation Statement (Reregistration) Jul-88 8580 5 Data Compensation Statement Reregistration Jul-88 8700 1 Mailing Key Update Notice Jul-88 8700 14 Open Dump Inventory Report Jun-85 8710 3 Contractor/Subcontractor Sign Out Log - RCRA CBI Jul-88 8710 8 Loan Receipt for Federal Employees for RCRA CBI Jul-88 8710 15 RCRA Reauthorization Questions Jul-88 Obsolete - 5 ------- Numerical List of EPA Public-Use Forms Date of o M B Current 0MB Expiration Form No. Edition Originator Title Number Date * 1730 01 Sep-88 PM-215 Report of Nonexpendable Government 9000-0075 Aug-90 Property Acquired by Contractor 1900 10 Nov-76 PM-214 Contractor’s Cumulative Claim and 2000-0005 Mar 88** Reconciliation 1900 34 Apr-83 PM-214 Guide for Preparation of Contractor’s 2000-0005 Mar 88** Claims 1900 34A Apr-83 PM-214 Guide for Preparation of Contractor’s Claim 2000-0005 Mar 88** 1900 55 Jan-82 PM-214 Hazardous Substance Response Fund 2000-0285 Sep 86** 3300 01 Aug-77 LE-130 Application for Certification of Pollution 2020-0001 Feb 87** Control Facility 3300 02 Aug-77 LE-130 Notice of State Certificate 2020-0001 Feb 87** 3300 03 Aug-77 LE-130 Notice of Federal Certification 2020-0001 Fcb.87** 3320 01 Oct-77 EN-336 Discharge Monitoring Report 2040-0004 Jun 88** 3320 OIT Jan-87 EN-336 NPDES Discharge Monitoring Report 2040-0004 Jun 88** 3500 05 Dec-80 EN-397 Unleaded Gasoline Field Inspection 2060-0009 May-89 3510 01 Oct-80 EN-336 General Information Consolidated Permits 2040-0086 Jul 88** Program (Form 1) 3510 02B Jun-80 EN-336 Application for Permit To Discharge 2040-0086 Jul 88** Wastewater (Form 2B) 3510 02C Feb-85 EN-336 Application for Permit To Discharge 2040-0086 Jul 88** Wastewater (Form 2C) 3510 02D Sep-86 EN-336 Application Form 2D-New Sources & 2040-0086 Jul 88 * New Dischargers: Application for Permit To Discharge Process Waste 3510 02E Sep-86 EN-336 Application Form 2E--Facilities Which 2040-0086 Jul-89 Do Not Discharge Process Wastewater 3510 03 Jun-80 OS-320 Application for Hazardous Waste Permit 2000-0061 Dec 83** * 3520 01 Sep-88 EN-340 Importation of Motor Vehicles and Motor 2060-0095 Dec-90 Vehicle Engines Subject to Federal Air Pollution Regulations 3520 02 May-85 EN-397F Lead Additive Report for Refiners 2000-0066 Mar 87** 3520 03 May-76 EN-340 Lead Additive Report for Manufacturing 2000-0041 Mar 84** Facility or Site 3520 05 May-85 EN-397F Lead Additive Report for Gasoline Importer 2060-0066 Mar 87** 3520 06A Jun-85 EN-397F Lead Additive Report Supplement A: 2060-0066 Mar 87** Constructive Allocations 3520 06B May-85 EN-397F Lead Additive Report Supplement B: 2060-0066 Mar 87** Transfers of Lead * 3520 08 Jul-88 EN-340 Application for Final Admission of 2060-0095 Dec-90 Nonconforming Imported Vehicle * 3520 08A Jul-88 EN-340 Continuation of Application for Final 2060-0095 Dec-90 Admission of Nonconforming Imported Vehicle * 3520 09 Jul-88 EN-340 Application for Final Admission of a 2060-0095 Dec-90 Catalytic Converter and Oxygen Sensor Equipped Vehicle 3540 01 May-77 EN-342 Notice of Arrival of Pesticides and Devices 2070-0020 Mar 88** * 3540 08 Nov-88 EN-342 Application for Registration of 2070-0069 Nov-89 Pesticide-Producing Establishment 3540 16 Jan-85 EN-342 Pesticides Report for Pesticide-Producing 2000-0029 Jan 88** Establishments 3560 03 Mar-85 EN-338 Compliance Inspection Report 2040-0057 Apr.88** * 4700 04 Nov-86 A-lOS Preaward Compliance Review Report for 2090-0014 Aug-89 Wastewater Treatment Construction Grants * Form available in electronic format. Contact the Forms Office for further details. ** Forms may not be used to gather information from the public without a valid and current 0MB clearance. Contact the Forms Office for further details. 0MB-i ------- Numerical List of EPA Public-Use Forms Date of 0MB Current 0MB Expiration Form No. Edition Originator Title Number Date 5700 12 A x-78 PM-216 Application for Federal Assistance 2030-0020 Jul-89 5700 20A May-82 PM-216 Assistance Agreement/Amendment 2010-0004 Jul-89 5700 20B Nov-86 PM-216 Assistance Amendment 2030-0020 Jul-89 5700 30 Nov-86 PM-216 Preapplication for Federal Assistance 2030-0020 Jul-89 5700 31 Oct-79 PM-216 Application for Federal Assistance 2010-0004 Aug-89 (Short Form) 5700 33 Nov-86 PM-216 Application for Federal Assistance 2030-0020 Jul-89 5700 33A May-74 PM-216 Application for Federal Assistance, 2030-0020 Jul-89 Narrative Statement 5700 33B May-74 PM-216 Application for Federal Assistance, 2030-0020 Jul-89 Narrative Statement 5700 33F Jul-76 PM-216 Application for Federal Assistance, 2030-0020 Jul-89 Narrative Statement 5700 330 Nov-75 PM-216 Application for Federal Assistance, 2030-0020 Jul-89 Narrative Statement 5700 33H Aug-86 EN-342 Pesticide Enforcement Cooperative 2030-0020 Jul-89 Agreement 5700 33! Dee-79 PM-216 Application for Federal Assistance, 2030-0020 Jul-89 Narrative Statement 5700 41 Apr-84 PM-216 Cost or Price Summary 2000-0453 0ct 87** 5700 48 May-84 PM-216 Procurement System Certification 2000-0453 Oct 87** 5720 12 Sep-85 PM-216 Application for Federal Assistance 2030-0018 Sep-90 (Construction Grants ooperaiive Agreements) 5770 02 Apr-78 PM-216 Fellowship Application 2010-0004 Jul-89 5770 03 Feb-77 PM-216 Fellowship Facilities and Commitment 2010-0004 Jul-89 Statement 5770 04 Feb-77 PM-216 Fellowship Applicant Qualifications 2010-0004 Jul-89 b qwry 5770 05 May-78 PM-216 Agency Fellowship Certificate 2010-0004 Jul-89 5770 06 Jun-73 PM-216 Fellowship Amendment 2010-0004 Jul-89 5770 07 Jun-73 PM-216 EPA Fellowship Activation Notice 2010-0004 Jul-89 5770 08 Jul-73 PM-216 Fellowship Agreement 2010-0004 Jul-89 5770 09 Jul-73 PM-216 EPA Fellowship Termination Notice 2010-0004 Aug-89 7500 08 Jul-80 WH-553 Report of Pollution-Caused Fish Kill 2040-0087 May-89 7500 42 Dec-80 WH-550 Federal Reporting Data System -- 2000-0043 Sep-90 Violations 7500 43 May-78 WH-550 Federal Reporting Data System -- 2000-0043 Sep-90 Variances and Exemption 7500 48 Nov-79 WH-550 lnventoiy of Injection Wells 2000-0056 Ju1 88** * 7500 55 Jan-89 EN-338 NPDES Laboratory Performance 2040-0089 Jul-89 Evaluation 7510 01 Jun-81 WH-595 Estimate of Municipal Wastewater 2040-0050 Dec 85** Treatment Facilities * 7520 01 Jan-88 WH-550E UIC Federal Reporting System Part 1: 2040-0042 Jul 88** Permit Review and IssuanceJV 1dlls in Area of Review * 7520 02A Jan-88 WH-550E Part H: Compliance Evaluation 2040-0042 Jul 88** * 7520 02B Jan-88 WH-550E Part H: Compliance Evaluation/ 2040-0042 Jul 88** Significant Noncompliance * 7520 03 Jan-88 WH-550E Part ifi: 1nspection ’Mechaniçal Integrity 2040-0042 Jul 88** Testing * 7520 04 Mar-88 WH-550E Part N: Quarterly Exceptions List 2040-0042 Jul 88** • Form available in elecironic formal. Contact the Fonns Office for further details. •* Forms may rmt be used to gather information from the public without a valid and current 0MB clearance. Contact the Fonns Office for further details. OMB-2 ------- Numerical List of EPA Public-Use Forms Date of 0MB Current 0MB Expiration Form No. Edition Originator Title Number Date * 7520 05 Jan-88 WH-550E Part V: Summary of UIC Grant 2040-0042 Jul 88** Utilization 7520 06 Feb-84 WH-550 Underground Injection Control Permit 2040-0042 Jul 88** Application 7520 07 Feb-84 WH-550 Application To Transfer Permit 2000-0042 Jul 88** 7520 08 Nov-83 WH-550 Injection Well Monitoring Report 2000-0042 Jul 88** 7520 09 Feb-84 WH-550 Completion Form for Class I Injection 2000-0042 JuI 88** Wells 7520 10 Feb-84 WH-550 Completion Report for Brine Disposal, 2040-0042 Jul 88** Hydrocarbon Storage 7520 11 Feb-84 WH-55() Annual Disposal/Injection Well 2000-0042 Jul 88** Monitoring Report 7520 12 Feb-84 WH-550 Well Rework Record 2000-0042 Jul 88** 7520 14 Mar-84 WH-550 Plugging and Abandonment Record 2040-0042 Jul 88** 7530 01 Sep-88 OS-420 Notification for Underground Storage 2050-0068 Sep-91 Tanks 7550 06 Jan-73 EN-336 NPDES--Application for Permit To 2040-0086 Jul 88** Discharge (Form A) 7550 08 Mar-74 EN-336 NPDES Application for Permit To 2040-0086 Jul 88** Discharge (Form C) 7550 09 May-73 EN-336 NPDES-Application for Permit To 2040-0086 Jul 88** Discharge (Form D) 7550 22 Jul-73 EN-336 NPDES-Application for Permit To 2040-0086 Jul 88** Discharge Wastewater (Form A) 7550 23 Jul-73 EN-336 NPDES-Application for Permit To 2040-0086 Jul 88** Discharge Wastewater (Form C) 7710 3C Nov-77 TS-788 TSCA Inventory Report Form C 158S77011 Jun 82** 7710 3D Nov-li TS-788 TSCA Inventory Report Form D 158S77011 Jun 82** 7710 3E Feb-79 TS-793 Chemical Substance Inventory Report 158S77011 Jun 82** Form E 7710 34 Sep-79 TS-793 Trade Name Product Identity Report 158-R0169 Jun 82** 7710 35 May-82 TS-778 Manufacturer’s Report: Preliminary 2000-0420 Mar 89** Assessment Information 7740 01 Dec-82 EN-342 TSCA Receipt for Samples and Documents 2070-0007 Mar-89 7740 02 L)ec-82 EN-342 TSCA Declaration of CBI 2070-0007 Mar-89 7740 03 Dec-82 EN-342 TSCA Notice of Inspection 2070-0007 Mar-89 7740 04 Dec-82 EN-342 TSCA Inspection Confidentiality Notice 2070-0007 Mar-89 7740 08 Dec-85 TS-793 Partial Updating of TSCA Inventory Data 2070-0070 Nov 87** Base: Production and Site Report 8500 21 Feb-87 H7505C Silvex/2,4,5-T Products: Claim for 2070-0071 May 87** Indemnification, Request for Federal Disposal * 8500 22 Jan-89 H7502C Dinoseb Products: Claim for 2070-007 1 Feb-90 Indemnification, Request for Federal Disposal 8510 08A Nov-80 TS-793 Urine Pesticide Residue Analysis Report 158-R0140 Nov 80** (MPM) 8510 08B Nov-80 TS-793 Urine Pesticide Residue Analysis Report 158-RO 140 Nov 80** (APM ) 8510 10 Feb-82 TS-798 Patient Summary Report 2000-0392 Sep 88** 8550 05 Feb-79 TS-768 Pesticide Incident Report 158-R0008 Jul 81** 8550 05A Feb-79 TS-769 IncidentReportUpdate 158-R0008 Jul.81** * 8570 01 Sep-88 H7505C Application for Pesticide 2070-0060 Jun-90 Amendment/Registration * Form available in electronic format. Contact the Forms Office for further details. ** Forms may not be used to gather information from the public without a valid and current 0MB clearance. Contact the Forms Office for further details. OMB-3 ------- Numerical List of EPA Public-Use Forms Date of 0MB Current 0MB Expiration Form No. Edition Originator Title Number Date 8570 04 Feb-85 H7505C Confidential Statement of Formula 2070-0060 Sep-90 8570 05 Apr-83 H7505C Application for Supplemental Registration 2070-0044 Mar-89 of Distributor * 8570 17 Feb-85 H7505C Application for an Experimental Use 2070-0040 Aug-90 Permit 8570 20 Jan-81 H7505C Data Reference Sheet 2070-0060 Sep-90 * 8570 25 Dec-87 H7505C Application for/Notification of State 2070-0055 Jun-90 Registration of a Pesticide To Meet a Special Local Need 8570 27 Oct-86 H7505C Formulato’s Exemption Statement 2070-0060 Sep-90 8570 28 Oct-86 H7505C Certification of Compliance with Data Gap 2070-0060 Sep-90 P rocedw 8570 29 Jul-86 H7505C Certification with Respect to Citation of 2070-0060 Sep-90 Data * 8570 30 Jan-89 H7502C Pesticide Regisuation Maintenance Fee 2070-0100 Jan-92 Filing 8580 01 Oct-82 H7505C FIFRA Section 3(C)(2)(B) 2070-0057 Nov-90 8580 03 Oct-82 H7505C Generic Data Exemption Statement 2000-0468 Nov-89 * 8580 04 May-88 H7505C Product Specific Data Report 2070-0057 Nov-89 8580 06 Oct-82 H7505C Certificate of Auemp To Enter into an 2070-0057 Nov-89 Agreement with Other Registrants for Development of Data 8700 12 Oct-88 OS-340 NotiflcaiionofHazardousWasteActivity 2050-0028 Oct-91 8700 13 Dec-87 OS-320 Hazardous WasteReport 2000-0058 Dec-88 8700 22 Sep-86 OS-340 Uniform Hazardous Waste Manifest 2050-0039 Sep 88** 8700 22A Sep-86 OS-340 Uniform Hazardous Waste Manifest 2050-0039 Sep 88** (Continuation) * 9310 01 Oct-87 OS-210 Application for Reimbursement to Local 2050-0077 Dec-90 Governments for Emergency Response * 9510 01 Jul-88 OS-120 Substantiation To Accompany Claims 2050-0078 Oct-90 of Trade Secrecy: Emergency Planning/ Community Right-To-Know Act * Form available in electronic formaL Contact the Forms Office for further details. ** Forms may not be used to gather information from the public without a valid and current 0MB clearance. Contact the Forms Office for further details. OMB-4 ------- List of EPA Public-Use Forms by 0mb Number Date of 0MB Current 0MB Expiration Form No. Edition Originator Title Number Date 8550 5A Feb-79 TS-769 IncidentReportUpdate 158-R0008 Jul 81** 8550 5 Feb-79 TS-768 Pesticide Incident Report 158-R0008 Jul 81** 8510 8B Nov-80 TS-793 Urine Pesticide Residue Analysis Report 158-RO 140 Nov 80** (APM) 8510 8A Nov-80 TS-793 Urine Pesticide Residue Analysis Report 158-R0140 Nov 80** (MPM) 7710 34 Sep-79 TS-793 Trade Name Product Identity Report 158-R0169 Jun 82** 7710 03E Feb-79 TS-793 Chemical Substance Inventory Report 158S7701 1 Jun 82** Form E 7710 03C Nov-77 TS-788 TSCA Inventory Report Form C 158S7701 1 Jun 82** 7710 03D Nov-77 TS-788 TSCA Inventory Report Form D 158S7701 1 Jun 82** 1900 10 Nov-76 PM-214 Contractor’s Cumulative Claim and 2000-0005 Mar 88** Reconciliation 1900 34A Apr-83 PM-214 Guide for Preparation of Contractor’s Claim 2000-0005 Mar 88** 1900 34 Apr-83 PM-214 Guide for Preparation of Contractor’s 2000-0005 Mar 88** Claims 3540 16 Jan-85 EN-342 Pesticides Report for Pesticide-Producing 2000-0029 Jan 88** Establishments 3520 3 May-76 EN-340 Lead Additive Report for Manufacturing 2000-0041 Mar 84** Facility or Site 7520 11 Feb-84 WH-550 Annual Disposal/Injection Well Monitoring 2000-0042 Jul 88** Report 7520 7 Feb-84 WH-550 Application To Transfer Permit 2000-0042 Jul 88** 7520 9 Feb-84 WH-550 Completion Form for Class I Injection 2000-0042 Jul 88** Wells 7520 8 Nov-83 WH-550 Injection Well Monitoring Report 2000-0042 Jul 88** 7520 12 Feb-84 WH-550 Well Rework Record 2000-0042 Jul 88** 7500 43 May-78 WH-550 Federal Reporting Data System -- Variances 2000-0043 Sep-90 and Exemption 7500 42 Dec-80 WH-550 Federal Reporting Data System -- 2000-0043 Sep-90 Violations 7500 48 Nov-79 WH-550 Inventory of Injection Wells 2000-0056 Jul 88** 8700 13 Dec-87 OS-320 Hazardous Waste Report 2000-0058 Dec 88** 3510 3 Jun-80 OS-320 Application for Hazardous Waste Permit 2000-0061 Dec 83** 3520 2 May-85 EN-397F Lead Additive Report for Refmers 2000-0066 Mar 87** 1900 55 Jan-82 PM-214 Hazardous Substance Response Fund 2000-0285 Sep 86** 8510 10 Feb-82 TS-798 Patient Summary Report 2000-0392 Sep 88** 7710 35 May-82 TS-778 Manufacturer’s Report: Preliminary 2000-0420 Mar 89** Assessment Information 5700 41 Apr-84 PM-216 Cost or Price Summary 2000-0453 Oct 87** 5700 48 May-84 PM-216 Procurement System Certification 2000-0453 Oct 87** 8580 3 Oct-82 H7505C Generic Data Exemption Statement 2000-0468 Nov-89 5770 5 May-78 PM-216 Agency Fellowship Certificate 2010-0004 Jul-89 5700 20A May-82 PM-216 Assistance Agreement/Amendment 2010-0004 Jul-89 5770 7 Jun-73 PM-216 EPA Fellowship Activation Notice 2010-0004 Jul-89 5770 8 Jul-73 PM-216 Fellowship Agreement 2010-0004 Jul-89 5770 6 Jun-73 PM-216 Fellowship Amendment 2010-0004 Jul-89 5770 4 Feb-77 PM-216 Fellowship Applicant Qualifications Inquiry 2010-0004 Jul-89 5770 2 Apr-78 PM-216 Fellowship Application 2010-0004 Jul-89 5770 3 Feb-77 PM-216 Fellowship Facilities and Commitment 2010-0004 Jul-89 Statement 5700 31 Oct-79 PM-216 Application for Federal Assistance (Short 2010-0004 Aug-89 Form) 5770 9 Jul-73 PM-216 EPA Fellowship Termination Notice 2010-0004 Aug-89 * Form available in electronic format. Contact the Forms Office for further details. ** Forms may not be used to gather information from the public without a valid and current 0MB clearance. Contact the Forms Office for further details. 0MB No. -1 ------- List of EPA Public-Use Forms by 0mb Number Date of 0MB Current 0MB Expiration Form No. Edition Originator Title Number Date 3300 1 Aug-77 LE-130 Application for Certification of Pollution 2020-0001 Feb 87** Control Facility 3300 3 Aug-77 LE-130 Notice of Federal Certification 2020-0001 Feb 87** 3300 2 Aug-77 LE-130 Notice of State Certificate 2020-0001 Feb 87** 5720 12 Sep-85 PM-216 Application for Federal Assistance 2030-0018 Sep-90 (Construction Grants/Cooperative Agreements) 5700 12 Apr-78 PM-216 Application for Federal Assistance 2030-0020 Jul-89 5700 33 Nov-86 PM-216 Application for Federal Assistance 2030-0020 Jul-89 5700 33A May-74 PM-216 Application for Federal Assistance, 2030-0020 Jul-89 Narrative Statement 5700 33B May-74 PM-216 Application for Federal Assistance, 2030-0020 Jul-89 Narrative Statement 5700 33F Jul-76 PM-216 Application for Federal Assistance, 2030-0020 Jul-89 Narrative Statement 5700 33 ( 3 Nov-75 PM-216 Application for Federal Assistance, 2030-0020 Jul-89 Narrative Statement 5700 33! Dec-79 PM-216 Application for Federal Assistance, 2030-0020 Jul-89 Narrative Statement 5700 20B Nov-86 PM-216 Assistance Amendment 2030-0020 Jul-89 5700 33H Aug-86 EN-342 Pesticide Enforcement Cooperative 2030-0020 Jul-89 Agreement 5700 30 Nov-86 PM-216 Preapplication for Federal Assistance 2030-0020 Jul-89 3320 1 ( t-77 EN-336 Discharge Monitoring Report 2040-0004 Jun 88** 3320 IT Jan-87 EN-336 NPDES Discharge Monitoring Report 2040-0004 Jun 88** 7520 10 Feb-84 WH-550 Completion Report for Brine Disposal, 2040-0042 Jul 88** Hydrocarbon Stomge * 7520 2A Jan-88 WH-550E Part II: Compliance Evaluation 2040-0042 Jul 88** * 7520 28 Jan-88 WH-550E Part II: Compliance Evaluation/Significant 2040-0042 Jul 88** Noncompliance * 7520 3 Jan-88 WH-550E Part ifi: Inspections/Mechanical Integrity 2040-0042 Jul 88** Testing * 7520 4 Mar-88 WH-550E Part IV: Quarterly Exceptions List 2040-0042 Jul.88** * 7520 5 Jan-88 WH-550E Part V: Summary of UIC Grant 2040-0042 Jul 88** Utilization 7520 14 Mar-84 WH-550 Plugging and Abandonment Record 2040-0042 Jul 88** * 7520 1 Jan-88 WH-550E UIC Federal Reporting System Part I: 2040-0042 Ju1 88** Permit Review and Issuance/Wells in Area of Review 7520 6 Feb-84 WH-550 Underground Injection Control Permit 2040-0042 Jul 88** Application 7510 1 Jun-81 WH-595 Estunate of Municipal Wastewater 2040-0050 Dec.85** Treatment Facilities 3560 3 Mar-85 EN-338 Compliance Inspection Report 2040-0057 Apr 88** 3510 28 Jun-80 EN-336 Application for PermitTo Discharge 2040-0086 Jul 88** Wastewater (Form 2B) 3510 2C Feb-85 EN-336 Application for Permit To Discharge 2040-0086 Jul 88** Wastewater (Form 2C) 3510 2D Sep-86 EN-336 Application Form 2D-New Sources & New 2040-0086 Jul 88** Dischargers Application for Permit To Discharge Process Waste 3510 1 ( t-80 EN-336 General Information Consolidated Permits 2040-0086 Jul 88** Program (Form 1) * Form available in electronic format. 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Contact the Forms Office for further details. 0MB No. -2 ------- List of EPA Public-Use Forms by 0mb Number Date of 0MB Current 0MB Expiration Form No. Edition Originator Title Number Date 7550 8 Mar-74 EN-336 NPDES Application for Permit To 2040-0086 Jul 88** Discharge (Form C) 7550 6 Jan-73 EN-336 NPDES--Application for Permit To 2040-0086 Jul 88** Discharge (Form A) 7550 9 May-73 EN-336 NPDES-Application for Permit To 2040-0086 Juf 88** Discharge (Form D) 7550 22 Jul-73 EN-336 NPDES-Application for Permit To 2040-0086 Jul 88** Discharge Wastewater (Form A) 7550 23 Jul-73 EN-336 NPDES-Application for Permit To 2040-0086 Jul 88** Discharge Wastewater (Form C) 3510 2E Sep-86 EN-336 Application Form 2E--Facilities Which Do 2040-0086 Jul-89 Not Discharge Process Wastewater 7500 8 Jul-80 WH-553 Report of Pollution-Caused Fish Kill 2040-0087 May-89 * 7500 55 Jan-89 EN-338 NPDES Laboratory Performance Evaluation 2040-0089 Jul-89 8700 12 Oct-88 OS-340 Notification of Hazardous Waste Activity 2050-0028 Oct-91 8700 22 Sep-86 OS-340 Uniform Hazardous Waste Manifest 2050-0039 Sep 88** 8700 22A Sep-86 OS-340 Uniform Hazardous Waste Manifest 2050-0039 Sep 88** (Continuation) 7530 1 Sep-88 OS-420 Notification for Underground Storage Tanks 2050-0068 Sep-91 * 9310 1 Oct-87 OS-210 Application for Reimbursement to Local 2050-0077 Dec-90 Governments for Emergency Response * 9510 1 Jul-88 OS-120 Substantiation To Accompany Claims of 2050-0078 Oct-90 Trade Secrecy: Emergency Planning/ Community Right-To-Know Act 3500 5 Dec-80 EN-397 Unleaded Gasoline Field Inspection 2060-0009 May-89 3520 5 May-85 EN-397F Lead Additive Report for Gasoline Importer 2060-0066 Mar 87** 3520 6A Jun-85 EN-397F Lead Additive Report Supplement A: 2060-0066 Mar 87** Constructive Allocations 3520 68 May-85 EN-397F Lead Additive Report Supplement B: 2060-0066 Mar 87** Transfers of Lead * 3520 9 Jul-88 EN-340 Application for Final Admission of a 2060-0095 Dec-90 Catalytic Converter and Oxygen Sensor Equipped Vehicle * 3520 8 Jul-88 EN-340 Application for Final Admission of 2060-0095 Dec-90 Nonconforming Imported Vehicle * 3520 8A Jul-88 EN-340 Continuation of Application for Final 2060-0095 Dec-90 Admission of Nonconforming Imported Vehicle * 3520 1 Sep-88 EN-340 Importation of Motor Vehicles and Motor 2060-0095 Dec-90 Vehicle Engines Subject to Federal Air Pollution Regulations 7740 2 Dec-82 EN-342 TSCA Declaration of CBI 2070-0007 Mar 89** 7740 4 Dec-82 EN-342 TSCA Inspection Confidentiality Notice 2070-0007 Mar 89** 7740 3 Dec-82 EN-342 TSCA Notice of Inspection 2070-0007 Mar 89** 7740 1 Dec-82 EN-342 TSCA Receipt for Samples and Documents 2070-0007 Mar 89** 3540 1 May-77 EN-342 Notice of Arrival of Pesticides and Devices 2070-0020 Mar 88** * 8570 17 Feb-85 H7505C Application for an Experimental Use Permit 2070-0040 Aug-90 8570 5 Apr-83 H7505C Application for Supplemental Registration 2070-0044 Mar 89** of Distributor * 8570 25 Dec-87 H7505C Application for/Notification of State 2070-0055 Jun-90 Registration of a Pesticide To Meet a Special Local Need * Form available in electronic format. 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Contact the Forms Office for further details. 0MB No. -3 ------- List of EPA Public-Use Forms by 0mb Number Date of 0MB Current 0MB Expiration Form No. Edition Originator Title Number Date 8580 6 Oct-82 H7505C Certificate of Attempt To Enter into an 2070-0057 Nov-89 Agreement with Other Registrants for Development of Data * 8580 4 May-88 H7505C Product Specific Data Report 2070-0057 Nov-89 8580 1 Oct-82 H7505C FIFRA Section 3(C)(2)(B) 2070-0057 Nov-90 * 8570 1 Sep-88 H7505C Application for Pesticide 2070-0060 Jun-90 Amendment/Registration 8570 28 Oct-86 H7505C Certification of Compliance with Data Gap 2070-0060 Sep-90 Procedures 8570 29 Jul-86 H7505C Certification with Respect to Citation 2070-0060 Sep-90 of Data 8570 4 Feb-85 H7505C Confidential Statement of Fonnula 2070-0060 Sep-90 8570 20 Jan-81 H7505C Data Reference Sheet 2070-0060 Sep-90 8570 27 Oct-86 H7505C Formulator’s Exemption Statement 2070-0060 Sep-90 * 3540 8 Nov-88 EN-342 Application for Registration of 2070-0069 Nov-89 Pesticide-Producing Establishment 7740 8 Dec-85 TS-793 Partial Updating of TSCA Inventory Data 2070-0070 Nov 87** Base: Production and Site Report 8500 21 Feb-87 H7505C Silvexf2,4,5-T Products: Claim for 2070-007 1 May 87** Indemnification, Request for Federal Disposal * 8500 fl Jan-89 H7502C Dinoseb Products: Claim for 2070-0071 Feb-90 Indemnification, Request for Federal Disposal * 8570 30 Jan-89 H7502C Pesticide Registration Maintenance Fee 2070-0100 Jan-92 Filing * 4700 4 Nov-86 A-105 Preaward Compliance Review Report for 2090-0014 Aug-89 Wastewater Treatment Construction Grants * 1730 1 Sep-88 PM-215 Report of Nonexpendable Government 9000-0075 Aug-90 Property Acquired by Contractor * Form available in electronic format. Contact the Forms Office for further details. ** Forms may not be used to gather information from the public without a valid and current 0MB clearance. Contact the Forms Office for further details. 0MB No. -4 ------- List of Standard Forms (SF) Date of Form Responsible Cuffent Unit of No. Office Edition Title Issue 1 PM-215 Jul-79 Printing and Binding Requisition Set 1C PM-215 Jan-60 Printing and Binding Requisition for Specialty Items Sht 7 PM-212 Dec-80 Service Record Can! 7A PM-212 May-80 Service Record -- Continuation Card 7D PM-212 Sep-64 Position Identification Strip Card 8 PM-212 Jun-87 Notice to Federal Employee about Unemployment Insurance Sht 13 PM-226 Sep-87 International Transactions of the Federal Government Sht 14 Nov-80 Telegraphic Message Shi 15 PM-212 Jul-83 Claim for 10-Point Veteran’s Preference Sht 18 PM-214 Nov-78 Request for Quotations Set 26 PM-214 Apr-85 AwarcjfContmct Sht 30 PM-214 Oct-83 Amendment of Solicitation/Modification of Contract Sht 33 PM-214 Apr-85 Solicitation, Offer, and Award Sht 39 PM-2 12 Nov-88 Request for Referral of Eligibles Set 39A PM-212 Oct-74 Request and Justification for Selective Factors and Sht Quality Ranking Factors 50 PM-212 Aug-88 Notification of Personnel Action Set 52 PM-212 Aug-88 Request for Personnel Action Sht 59 PM-212 Jan-79 Request for Approval of Noncompetitive Action Sht 61 PM-212 Jun-86 Appointment Affidavits Sht 61B PM-212 Oct-88 Declaration of Appointee Sht 62 PM-212 Oct-79 Agency Request To Pass Over a Preference Eligible or Object Sht to an Eligible 63 Aug-81 Memorandum of Call P d 65A PM-215 Dec-72 U.S. Government Messenger Envelope -- 4 1/8” x 9 1/2” Envelope 65B PM-21 5 Dec-71 U.S. Government Messenger Envelope -- 9 3/4” X 12” Envelope 65C PM-215 Dec-71 U.S. Government Messenger Envelope -- 12” X 16’ Envelope 66 PM-212 Jan-89 Official Personnel Folder Folder 71 Mar-79 Application for Leave Sht 75 PM-212 Oct-86 Request for Pi 1iminary Employment Data Sht 76 PM-212 Jul-88 Federal Postcard Registration and Absentee Ballot Pam Request (FPCA) 78 PM-2 12 Oct-69 Certificate of Medical Examination Set 78A PM-212 Nov-76 Medical Appointment and Report Can! 81 PM-215 Feb-89 Request for Space Sht 83 PM-223 Sep-83 Request for 0MB Review Sht 83A PM-223 Sep-83 Instructions for Standard Form 83 Pam 85 PM-212 Dec-87 Data for Nonsensitive Positions Set 86 PM-212 Oct-87 Questionnaire for Sensitive Position Set 87 PM-212 Apr-84 Fingerprint Chart Card 88 PM-212 Mar-89 Report of Medical Examination Sht 91 PM-2 15 Nov-76 Operator’s Report of Motor Vehicle Accident Card 93 PM-2l2 Oct-74 Report of Medical History Sht 98 PM-214 Feb-73 Notice of Intention To Make a Service Contract and Set Response to Notice 98A PM-2 14 Feb-73 Notice of intention To Make a Service Contract and Response Set to Notice (Attachment A) 99 PM-214 May-65 Notice of Award of Contract Set 100 May-84 Employer Information Report, EEO-1 Set 105 PM-212 Dec-79 Certificate of Membership in the United States Civil Service Pam Retirement System 108 PM-225 May-69 Statement of Receipts Sht I 13A PM-212 Jun-88 Monthly Report of Federal Civilian Employment Sht 115 PM-2 I 1D Aug-83 Request for Records Disposition Authority Set 1 15A PM-2 1 1D Aug-83 Request for Records Disposition Authority -- Continuation Sht SF-i ------- List of Standard Forms (SF) Date of Form Responsible Current Unit of No. Office Edition Title Issue 120 PM-215 Apr-57 Report of Excess Personal Property Set 122 PM-215 Jun-74 Transfer Order --Excess Personal Property Set 126 PM-215 Jul-78 Report of Personal Property for Sale Set 127 PM-212 Jul-86 Request for Official Personnel Folder (Separated Employee) Set 129 PM-214 Oct-83 Solicitation Mailing List Application Sht 132 PM-225 Jul-76 Apportionment and Reapportionment Schedule Sht 133 PM-226 Jul-85 Report on Budget Execution Sht 135 PM-211D Jul-85 Records Transmittal and Receipt Sht 135A PM-211D Jul-85 Records Transmittal and Receipt (Continuation Sheet) Sht 144 PM-212 Sep-83 Statement of Prior Federal Service Pam 145 PM-215 Jun-82 Telephone Service Request Set 146 PM-215 Nov-76 Changes in Telephone Listings Sht 152 PM-21 1D Jan-87 Request for Clearance or Cancellation of a Standard or Optional Sht Form or Exception 162 PM-211D Jun-88 Interlibrary Loan Request Set 171 PM-212 Jun-88 Application for Federal Employment Pam l7lA PM-212 Jun-88 Continuation Sheet for Standard Form 171 Sht 172 PM-212 Jun-88 Amendment to Application for Federal Employment-- SF 171 Sht 177 PM-212 Sep-84 Statement of Physical Ability for Light Duty Work Sht 182 PM-212 Dec-79 Request, Authorization, Agreement, and Certification of Set Training 210 PM-226 Jul-81 Signature/Designation Card forCertifying Officer Cani 215 PM-226 May-78 Deposit Ticket Set 220 PM-226 Nov-88 Report on Financial Position Sht 221 PM-226 Nov-88 Report on Operations Sht 224 PM-226 May-82 Statement of Transactions (Classified According to Sht Appropriation, Fund and Receipt Account, and Related Control Totals) 225 PM-226 Nov-78 Report of Obligations Sht 238 PM-226 Apr-75 SIBAC Adjustment Voucher for Charge-Backs Set 256 PM-212 Aug-87 Self-Identification of Handicap Sht 258 PM-21 1D Oct-78 Request To Transfer, Approval, and Receipt of Records to Set National Archives of the United States 269 PM-226 Apr-88 Financial Status Report (Long Form) Sht 270 PM-226 Jul-76 Request for Advance of Reimbursement Sht 271 PM-216 Jul-76 Outlay Report and Request for Reimbursement for Sht Construction Programs 272 PM-226 Jul-76 Federal Cash Transactions Report Sht 272A PM-226 Sep-76 Federal Cash Transactions Report -- Continuation Sht 273 Oct-83 Reinsurance Agreement for a Miller Act Performance Bond Sht 274 Oct-83 Reinsurance Agreement for a Miller Act Performance Bond Sht 275 Oct-83 Reinsurance Agreement in Favor of the United States Sht 308 May-85 Request for Determination and Response to Request Sht 344 Feb-74 Multiuse Standard Requisitioning/Issue System Document Set 360 PM-223 Dec-88 Request To Approve an Interagency Reporting Requirement Pal 361 Mar-84 Transportation Discrepancy Report Set 424 PM-216 Apr-88 Application for Federal Assistance Sht 1012 PM-226 Oct-77 Travel Voucher Sht 1012A PM-226 Oct-77 Travel Voucher (Memorandum) Sht 1034 Oct-87 Public Voucher for Purchases and Services Other Than Personal Sht 1034A Oct-87 Public Voucher for Purchases and Services Other Than Sht Personal (Memorandum) 1035 Sep-73 Public Voucher for Purchases and Services Other Than Sht Personal (Continuation Sheet) SF-2 ------- List of Standard Forms (SF) Date of Form Responsible Current Unit of No. Office Edition Title Issue 1035A Sep-73 Public Voucher for Purchases and Services Other Than Sht Personal (Memorandum) (Continuation Sheet) 1038 PM-226 Oct-77 Advance of Funds Application and Account Set 1080 PM-226 Apr-82 Voucher for Transfers Between Appropriations and/or Funds Sht 1081 PM-226 Sep-82 Voucher and Schedule of Withdrawals and Credits Set 1096 PM-226 Sep-82 Schedule of Voucher Deductions Set 1098 PM-226 Jul-80 Schedule of Canceled or Undelivered Checks Set 1128 PM-226 ‘ ‘ Payroll for Personal Services -- Payroll Certification and Sht Summary 1 128A PM-226 *** Payroll for Personal Services -- Payroll Certification and Sht Summary -- Memorandum 1143 Sep-73 Advertising Order Sht 1150 PM-226 Dec-77 Record of Leave Data Set 1151 PM-226 Dec-79 Nonexpenditure Transfer Authorization Sht 1152 Sep-67 Designation of Beneficiary -- Unpaid Compensation of Set Deceased Civilian Employee 1154 PM-226 Sep-67 Public Voucher for Unpaid Compensation Due a Deceased Sht Civilian Employee 1164 PM-226 Nov-77 Claim for Reimbursement for Expenditures on Official Sht Business 1165 PM-226 Jun-83 Receipt for Cash -- Subvoucher Booklet 1166 PM-226 May-84 Voucher and Schedule of Payments Set 1 166A PM-226 May-84 Voucher and Schedule of Payments -- Memo Set 1167 PM-226 May-84 Voucher and Schedule of Payments (Continuation Sheet) Set 1170 PM-226 Nov-85 Redemption of Unused Tickets Set 1184 PM-226 Jun-84 Unavailable Check Cancellation Set 1186 Apr-83 Transmittal for Transportation Schedules and Related Sht Documents 1187 PM-212 Jan-79 Request for Payroll Deductions for Labor Organization Dues Set 1188 Jan-79 Cancellation of Payroll Deductions for Labor Organization Set Dues 1189 PM-226 Jan-78 Request by Employee for Payment of Salaries or Wages by Set Credit to Account at a Financial Organization 1192 PM-226 Mar-79 Authorization for Purchase and Request for Change: U.S. Can! Series EE Savings Bond 1195 PM-226 Mar-81 Recommendation for Designation and Revocation of Agent To Set Receive and Deliver Checks and Savings Bonds 1198 PM-226 Mar-82 Request by Employee for Allotment of Pay for Credit to Set Savings Account with a Financial Organization 1 199A PM-226 Jun-87 Direct Deposit Sign-Up Form Set 1221 PM-226 Mar-82 Statement of Transactions According to Appropriations, Set Funds, and Receipt Accounts 2800 PM-212 Apr-86 Application for Death Benefits -- Civil Service Retirement Set System 2801 PM-212 Jan-82 Application for Immediate Retirement Set 2802 Nov-87 Application for Refund of Retirement Deductions -- Sht Civil Service Retirement System 2803 PM-212 Mar-87 Application To Make Deposit or Redeposit -- Sht Civil Service Retirement System 2804 PM-212 May-80 Application To Make Voluntary Contributions -- Sht Civil Service Retirement System 2805 PM-212 Oct-88 Request for Recovery of Debt Due the United States Set (Civil Service Retirement System) *** No date SF-3 ------- List of Standard Forms (SF) Date of Form Responsible Current Unit of No. Office Edition Title Issue 2806 PM-212 Feb-80 Individual Retirement Record (Civil Service Retirement Sht System) 2806-1 PM-212 Feb-80 Notice of Correction of Individual Retirement Record-- Sht Civil Service Retirement System 2807 PM-212 Jul-80 Register of Sepaiations and Transfers — ShE Civil Service Retirement System 2808 PM-212 Jul-84 Designation of Beneficiary -- Civil Service Retirement System Sht 2809 PM-212 Jun-88 Health Benefits Registration Form -- Federal Employees Set Health Benefits Program 2809A PM-212 Jul-87 Federal Employees Health Benefits Program -- Information for Pam Federal Civilian Employees and U.S. Postal Service Employees 2810 PM-212 Jan-87 Federal Employees Health Benefits Program -- Notice of Set Change in Health Benefits Enrollment 2811 PM-212 Jun-84 Transmittal and Summary Report to Carrier -- Federal Set Employees Health Benefits Program 2812 PM-226 Aug-88 Report of Withholdings and Contributions for Health Benefits, Sht Life Insurance, and Retirement 2812A PM-226 Aug-88 Report of Withholdings and Contributions for Health Benefits Sht by Enrollment Code SF-4 ------- List of Optional Forms (OF) Date of Form Responsible Current Unit of No. Office Edition Title Issue 5 PM-212 Mar-82 Inquiry as to Availability Sht 8 PM-212 Jan-85 Position Description Sht 11 PM-21 1D Jul-87 Reference Request -- Federal Records Centers Set 17 PM-214 Oct-83 Sealed Bid Label Label 19 PM-226 Jul-68 Request for Disposition of Check/Savings Bond Set 21 PM-21 ID Feb-62 Cmss-Reference Set 23 PM-211D Feb-62 Chargeout Record Card 30 PM-215 Mar-67 Motor Vehicle Service and Inspection Work Orders Can! 36 PM-215 Mar-67 PM Schedule and Maintenance Control Card Card 41 PM-215 Jul-76 Routing and Transmittal Slip Pa! 65 WH-546 Dec-78 ADP Transcript Sheet Pal 69 PM-212 Feb-89 Assignment Agreement -- Title IV of the Sht Intergovernmental Personnel Act of 1970 101 PM-223 Feb-74 Summary Worksheet for Estimating Reporting Costs Sht 178 A-106 Jan-78 Application for Passport/Registration Sht 185 A-l06 Aug-85 Outgoing Telegram (OCR) Slit 185A A-106 Aug-85 Outgoing Telegram (OCR) (Continuation Sheet) Sht 336 PM-215 Apr-86 Continuation Sheet Sht 345 PM-215 Nov-85 Physical Fitness Inquiry for Motor Vehicle Operator Sht 346 PM-215 Nov-85 U.S. Government Motor Vehicle Operator’s Card Identification Card 347 PM-214 Oct-83 Order for Supplies or Services Set 348 PM-214 Oct-83 Order for Supplies or Services Schedule -- Continued Set 1017G PM-226 Sep-79 Journal Voucher Sht OF-i ------- |