United States         Information Resources      April 1989
Environmental Protection    Management
Agency            (PM-211)




Forms Catalog

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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

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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

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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

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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

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Current EPA Forms
asof
April 1989

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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

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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

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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

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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

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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

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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

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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

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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. Contact the Forms Office for details.
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. Contact the Forms Office for details.
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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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. 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. -2

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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. Contact the Forms Office for further details.
** Forrm 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. -3

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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

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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

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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

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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

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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

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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

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