United States Office of Information EPA-202-B-96-001
Environmental Protection Resources Management May 1997
Agency
V>EPA Form Catalog
Internet Address (URL) • http://www.epa.gov
Recycled/Recyclable • Printed with Vegetable Oil Based Inks on Recycled Paper (20% Postconsumer)
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Table of Contents
Page
Introduction iii
Numerical List of EPA Forms 1
1100-1199 Organization and Functions 1
1200-1299 Intergovernmental Activities 1
1300-1399 Administrative Management 1
1400-1499 Protective Services ; 1
1500-1599 Public Affairs 2
1600-1699 Interagency Agreements 2
1700-1799 Personal Property 2
1900-1999 Contracts Management 2
2000-2099 Emergency Programs 4
2100-2199 Library Systems 4
2200-2299 Publications and Communications Materials 4
2300-2399 Printing and Distribution 4
2500-2599 Accounting and Financial Systems 4
2600-2699 Travel and Transportation 5
2700-2799 Audit Investigation Management 6
3100-3199 Human Resources Management 6
3300-3399 Legal.. 8
3500-3599 Enforcement 9
4500-4599 International Activities 11
4700-4799 Equal Opportunity 11
4900-4999 Motor Vehicle and Aircraft Management 11
5000-5099 Telecommunications 11
5100-5199 Office Services 12
5700-5799 Grants 12
7500-7599 Water 13
7600-7699 Air 14
7700-7799 Toxic Substances • 15
8500-8599 Pesticides 16
8700-8799 Solid Waste 17
9000-9999 Superfund I8
Region 03 Region 3 Forms 19
Region 04 Region 4 Forms 19
Region 06 Region 6 Forms 20
Region 09 Region 9 Forms 21
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Page
Alphabetical List of EPA Forms 22
Appendices
EPA Forms Available in Electronic Format Electronic-i
Numerical List of EPA Public-Use Forms 0MB-i
List of EPA Public-Use Forms by 0MB Number 0MB No-i
Source Information for EPA Forms Source-i
List of EPA Forms Declared Obsolete Since April 30, 1989 Obsolete-i
11
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Introduction
What This Catalog Does
Forms-based information is vital to the efficient operation of the EPA and its
management of mission-related programs. This Forms Catalog identifies all
administrative and program-related forms currently used by the Agency, as well as forms
declared obsolete during a survey conducted in mid-1995. It also provides information on
the sources of forms supplies and an order blank used to request forms from the Agency’s
distribution center in Cincinnati, Ohio, or from responsible program offices.
The electronic version of this Catalog, found on the Agency’s Value-Added Backbone
System, is a first step in a development program designed to provide Agency personnel
with timely information about available forms, along with electronic versions of actual
forms that may be filled, approved and routed via computer, mitigating the need for
paper forms.
Getting the Form You Need
This Catalog contains three principal lists of forms. The first is sorted by the EPA Form
Number, in ascending order. The second is sorted by the alphabetical name of the
form. Third is a list of forms used by the Agency to collect information from the public;
these require approval from the Office of Management and Budget (0MB) for EPA
distribution and use. This list is sorted twice: once by EPA Form Number, and once by
0MB Approval Number.
The Agency does not stock or distribute General Services Administration (GSA)
“Standard Forms” (SF series), or “Optional Forms” (OF series). These should be obtained
from the nearest GSA office. The GSA forms are available over the Internet on
http://www/gsalform. If you have any questions, please call 817-978-2604.
EPA pre-printed paper forms are available from several sources. Most Agency forms are
stocked and distributed by the National Center for Environmental Publications and
Information (NCEPI) in Cincinnati, Ohio. Other program-related administrative and
public use forms may be distributed solely by the program offices responsible for them.
In addition, a limited number of forms are available on a self-service basis in the EPA
FonnSmart Center at Headquarters. The Center is located in Room M3307CY
(Courtyard), Mail Code 3408; service hours are 8:00 a.m. to 4:30 p.m. daily.
To assist you in obtaining the forms you need, this Catalog also contains a list of EPA
forms, identified by EPA form number, that shows Source information for all active
forms. For your convenience, an order form is included in the Appendices of the catalog.
Forms also may be requested by phone or facsimile machine.
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The “Source” colunm in each of the lists will indicate “A” if the form can be obtained
from the NCEPI, “B” if the form is available in the EPA FormSmart Center
(Headquarters), “C” if the form is distributed by a program office, and “D” if the form
comes from another source (e.g. the National Technical Information Service in
Springfield, VA, a Federal agency, or a state government).
To order forms from the National Center:
To order forms from NCEPI, you may do any of the following:
• Contact NCEPI via telephone:
(513) 489-8190 (from within a Federal Agency or International)
(800) 490-9198 (from outside a Federal Agency)
• Complete EPA Form 2360-1
• Submit a memorandum, stating your name, form number, quantity, your
complete return mailing address(mail code), and telephone number
• Contact NCEPI via facsimile (fax) at 513-489-8695
• Send an e-mail to allaire-michael on the LAN
• Send a request through the mail to:
US EPA-NCEPI Forms Distribution Office
P.O. Box 42419
Cincinnati, OH 45242
To obtain a form distributed by a program office, first fmd the Mail Code for the
office responsible for the form (located under the “Originating Office” column on each
sort list). Order a form by mail by sending a copy of the order blank (found in the
Appendices of this Catalog) to the program office via the mail code shown. Order a form
by phone by calling the program office telephone number corresponding to the form
number, as found in the Appendix “Source Information for EPA Forms.”
Electronic Forms
An increasing number of forms used for general administrative and program management
applications are becoming available in electronic format. These are distributed and
supported by the Enterprise Systems Division (ESD) of the Office of information
Resources Management. In the future, electronic forms likely will be maintained and
distributed on the Value Added Backbone System (VABS) network and the EPA Intranet
for use by Agency personnel nationwide. For information on the availability and use of
iv
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electronic forms, please contact the Director, Enterprise Systems Division, Mail Code
3403, US EPA, 401 M Street, Washington, DC 20460, or telephone (202) 260-5220.
Other electronic form applications involving the use of Electronic Document Interchange
(EDI) procedures also are under development to improve the exchange of data between
the Agency and the commercial sector (the regulated community, EPA contractors and
suppliers of goods and services to the Agency). These initiatives are fostered by the
National Performance Review (NPR) under the guidance of the Agency’s Office of
Policy, Planning and Evaluation (OPPE). For further information on electronic commerce
with EPA, please contact the Director, Regulatory Management Division, OPPE, Mail
Code 2136, US EPA, Washington, DC 20460.
Contacting the Agency Forms Officer
We hope this Forms Catalog will be helpful in the selection and use of Agency forms.
Please forward any corrections and suggestions for improvement of this Catalog to the
Agency Forms Officer, Enterprise Information Management Division, Mail
Code 3408, US EPA, Washington, DC 20460. Please address any questions to the Forms
Officer by calling (202) 260-2866, via facsimile at (202) 401-8390, or by email to:
“FORMS OFFICER”.
V
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Numerical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
1100-1199 — Organization and Functions
1100 — Organization
1110 1 Jul-83 3610 Request for Change in Organization Sht A,B
Structure
1200-1299 — Intergovernmental Activities
1265 93 Dec-93 6205J SNAP Information Notice for Significant Set C
Activity
1265 94 Dec-93 6205J TSCAISNAP Addendum for Significant Set C
Activity
1300-1399 — Administrative Management
1300 — General
1300 13 Apr-86 3404 Clerical Work Request Pad A
1315 — Directives
1315 4 Aug-86 3610 Checklist of EPA Transmittals Sht A,C
1315 5 Jul-82 3610 Directives Processing Worksheet Sht A
1315 10 Dec-79 3610 Directive Number Assignment Card A,C
1315 11 May-86 3610 Notice Sht A
1315 12A May-86 3610 EPA Order Sht A
1315 17 Jan-95 3610 Directives Clearance Record Sht A,C
1320 — Correspondence
1320 1 A Jan-90 3204 Concurrence Sheet (Official File Copy) Set A,B
(Single Sheet)
1320 3 Mar-84 3204 Mailing Label Label A,B
1320 8 Apr-73 3204 EGD Contractor’s 4th Class Mailing Label Label A,B,C
1325 4 Jan-87 2136 ICR Clearance Control Set C
1335 — Forms
1335 4 Nov-80 3404 Forms Number Assignment Sheet Sht B,C
1400-1499 — Protective Services
1480 — Physical Security
1480 2 Jan-80 2410 Personnel Security Action Request Sht A
1480 6 Jun-71 2441 FBI Record Check Request Sht C
1480 7 Mar-80 2410 Security File Review Sht C
1480 19 Feb-74 2410 Security Termination Statement Sht A
1480 27 2410 Security Investigation Review/Analysis Sht C
1480 36 Jul-96 3204 EPA Bomb Data Info Sht A,C
1480 40 Feb-84 2410 Authority for Release of Information Set A
1480 41 Jan-86 2410 Record of Communication (Records Sht C
Checks/Clearances)
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Numerical List of EPA Forms
Date of
Current Origin-
Form No. Edition ator Title
1500-1599 — Public Affairs
1550 — Freedom of Information
1550 9 Feb-94 7506C Freedom of Information Request Response Set C
1600-1699 — Interagency Agreements
1610 — Interagency Agreements
1610 1 Oct-88 3303F Interagency Agreement
1700-1799 — Personal Property
1900-1999 — Contracts Management
1900 — General
Pam A,B,C
Con-
struc-
tion
Stock
Code
1700 — General
1700 4 Jul-94
1700 7 Oct-74
1700 8 Jul-94
1700 9 Jul-96
3303F
3204
2376
3204
Request for Shipping Service
Property Receipt and Transfer Document
Voucher for Payment and Release
Property Pass Request Order
Set
Set
Sht
Sht
1740 — Inventory Management
1740 9 Aug-94 3303F Owned Personal Property System Input
Data
A,B,C
A,B,C
A,B,C
C
3801F
3801F
3801 F
1900
1900
1900
1900
1900
1900
1900
2 Dec-81
3 Jun-75
5 Jun-71
6 Feb-81
7 Apr-85
8 Aug-94
10 Feb-91
Sht A,B
Sht A
Sht A
Set A
3801 F
3801 F
3801 F
3801 F
Set
A
Sht
A,B
Set
A,B,C
Sht
A.B
Sht
A
ProfitlFee Objectives
Assignee’s Release
Contractor’s Assignment of Refunds,
Rebates, and Credits
Contractor’s Release
Request for Cost Analysis
Procurement Request/Order
Contractor’s Cumulative Claim and
Reconciliation
3801 F Worksheet for Small Purchases
3801 F Contract Memorandum of Transmittal and
Checklist
3801F Contract Checklist
3801 F Contracting Officer’s Evaluation of
Contractor Performance
Project Officer’s Evaluation of Contractor
Performance
Guide for Preparation of Contractor’s
Claims
Guide for Preparation of Contractor’s Claim
Request for Equal Opportunity Clearance
of Contract Award
Record of Procurement Request Review
1900 13 Apr-85
1900 19 Aug-88
1900 20 Apr-85
1900 26 Apr-85
1900 27 Apr-84 3801F
1900 34 Apr-83 3801F
1900 34A Apr-83 3801F
1900 35 Jul-84 3801F
1900 37 Apr-85 3801F
Sht A
Set A,B,C
Set A,B,C
Pam A
Pam
Sht
A
A
Sht A
2
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Numerical List of EPA Forms
Date of Con—
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
1900 41 A Jun-79 3801F CPAF Contract Summary of Significant Sht A
Performance Observation
1900 41 B Jun-79 3801F CPAF Contract Individual event Sht A
Performance Observation
1900 44 May-94 3801F Purchase Order Register Sht A,C
1900 44 B Jul-96 3801F Contract Summary of Significant Sht A
Performance Obser
1900 48 Jul-94 3801 F Order for Services-Emergency Response to Pam C
Hazardous Substance Release
1900 49 Sep-94 380 iF Notice To Proceed with Emergency Pam C
Response to Hazardous Substance Release
1900 53 Apr-84 3801F Determination and Findings: Authorization Sht C
To Use a Time and Materials Contract
1900 54 Apr-85 380 iF Memorandum to the File: Synopsis Sht C
Exemption
1900 56 Apr-85 3801 F Letter Contract for State/Local Government Pam C
Response to Emergency Hazardous
Substance Release
1900 58 Apr-84 3801F Notice Regarding Work Stoppage Sht C
1900 59 Jul-94 380 IF Delivery Order for Emergency Response Set A
1900 60 Mar-91 3801 F Announcement of Contract Award Sht A
1900 60 A Apr-90 3801F Notification of Work Assignment For Sht A
Superfund Remedial Action Construction
1900 61 Feb-84 380 IF Proposal Technical Evaluation Sht A
1900 62 Feb-84 3801F Determination and Findings: Authority To Sht C
Use a Letter Contract
1900 63 Sep-94 380 IF Monthly Requisition and/or Receiving Set A,B
Report for Blanket Purchase Orders
1900 64 Jul-84 380 IF Termination Settlement Memorandum of Sht A,C
Transmittal and Checklist
1900 65 Jun-94 380 IF Designation & Appointment of Project Sht A
Officer/Work Assignment
Manager/Delivery Order
1900 65 A Nomination and Appointment of A,B,C
Contracting Officer’s Representative (COR)
1900 68 Notice of Contract Costs Suspended and/or A,B,C
Disallowed
1900 69 Work Assignment A,B,C
1900 69 A Work Assignment Supplement A,B,C
1900 70 EPA Contract Checklist
1900 71 EPA Reviews, Concurrences, and
Approvals
1900 72 EPA Reviews, Concurrences, and
Approvals
1950 1 Credit Card Requisition
3
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Numerical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
2000-2099 — Emergency Programs
2070 — Environmental Programs
2070 11 Jul-81 5201 Potential Hazardous Waste Site Slit C
Identification
2070 12 Jul-81 5201 Potential Hazardous Waste Preliminary Pam C
Assessment
2070 13 Jul-81 5201 Potential Hazardous Waste Site--Site Pam C
Inspection Report
2070 14 Sep-91 5201 Potential Hazardous Waste Site Current Pam C
Disposition
2100-2199 — Library Systems
2170 — Services
2170 6 Feb-88 3404 Response to Request for Publication Card C
2200-2299 — Publications and Communications Materials
2200 — General
2200 9 Jul-93 3204 Printing, Distribution, and Inventory A,B,C
2300-2399 — Printing and Distribution
2340 — Printing and Duplication
2340 15 Aug-94 3303 F Federal Register Typesetting Request Set A,B,C
2340 17 May-84 3204 Notice of Pending Delivery/Shipment Set A,B,C
2360 — Distribution
2360 1 Feb-84 3204 Publications/Forms Request Set A
2500-2599 — Accounting and Finance
2505 — Collections and Securities
2505 2 May-81 3303F Record of Public Funds Received Set A
2505 4 Feb-94 3303F Bill for Collection Set A,B,C
2545 — Imprest Fund
2545 1 Nov-71 3303F Verification of Imprest Fund Sht A
2545 2 Mar-92 3303F Request and Receipt for Cash Advance Set A
2550 — Accounting and Financial Systems
2550 4 Dec-79 3303F Interoffice Transfer Voucher Set A
2550 6 Mar-80 3303F Redistribution of Payroll Charges Set A,B,C
2550 9 Apr-74 3303F Commitment Notice Sht A,B,C
2550 10 Oct-94 3303F Miscellaneous Obligation Document Sht A,B,C
2550 19 Sep-94 3303F Project Officer Invoice Approval Set A,B.D
2550 21 Oct-94 3303F Project Officer’s Interagency Agreement Set A,B,C
Invoice Approval D
2550 22 Mar-90 3303F Invoice Summary Report Set D
4
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Numerical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
2550 23 Sep-94 3303F Financial and Accounting Data Sht A,B,C
Continuation Sheet
2560 — Payroll
2560 1 Oct-71 3303F Timekeeper Signature Card Card A
2560 2 Nov-86 3303F Payroll Error Notice Set A
2560 4 Oct-90 3303F Authorization for Mailing Pay Checks Sht A,B
2560 5 Sep-94 3303F Change in Fixed Account Number Sht A,B,C
2560 7 Aug-94 3303F Request for and Authorization of Overtime Set A,B,C
Work
2560 12 Jul-74 3303F Time and Attendance Chargeout Card Card C
2560 18 Sep-77 3303F DIPS Payroll Master Input Data Sht A
2560 21 Oct-78 3303F Emergency Salary Payment Voucher Sht C
2560 22 Jul-81 3303F Cumulative Pay Adjustment Sht C
2560 23 Jul-81 3303F Current Pay Adjustment Sht C
2560 25 Oct-88 3303F Statement of Earnings and Leave Set A,B,C
2560 28 Aug-94 3303F Payroll Distribution Time Sheet Set A,B,C
2560 28 A Aug-94 3303F Payroll Distribution Time Sheet Set A,B,C
(Continuation)
2560 29 Apr-89 2410 Eligibility & Rate Determination Schedule Sht A,C
for Administratively Uncontrollable
Overtime (AUO) Pay
2560 30 May-89 2410 Time Report for Administratively Sht A,C
Uncontrollable Overtime (AUO)
2560 31 Oct-91 3303F Authorization For Change Of Address Set A
2560 32 May-90 3303F Cashier Reimbursement Voucher Sht A
2565 — Time and Attendance
2565 1 Sep-94 3303F Time and Attendance Card Card A.B,C,
D
2565 2 Jul-94 3303F Time and Attendance Card (Salmon) Card A,B,C
2565 3 Jan-92 3303F Time and Attendance Card (Yellow) Card A,B,C
2570—Travel
2570 6 Dec-80 3303F Treasury Financial Communication System Card A
(TFLS) Ticket
2570 7 Jul-95 3303F Conference Planning -- Cost Comparison Sht
for Site Selection
2570 8 Jul-95 3303F Claim for Relocation Income Tax Sht A
Allowance for the Year
2600-2699 — Travel and Transportation
2610 — Authorization
2610 1 Aug-94 3303F Travel Authorization Set A,B,C
2610 1 A Aug-94 3303F Travel Authorization - Permanent Change Set A,B,C
of Station
5
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Numerical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
2620 — Expenses
2620 1 Dec-86 3303F Employee Application for Reimbursement Sht A
of Expenses
2620 2 Feb-92 3303F Actual Subsistence Expenses While Sht A
Occupying Temporary Quarters
2635 — Permanent Change of Station
2635 1 Nov-72 3303F Information for Authorization of Moving Sht A
and Related Travel Expenses
2635 2 Aug-77 3303F Relocation Expenses Payment Record Set A
2700-2799 — Audit Investigation Management
2720 — Investigations
2720 2 May-83 2410 Notice of Scheduled Investigation Sht A
2720 4 Apr-90 2410 Office of Investigations Monthly Report Sht A
2720 6 Mar-87 2410 Evidence Custody Set A
2720 13 Apr-83 2410 Investigative Report Cover A
2720 14 Nov-84 2410 Report of Investigation-Narrative Sht A
2720 15 Nov-84 2431 Report of Interview Sht A
2720 16 Jul-83 2431 Report of Investigation Sht A
2720 17 Jul-86 2410 Investigation Cover Sheet Sht A
2720 18 Oct-84 2410 Advice of Rights for a Federal Employee Sht C
2720 19 Oct-84 2410 Notice to a Federal Employee: Duty To Sht C
Respond to Questions
2720 20 A Oct-84 2410 Advice of Rights (Non-Employee Sht C
Custodial Interview)
2720 20 B Oct-84 2410 Advice of Rights (Federal Employee in Sht C
Custody)
2720 26 Feb-92 2410 Record of Non-Cost Training Activity Sht C
3100-3199 — Human Resources Management
3100 — General
3100 1 Feb-81 3622 Agreement to Remain in the Govermnent Set A,B,C
3100 13 Jan-78 3610 Medical Report Sht C
3100 14 May-80 3610 Volunteer Service Program Participation Sht A
Agreement
3100 17 Jan-84 3622 Probationary Period Sht A
3100 18 May-84 3610 Personnel Action Tickler Notice
3110 — Enforcement Administration
3110 1 Aug-92 3610 Employee Separation or Transfer Checklist Set A,B,C
3110 11 Feb-92 3610 Service Computation Date Worksheet Sht C
31 10 15 Aug-91 3610 Expert or Consultant Supplemental Sht A,B,C
Information
3110 26 Oct-74 3610 Competitive Level Code Log Sht C
6
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Numerical List of EPA Forms
3115 — Promotion and Placement
3130 — Incentive Awards
Date of
Con-
Current
Origin-
struc-
Stock
Form No.
Edition
ator
Title
tion
Code
3110 38
Dec-94
3610
Vacancy Announcement
Sht
C
3110 43
Jul-86
3610
Organization Code Sheet
Sht
A,B,C
3110 46
Dec-94
3610
Vacancy Announcement (Headquarters)
Sht
C
3110 47
Sep-93
3610
EPA Direct Hire Announcement
Sht
C
Sht C
Sht
Sht
Sht
Sht
Sht
Sht
A
A,B,C
A,B,C
A
A
A
Sht A,B,C
Sht A
Set
Sht
Sht
Sht
A,B,C
A,C
A
A
3115 3 A Dec-94 3610 Merit Promotion Vacancy Announcement
(Upward Mobility)
3115 4 Sep-84 3622 Staffing Requisition
3115 7 Feb-92 3610 Evaluation and Rating Worksheet
3115 8 Sep-84 3610 Merit Promotion Certificate
3115 8 A Sep-84 3610 Merit Promotion Certificate (Continuation)
3115 8 B Sep-84 3610 Nonstatus Candidate Referral List
3115 8 C Sep-84 3610 Noncómpetitive Candidate Referral
Certificate
3115 8 D Oct-84 3610 Certificate for Upward Mobility
3115 8 E Nov-86 3610 Candidate Referral Certificate: Temporary
Position
3115 9 Sep-84 3610 Merit Promotion Information Record
3115 13 Sep-84 3610 Merit Promotion Program Checklist
3115 14 Feb-92 3610 Merit Promotion Application Rating Sheet
3115 15 Sep-84 3610 Merit Promotion Rating Plan Specifications
3115 17 Oct-84 3610 Interview Rating Sheet for Upward
Mobility Positions
3 115 18 Oct-84 3610 Job Element Rating Sheet for Upward
Mobility Positions
3115 22 Oct-84 3610 Appraisal of Other Characteristics Needed
for Upward Mobility
3115 24 Aug-87 3634 Performance Agreement, Appraisal, and
Certification
3115 28 Sep-84 3610 Job Analysis Record
3115 32 Dec-94 3610 Promotion and Career Opportunities Sheet
3115 34 Jul-95 3610 Candidate Referral List
Recommendation for Monetary Award
Recommendation for Incentive Award
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
Certificate of Retirement
Special Achievement Award Certificate
Sht C
Sht C
Sht A,B,C
Sht A
Sht
Sht
Sht
A
C
C
3130
3130
3130
3130
3130
3130
3130
3130
3130
3130
1
IA
4
6
7A
7B
7C
7D
9
10
Aug-94
Aug-94
Jul-82
Sep-90
Jul-86
Jul-86
Jul-86
Jul-86
Jan-88
Sep-88
3610
3303F
3634
3610
3622
3622
3622
3610
3622
3610
Set A.B.C
Set A.B.C
Sht A
Sht
Sht
Sht
Sht
Sht
Sht
Sht
A
A.B.C
A,B,C
A,B,C
A,B,C
A,B,C
A,B,C
7
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Numerical List of EPA Forms
3140 — Employee Development and Training
3140 18 Jun-95 3633 Assignee’s Evaluation of Mobility
Assignments
3140 20 Jun-95 3633 Supervisor’s Evaluation of EPA’S IPA
Personnel Exchange Program
3140 32 Sep-92 3634 Performance Agreement, Appraisal and
Certification for Supervisors, Managers,
and Executives
3150 — Position and Compensation Classification
3150 1 Feb-87 3622
3150 5 Sep-73 3622
3150 15 Dec-73 3622
3150 21 Dec-77 3622
3155 — Pay Administration
3155 1 Apr-77 2376 Request for Waiver of Claim for Erroneous Sht
Payment
Overpayment Investigation Report
Supplemental Pay for Federal and Non-
Federal IPA Detailees
3634 Retention Allowance Request and
Approval
3155 5 Apr-94 3634 Recruitment or Relocation Bonus Request
and Approval
3155 6 Apr-94 3634 Recruitment or Relocation Bonus Service
Agreement
3155 8 Apr-94 3634 Emergency Designation and Authorization
for an Exemption to Bi-Weekly Limitation
3155 9 Apr-94 3634 Request for Approval of Superior
Qualifications Appointment
3155 10 Apr-94 3634 Request, Approval, and Agreement for
Advance in Pay
3160 —
Atte
ndance an
d Leave
3160
2
Oct-82
3634
Restoration of Forfeited Annual Leave
3160
3
Nov-76
3634
Request for Flexible Hours
3160
6
Nov-89
3610
Application to Contribute to EPA Leave
3160 7 Nov-89 3610 EPA Leave Recipient Action Form Sht A,B,C
3300-3399 — Legal
3300 — General
3300 1 Application for Certification of a Pollution
Control Facility
Date of
Con-
Current
Origin-
struc-
Stock
Form No. Edition
ator Title tion
Code
Sht C
Sht C
Set A,B,C
Position Description
Position Description Amendment
Group Action Request List
Factor Evaluation System Evaluation
Statement
Sht
Sht
Sht
Sht
3155 2 Apr-73 2376
3155 3 Jul-94 3033F
A,C
A,C
A,B,C
A
3155 4 Apr-94
Sht A
Set A
Pam A,C
Pam A,C
Sht A,C
Sht
Sht
Sht A,B,C
Sht A,B,C
Sht A,B,C
Bank
8
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Numerical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
3300 4 Jun-93 2312 Law Library (Charge-Out) Card C
3300 14 Jan-93 2233 Voucher For Payment To Informants Set C
3320 1 Dec-91 4203 Discharge Monitoring Report Set
3340 — Patents and Copyrights
3340 1 Aug-72 2310 Employee Report of Invention Set A
3340 2 Aug-72 2310 Invention Rights Questionnaire Set C
3370 Tort Claims
3370 1 Jan-84 2376 Employee Claim for Loss or Damage to Sht C
Personal Property
3500-3599 — Enforcement
3510 — Permits
3510 1 Aug-90 4203 General Information Consolidated Permits Set A
Program (Form 1)
3510 2 B Apr-91 4203 Application for Permit To Discharge Sht A
Wastewater (Form 2B) Concentrated
Animal Feeding Ops.
3510 2 C Aug-90 4203 Application Form 2C - Wastewater Pam A
Discharge Information
3510 2 D Aug-90 4203 Application Form 2D-New Sources & New Pam A
Dischargers: Application for Permit To
Discharge Process Waste
3510 2 E Aug-90 4203 Application Form 2E--Facilities Which Do Pam A
Not Discharge Process Wastewater
3510 2 F Jan-92 4203 Application for Permit to Discharge Set A,C,D
Stormwater
3510 3 A Dec-80 5302W Acknowledgment of Application for a Card
Hazardous Waste Permit
3510 6 Aug-92 4203 Notice of Intent (NOl) Sht A,C,D
3510 7 Aug-92 4203 Notice of Termination (NOT) Sht A,C,D
3520 — Air
3520 1 Sep-94 6401 Importation of Motor Vehicles and Motor Mult A,D
Vehicle Engines Subject to Federal Air Sht
Pollution Requirements
3520 2 Feb-88 6406J Lead Additive Report for Refinery Sht C
3520 5 May-90 6406J Lead Additive Report for Gasoline Sht C
Importer
3520 6 B May-85 6406J Lead Additive Report Supplement B: Sht C
Transfers of Lead
3520 8 Oct-90 6401 Application for Final Admission of Sht C
Nonconforming Imported Vehicle
3520 9 Sep-94 6401 Application for Final Admission - U.S. Slit C
Version Vehicle
9
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Numerical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
3520 12 Mar-90 6406J Fuel Manufacturer Notification for Motor Sht C
Vehicle Fuel
3520 13 Mar-90 6406J Fuel Additive Manufacturer Notification Sht C
3520 14 Sep-94 6101 Application for EPA Prior Written Sht C
Approval
3520 15 Sep-94 6101 Application for Final Admission - Sht C
Plumbtesmo Test Report
3520 16 Aug-94 6406J Supplemental Notification for a Fuel or Sht C
Fuel Additive Manufacturer - Registration
of Fuel and Fuel Additives
3520 20 A Jun-94 6406J Reformulated Gasoline Company Sht C
Registration
3520 20 B Jun-94 6406J Reformulated Gasoline Facility Sht C
Registration
3520 20 C Jun-94 6406J Reformulated Gasoline Facility Batch Sht C
Report
3520 20 D Feb-95 6406J Reformulated Gasoline and Anti-Dumping Sht C
Quarterly Certification
3520 20 E Feb-95 6406J Reformulated Gasoline and Anti-Dumping Sht C
Annual Compliance Designation
3520 21 Oct-94 6401 Importation of Non-Road Vehicles and Sht A,D
Equipment Subject to Federal Air Pollution
Regulations
3550 — Investigative Activities
3550 4 Jul-95 Statement (Initial page, with signature) Sht C
3550 4 A Jul-95 Statement (Initial page, no signature) Sht C
3550 4 B Jul-95 Statement (Continuation Sheet) Sht C
3550 4 C Jul-95 Statement (Conclusion, with signature) Sht C
3550 5 Jul-95 Witness Narrative Statement (Initial page, Sht C
with signature)
3550 5 A Jul-95 Witness Narrative Statement (Continuation Sht C
page)
3550 5 B Jul-95 Witness Narrative Statement (Initial page, Sht C
no signature)
3550 5 C Jul-95 Witness Narrative Statement (Includes Sht C
signature, conclusion page)
3550 8 Jul-95 Memorandum of Interview Sht C
3550 8 A Jul-95 Memorandum of Interview (Continuation Sht C
Sheet)
3550 9 Jul-95 Report of Investigation Sht C
3550 11 Jul-95 Case Opening Checklist Sht C
3550 13 Jul-95 Request for Laboratory/Technical Support Sht C
3550 14 Jul-95 Employee’s Monthly Activity Report Sht C
3550 15 Jul-95 Property Inventory/Chain of Custody Sht C
10
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Numencal Lust of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
3550 15 A Jul-95 Property Inventory/Chain of Custody Sht C
(Continuation Sheet)
3550 21 Jul-95 Electronic Surveillance Authorizaiton Sht C
3550 22 Jul-95 Report of Use - Electronic Surveillance Sht C
3560 — Water
3560 3 Sep-94 2223-A Water Compliance Inspection Report Sht A
3560 4 Feb-80 2223-A Deficiency Notice Set A
4500-4599 — International Activities
4550 — International Travel Plans
4550 1 Aug-94 2610 International Trip Report Set A,B,C
4550 5 Apr-93 2610 International Travel Plan Set A,B,C
4550 7 Nov-80 2610 Passport Log Card C
4700-4799 — Equal Opportunity
4700 — General
4700 4 Jan-90 1201 Preaward Compliance Review Report for Sht A
All Applicants Requesting Federal
Assistance
4700 14 May-84 1201 EEO Contractor Invoice Set C
4900-4999 — Motor Vehicle and Aircraft Management
4920 — Operation
4920 3 Mar-94 3204 Daily Vehicle Utilization Report Sht A
4920 5 Nov-83 3204 Accumulative Daily Request--Carrier Sht C
4920 8 Nov-83 3204 Request for EPA Driver Service Set C
4920 15 Nov-92 3204 Parking ViolatIon Set C
4920 16 Jul-93 3204 Vehicle Operations Summary (Quarterly) Sht A
4920 17 Jul-93 3204 Vehicle Operations Report (Monthly) Sht A
4920 18 Jul-93 3204 EPA Motor Vehicle Status Change Notice D
4920 19 Jul-93 3204 EPA Motor Vehicle Master Record Sht A
5000-5099 — Telecommunications
5000 — Data Communications
5000 1 HQ Data Communications Quality Service
Survey
5020 — Telephone System
5020 1 Jul-94 3707 Washington Telecommunications Service Sht B,C
Request
5040 — Teletype and Facsimile System
5040 10 Aug-90 3707 Signature Card Card A
5040 11 Aug-90 3707 Classified Fax Cover Sheet Sht A
5040 12 Jul-92 3707 Telecommunications Quality Survey Card C
11
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Numerical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
5040 13 Jun-93 3707 Headquarters Express Locator Form Card B,C
5040 14 Feb-92 3707 Headquarters Subject Directory Change Card A,B,C
Form
5100-5199 — Office Services
5100 — General
5100 8 Aug-94 3303F Facilities Services Request Set A,B,C
5100 9 May-94 3204 EPA Headquarters Transit Subsidy Sht C
Enrollment Form
5100 10 May-94 3204 EPA Headquarters Transit Subsidy Sht
Recertification
5160 — Parking Permits
5160 1 Jan-95 3204 Parking Permit Application Sht A
5170 — Conference Facilities
5170 5 Off-Site Conference Room Rental
5180 — Mail and Messenger Services
5180 12 May-79 3204 Mail Label - Third Class Label C
5180 14 May-79 3204 Mail Label - Fourth Class Label C
5180 16 May-91 3204 Business Reply Label Label C
5180 17 Mar-87 3204 Daily Record of Postage Meter Register Sht A,B,C
Readings
5180 18 Aug-88 3204 Custom Designed Mail Special Envelope Env A
5700-5799 — Grants
5700— General
5700 12 Jan-91 3903F Application for Federal Assistance Pam A
5700 12 A Nov-90 3903F Instructions for Completing EPA Form Pam A
5700- 12
5700 12 C Application for Federal Assistance, page 3
5700 12 D Application for Federal Assistance, page 4
5700 14 Mar-94 390 iF Assistance Funding Order Sht A
5700 20 A Aug-94 3901F Assistance Agreement/Amendment Pam A
5700 20 B Aug-94 3901F Assistance Amendment Sht A
5700 29 Jul-82 390 IF Grant Audit Request Sht A
5700 30 Nov-90 390 iF Preapplication for Federal Assistance Pam A
5700 31 Oct-79 3901F Application for Federal Assistance (Short Pam A
Form)
5700 33 Sep-90 390 iF Application for Federal Assistance Pam A
5700 33 A Sep-90 390 IF Application for Federal Assistance, Sht A
Narrative Statement
5700 33 B Sep-90 390 IF Application for Federal Assistance, Pam A
Narrative Statement
12
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Numerical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
5700 33 C May-74 390 IF Application for Federal Assistance (Water Pollution
Control Areawide Waste Treatment Management
Planning Grants)
5700 33 F Sep-90 390 IF Application for Federal Assistance, Sht A
Narrative Statement
5700 33 G Sep-90 390 IF Application for Federal Assistance, Pam A
Narrative Statement
5700 33 1 Dec-79 390 IF Application for Federal Assistance, Sht A
Narrative Statement
5700 34 Mar-74 390 IF Multipurpose Wastewater Treatment Reimbursement
5700 41 Nov-90 390 iF Cost or Price Summary Pam A
5700 42 Feb-85 390 IF Grant Record Adjustment Notice Set A
5700 48 Nov-90 390 iF Procurement System Certification Sht A
5700 49 Nov-88 390 IF Certification Regarding Debarment, Pam A
Suspension, and Other Responsibility
Matters
5700 51 May-93 390 IF Assistance Administrative Summary Sheet Sht A
5720 — Construction
5720 12 Aug-90 390 IF Application for Federal Assistance Pam A
(Construction Grants/Cooperative
Agreements)
5770 — Training and Fellowships
5770 2 Feb-91 3901F Fellowship Application Pam A
5770 3 Aug-90 390 IF Fellowship Facilities and Commitment Sht A,C
Statement
5770 4 Feb-77 3901F Fellowship Applicant Qualifications Sht A,C
Inquiry
5770 5 May-78 390 IF Agency Fellowship Certificate Sht A,C
5770 6 Sep-90 390 IF Fellowship Amendment Sht A
5770 7 Jun-73 390 IF EPA Fellowship Activation Notice Set A
5770 8 Jul-73 390 IF Fellowship Agreement Sht A
5770 9 Jul-73 390 IF EPA Fellowship Termination Notice Sht A
7500-7599 — Water
7500 — General
7500 2 Jul-75 7201 Official Sample Seals Label A,B,C
7500 48 Sep-94 4602 Inventory of Injection Wells Sht
7500 53 Sep-80 5202G SPCC Inspection Field Sheet Sht A
7500 54 Sep-80 5202G Detailed SPCC Documentation for Set A
Inspection
7500 55 Jan-93 2225A NPDES Laboratory Performance Pam A,D
Evaluation
13
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Numerical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
7520 — Underground Injection Control
7520 1 Sep-90 4602 UIC Federal Reporting System Part I: Set A
Permit Review and Issuance/Wells in Area
of Review
7520 2 A Sep-90 4602 Part II- A: Compliance Evaluation Set A
7520 2 B Sep-90 4602 Part II- B: Compliance Set A
Evaluation/Significant Noncompliance
7520 3 Sep-90 4602 Part HI-A: Inspections/Mechanical Set A
Integrity Testing
7520 4 Sep-90 4602 Part IV: Quarterly Exceptions List Set A
7520 5 Sep-90 4602 Part V: Summary of UIC Grant Utilization Set A
7520 6 Sep-90 4602 Underground Injection Control Permit Sht A
Application
7520 7 Sep-90 4602 Application To Transfer Permit Sht A
7520 8 Sep-90 4602 Injection Well Monitoring Report Sht A
7520 9 Sep-90 4602 Completion Form for Class I Injection Sht A
Wells
7520 10 Sep-90 4602 Completion Report for Brine Disposal, Sht A
Hydrocarbon Storage, or Enhanced
Recovery Well
7520 11 Sep-90 4602 Annual Disposal/Injection Well Monitoring Sht A
Report
7520 12 Sep-90 4602 Well Rework Record Sht A
7520 14 Sep-90 4602 Plugging and Abandonment Plan Sht A
7530 — Underground Storage Tanks
7530 1 Feb-92 5401W Notification for Underground Storage Pam C
Tanks
7550 — Permits
7550 6 Nov-90 4203 NPDES--Application for Permit To Sht A
Discharge (Form A)
7550 6 A Oct-90 4203 Instructions for EPA 7550-06 Sht A
7550 22 Aug-90 4203 NPDES-Application for Permit To Set A
Discharge Wastewater (Form A)
7550 22 A Aug-90 4203 Application for Permit to Discharge Pam
Wastewater. Supplementary Instructions
for Standard Form A - Municipal
7600-7699 — Air
7600 — Ozone
7600 5 Jan-94 6205J Stratospheric Ozone Protection Program Set
Controlled Substance Report
7610 — Acid Rain
7610 1 Dec-94 6204J Certificate of Representation Set C
14
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Numerical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
7610 3 Nov-92 6204J Phase I Permit Set C
7610 3 A Nov-92 6204J Phase I Extension Plan Set C
7610 3 B Nov-92 6204J Substitution Plan Set C
7610 3 C Nov-92 6204J Reduced Utilization Plan Set C
7610 4 Nov-92 6204J Dispatch System Set C
7610 5 Jan-93 6204J Allowance Account Information Sht C
7610 6 Jan-93 6204J Allowance Transfer Form Sht C
7610 7 Jan-95 6204J Bid Form Sht C
7610 7 A Jan-95 6204J Letter of Credit Sht ‘C
7610 8 Jan-95 6204J S02 Allowance Offer Sht C
7610 9 Apr-94 6204J Direct Sale Application Sht C
7610 10 Jan-93 6204J Conservation/Renewables Reserve Sht C
7610 11 Mar-93 6204J Conservation Verification Protocol Set C
7610 12 Jan-93 6204J Monitoring Plan Sht C
7610 13 Jan-93 6204J Certification Test Notice (Optional) Sht C
7610 14 Jan-93 6204J Certification Application Sht C
7610 15 Jan-93 6204J Quarterly Reports C
7610 16 P Apr-93 6204J Petition Submittal Notice (Optional) Sht
7610 16 Dec-94 6204J Phase II Permit Application Set C
7610 17 Dec-94 6204J Repowering Extension Plan Set C
7610 18 Repowering Technology Petition
7610 19 Jan-94 6204J New Unit Exemption Sht C
7610 20 Dec-94 6204J Retired Unit Exemption Sht C
7610 21 Mar-94 6204-J Phase 1, Permit Application NOx Sht C
Compliance Plan
7610 22 Mar-94 6204-J NOx Averaging Plan Set C
7610 23 Mar-94 6204-J NOx Compliance Extension Sht C
7610 24 Mar-94 6204-J Alternative Emission Limitation Sht C
Demonstration Period Petition
7610 25 Mar-94 6204-J Final Alternative Emission Limitation Sht C
7700-7799 — Toxic Substances
7710 — General
7710 19 Sep-81 7407 Confidentiality Agreement--TSCA Sht A
Contractor Employee
7710 25 Jan-91 7405 Premanufacture Notice for New Chemical Set D
Substances
7710 30 Jan-94 7502C Time Accounting Information System Set
Record
7710 35 May-82 7405 Manufacturer’s Report: Preliminary Pam C
Assessment Information
7710 45 Sep-81 7407 Destruction Log Sht A
7710 51 Jul-87 7405 Dioxins/Furans Report Pam C -
7710 52 7405 Comprehensive Assessment Information Pam C
Rule (CAIR) Report
15
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Numerical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
7710 53 Sep-89 7404 Notification of PCB Activity Sht C
7710 56 Sep-94 7405 Notice of Commencement of Manufacture Pam C
or Import
7740 — TSCA
7740 1 Dec-82 7201 TSCA Receipt for Samples and Documents Set
7740 2 Oct-96 7201 TSCA Declaration of CBI Set
7740 6 Sep-92 7407 Federal TSCA CBI Access Request, Sht A
Agreement, and Approval (Document &
Computer)
7740 6 A Jan-92 7407 Federal TSCA CBI Access Request, Sht A
Agreement, & Approval:
Contractor/Subcontractor Employee
7740 8 Feb-94 7407 Partial Updating of TSCA Inventory Data Set C
Base: Production and Site Report
7740 9 Oct-92 7407 TSCA Confidential Business Information Card A
(Cover Sheet)
7740 10 Oct-85 7407 Receipt Log: TSCA CBI Sht A
7740 11 Oct-85 7407 Inventory Log: TSCA CBI Sht A
7740 12 Oct-85 7407 Memorandum of TSCA CBI Telephone Sht A
Conversation
7740 13 Oct-85 7407 TSCA CBI Visitors Log Sht A
7740 14 Oct-85 7407 Temporary Loan Receipt for TSCA CBI Set A
7740 15 Oct-85 7407 TSCA CBI Meeting Sign-in Sheet Sht A
7740 16 Oct-85 7407 Confidentiality Agreement for US Set A
Employees Upon Relinquishing TSCA CBI
Access Authority
7740 17 Sep-92 7407 Request for Approval of Contractor Access Sht A
to TSCA Confidential Bus. Info.
7740 23 Sep-92 7407 TSCA Security Manual Update Sht A
Transmittal Sheet
7740 24 Sep-92 7407 Federal Agency, Congress and Federal Sht A
Court Sign Out Log
7740 25 Sep-92 7407 TSCA CBI ADP User Registration Sht A
7740 26 Sep-92 7407 Permanent Transfer Receipt for TSCA Sht A
CBI
7740 27 Sep-92 7407 Contractor Information Sheet Sht A
7740 28 Sep-92 7407 TSCA Confidential Business Information Sht A
Document Reconciliation Certification
8500-8599 — Pesticides
8500 — General
8500 6 Nov-72 7503W Pesticide Sample Record Card C
8500 7 Feb-73 7505C Enforcement Case Review Set C
8500 7 A Feb-73 7505C Enforcement Case Review Set C
8500 12 Apr-75 7503W Microbiological Laboratory Report Sht C
16
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Numerical List of EPA Forms
Date of
Current Origin-
Form No. Edition ator
8500 22 Jan-89 7502C
8500 23 Jun-90 7502C
8500 24 Feb-88 7502C
8510 — Human Health
8510 14 Oct-76 7503W
8550 11 Apr-75 7503W
8570 — Product Registration
8570 1 Aug-94
8570 4 Aug-94
8570 5 Aug-94
8570 20 Jan-91 7505C
8570 25 Jan-94 7505C
8570 27 Jul-91 7505C
8570 28 Jan-91 7505C
8570 29 May-94 7505C
8570 30 Oct-93 7502C
8570 32 May-91 7505C
8580 — FIFRA
8580 1
8580 4
Title
Dinoseb Products: Claim for
Indemnification, Request for Federal
Disposal
Request for Document Center Services
FIFRA Sensitive Information Transmittal
Biological Report of Analysis
Microbiological Laboratory Report
Pesticide Registration Maintenance Fee
Filing
Certification of Attempt to Enter into an
Agreement with other Restraints for
Development of Data
Con-
struc-
tion
Pam
Set C
Set C
Set A,C
Sht C
Set C
Set C
Set C
Set C
Set C
Set C
Set A
Sht C
Sht C
8700-8799 — Solid Waste
Nov-93 5301 Notification of Regulated Waste Activity
Jul-90 5301 Acknowledgment of Notification of
Hazardous Waste Activity (Verification)
5301 Hazardous Waste Report
8700 22 Sep-88 5301 Uniform Hazardous Waste Manifest Sht
Stock
Code
C
7505C Application for Pesticide
Amendment/Registration
7505C Confidential Statement of Formula
7505C Notice of Supplemental Registration of
Distribution of a Registered Pesticide
Product
8570 6 May-76 7505C Notice of Registration
8570 17 Jan-94 7505C Application for an Experimental Use
Permit
Data Reference Sheet
Application for/Notification of State
Registration of a Pesticide To Meet a
Special Local Need
Formulator’s Exemption Statement
Certification of Compliance with Data Gap
Procedures
Certification with Respect to Citation of
Data
Set
Set
C
C
Set C
Set C
Sht C
Oct-82
May-88
7505C FIFRA Section 3(C)(2)(B)
7505C Product Specific Data Report
8700 — General
8700 12
8700 12B
8700 13 Al Aug-93
B
Pam A
Set C
Pam D
17
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Numerical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
8700 22 A Sep-88 5301 Uniform Hazardous Waste Manifest Sht
(Continuation)
8700 23 Nov-93 5301 RCRA Part A Permit Application Pam A
8710 — RCRA
8710 1 Oct-82 5305 Inventory Log (RCRA CBI) Sht C
8710 2 Oct-82 5301 User Sign-Out Log (RCRA CBI) Sht C
8710 4 Oct-82 5305 Federal Agency, Congr ss, and Federal Sht C
Court Sign-Out Log (RCRA CBI)
8710 5 Oct-82 5305 Request for Approval of Contractor Access Sht
to RCRA Confidential Business
Information
8710 6 Oct-82 5305 RCRA Confidential Business Information Sht C
Meeting Sign-in Sheet
8710 7 Oct-82 5305 Destruction Log (RCRA CBI) Sht C
8710 9 Oct-82 5305 RCRA Contractor Employee Sht C
Confidentiality Agreement
8710 10 Oct-82 5305 Confidentiality Agreement for US Sht C
Employees Upon Termination/Transfer
8710 11 Oct-82 5305 Authorization for Access to RCRA CBI Sht C
8710 12 Oct-82 5305 Request for Approval of Temporary Sht C
Employee for Access to RCRA CBI
8710 13 Oct-82 5305 RCRA Confidential Business Information Sht C
8710 14 Oct-82 5305 Confidentiality Agreement for Contractor Sht C
Employees Upon Termination/Transfer
8710 16 Oct-93 5301 1990 Inventory of Federal Hazardous Pam C
Waste Activity
9000-9999 — Superfund
9110 — Scientific
9110 1 Nov-90 5201 Inorganic Traffic Report Set C
9110 2 Nov-90 5201 Organic Traffic Report Set C
91 10 3 5201 Packing List/Chain of Custody
9110 5 Mar-93 52040 Organic Traffic Report/Chain of Custody Set C
Form
9310 — Administration
9310 1 Jul-91 5201 Application for Reimbursement to Local Pam A,D
Governments for Emergency Response
9350 1 Dec-94 7408 EPA Toxic Chemical Release Inventory Pam A,C
Reporting - Form R
9350 2 New 7408 Toxic Chemical Release Inventory Sht A,C,D
Certification Statement
9510 — Community Right-to-Know
18
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Numerical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
9510 1 Jul-88 5101 Substantiation To Accompany Claims of Pam A,C
Trade Secrecy: Emergency Planning!
Community Right-To-Know Act
Regional Forms
Region 03
R210 I 3ES3 I Document Distribution Form C
R280 I 3ES3 1 Data Acceptance or Rejection Forms C
R280 2 3ES3 1 Data Acceptance or Rejection Tracking ‘C
Reports
R280 3 3ES3 1 Delivery of Analytical Services Request C
Forms
R750 I 3WM55 PPETS Annual Report Form - 1994 C
R750 2 3WM55 PPETS Audit Form C
R750 3 3WM55 PPETS Pretreatment Compliance C
Inspection
R750 4 3WM55 PPETS Update C
R750 5 3WM55 Audit Checklist C
R750 6 3WM55 PCI Checklist C
R750 7 3WM55 Industrial User Oversight Checklist C
R750 8 3WM55 Legal Authority Checklist C
R750 9 3WM55 Enforcement Response Plan Checklist C
R750 10 3WM55 SPCC Facility Inspection C
R750 11 3ES3 1 Quality Assurance Project Plan and C
Sampling Plan Review Checklists
R750 12 3ES31 Field Inspection Checklist C
R750 13 3ES3 1 Laboratory Inspection Checklist C
R750 14 3ES3 I Regional Sample Control Center’s Monthly C
Reports
R750 15 3ES3 I QA Project Plan Review Checklist C
R750 16 3ES31 RSCC Sample Projection Form C
R850 I 3ATI 1 FIFRA Section 27 Case Referral
Disposition Worksheet
R850 2 FIFRA Investigation Referral Form
R850 3 FIFRA Enforcement Case
Recommendation Worksheet
R850 4 FYI’S Data Input Forms
R850 5 NARS Data input Form
R850 6 NESHAP Inspection Checklist
Region 04
RI 34 1 Record Transfer Inventory Form Sht C
R134 2 Jan-94 Records Checkout Form Sht C
R134 3 Jan-94 Record Inventory Sht C
R134 4 Record Checkout Form for Regional Sht C
Records Tracking System
19
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Numerical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Tide tion Code
R148 I Secured Hours Building Access Sht C
R155 I Jan-94 FOIA Work Request Sht C
RI 55 2 Jan-94 FOIA Exemption Sht C
R171 1 Loan Request for Computer Equipment Sht C
R190 I Purchase Justification Sht C
R217 I 4PM-1F Inter Library Loan Request Sht C
R217 2 Mar-95 4PM-1F Dun & Bradstreet Request Tracking Form Sht C
R217 3 Mar-95 4PM-IF Request for Services Sht C
R261 1 Quick Trip Permit Sht C
R265 1 Jan-94 Attorney Timesheet - Water Branch Sht C
R265 2 Jan-94 Attorney Timesheet - Criminal Branch Sht C
R265 3 Jan-94 Attorney Timesheet - OPA Branch Sht C
R265 4 Jan-94 Attorney Timesheet - RCRAIAir Branch Sht C
R3 16 1 Flexiplace Program - Work Agreement for Sht C
Episodic Participants
R3 16 2 Flexiplace Program - Work Agreement for Sht C
Routine Participants
R3 16 3 Flexiplace Program - Participation Sht C
Termination Form for Termination Prior to
Project Completion
R3 16 4 Flexiplace Program - Employee Self- Sht C
Certification Time and Attendance Report
R3 16 5 Flexiplace Program - Employee Self- Sht C
Certification Safety Checklist
R316 6 Flexiplace Program - Supervisor-Employee Sht C
Checklist
R316 7 Flexiplace Application Form Sht C
R3 16 8 Episodic Flexiplace Assignment Form Sht C
Region 06
R0 16 Nov-77 Office Machines Repair Form Set C
R02 I May-78 Car Reservation Request Set D
R027 Jan-83 Reference File Material Sht C
R03 I Sep-77 Long Distance Phone Record Sht C
R035 Mar-90 Request for Duplication Set C
R042 Sep-93 Periodical Log Card C
R059 Apr-91 Service Request Set C
R060 Mar-89 Court Reporter Checklist Sht C
R061 Apr-89 Room Rental Checklist Sht D
R065 A Aug-89 Notice of Deficiency Set C
R070 Nov-77 DMR Calculation Check Set C
R123 Feb-84 Record of Communication Set C
R124 Sep-93 Request for Special Mail Handling Card C
R136 May-85 Exemption Certificate Card C
R138 Name Plate Card C
20
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Numerical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
R139 Oct-93 Compressed Work Schedule Pay Period Sht C
Schedule Change
R140 Compressed work Schedule Request Sht C
R144 Jul-90 Freedom of Information File Review Form Sht C
R148 Apr-91 In-House Conference Room Service Set C
Request
R149 Nov-91 Telephone Service Request Sht C
R150 Dec-91 Request for Goods and Services Sht C
R151 Aug-91 POV Cost Comparison Sht C
R152 Aug-91 Request for Actual Lodging Costs
R153 Aug-91 POV Comparison to Airport Sht C
R154 Sep-94 Individual Issue Form Set C
R155 Jul-93 Request for Space Alterations Sht C
R156 Apr-933 Request for Non-FTh Position Sht C
R159 Apr-92 Calling Authority Form Sht C
Ri 60 Dec-92 Request for Delegation of Authority Sht C
R16l Jun-95 Sample Analysis Tag Label C
RI 62 Jun-94 Parking Permit Application Sht C
RI 63 Mar-94 Grants Document Cover Sheet Sht C
Region 09
R171 I Video Monitor Request
R257 I Jul-94 Travel Request Form
R5 10 1 May-94 AMB Service Request
R5 17 1 May-92 Conference Room Reservation Form
21
-------
Alphabetical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
8710 16 Oct-93 5301 1990 Inventory of Federal Hazardous Pam C
Waste Activity
4920 5 Nov-83 3204 Accumulative Daily Request--Carrier Sht C
3510 3 A Dec-80 5302W Acknowledgment of Application for a Card
Hazardous Waste Permit
8700 12 B Jul-90 5301 Acknowledgment of Notification of Set C
Hazardous Waste Activity (Verification)
2620 2 Feb-92 3303F Actual Subsistence Expenses While Sht A
Occupying Temporaiy Quarters
2720 20 A Oct-84 2410 Advice of Rights (Non-Employee Sht C
Custodial Interview)
2720 20 B Oct-84 2410 Advice of Rights (Federal Employee in Sht C
Custody)
2720 18 Oct-84 2410 Advice of Rights for a Federal Employee Sht C
5770 5 May-78 3901F Agency Fellowship Certificate Sht A,C
3100 1 Feb-81 3622 Agreement to Remain in the Government Set A,B,C
7610 5 Jan-93 6204J Allowance Account Information Sht C
7610 6 Jan-93 6204J Allowance Transfer Form Sht C
7610 24 Mar-94 6204-J Alternative Emission Limitation Sht C
Demonstration Period Petition
R09 R5 10 1 May-94 AMB Service Request
1900 60 Mar-91 3801F Announcement of Contract Award Sht A
7520 11 Sep-90 4602 Annual Disposal/Injection Well Monitoring Sht A
Report
8570 17 Jan-94 7505C Application for an Experimental Use Set C
Permit
3300 1 Application for Certification of a Pollution
Control Facility
3520 14 Sep-94 6101 Application for EPA Prior Written Sht C
Approval
5700 12 Jan-91 3903F Application for Federal Assistance Pam A
5700 33 Sep-90 3901F Application for Federal Assistance Pam A
5720 12 Aug-90 390 iF Application for Federal Assistance Pam A
(Construction Grants/Cooperative
Agreements)
5700 31 Oct-79 3901F Application for Federal Assistance (Short Pam A
Form)
5700 33 C May-74 3901F Application for Federal Assistance (Water
Pollution Control Areawide Waste
Treatment Management Planning Grants)
5700 33 A Sep-90 390 iF Application for Federal Assistance, Sht A
Narrative Statement
5700 33 B Sep-90 3901F Application for Federal Assistance, Pam A
Narrative Statement
5700 33 F Sep-90 3901F Application for Federal Assistance, Sht A
Narrative Statement
22
-------
Alphabetical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
5700 33 G Sep-90 390 IF Application for Federal Assistance, Pam A
Narrative Statement
5700 33 1 Dec-79 390 iF Application for Federal Assistance, Sht A
Narrative Statement
3520 15 Sep-94 6101 Application for Final Admission - Sht C
Plumbtesmo Test Report
3520 9 Sep-94 6401 Application for Final Admission - U.S. Sht C
Version Vehicle
3520 8 Oct-90 6401. Application for Final Admission of Sht C
Nonconforming Imported Vehicle
3510 2 F Jan-92 4203 Application for Permit to Discharge Set A,C,D
Stormwater
3510 2 B Apr-91 4203 Application for Permit To Discharge Sht A
Wastewater (Form 2B) Concentrated
Animal Feeding Ops.
7550 22 A Aug-90 4203 Application for Permit to Discharge Pam
Wastewater. Supplementary Instructions
for Standard Form A - Municipal
8570 1 Aug-94 7505C Application for Pesticide Set C
Amendment/Registration
9310 1 Jul-91 5201 Application for Reimbursement to Local Pam A,D
Governments for Emergency Response
8570 25 Jan-94 7505C Application for/Notification of State Set A
Registration of a Pesticide To Meet a
Special Local Need
3510 2 C Aug-90 4203 Application Form 2C - Wastewater Pam A
Discharge Information
3510 2 D Aug-90 4203 Application Form 2D-New Sources & New Pam A
Dischargers: Application for Permit To
Discharge Process Waste
3510 2 E Aug-90 4203 Application Form 2E--Facilities Which Do Pam A
Not Discharge Process Wastewater
3160 6 Nov-89 3610 Application to Contribute to EPA Leave Sht
Bank
7520 7 Sep-90 4602 Application To Transfer Permit Sht A
3115 22 Oct-84 3610 Appraisal of Other Characteristics Needed Sht A
for Upward Mobility
3140 18 Jun-95 3633 Assignee’s Evaluation of Mobility Sht C
Assignments
1900 3 Jun-75 380 iF Assignee’s Release Sht A
5700 51 May-93 390 iF Assistance Administrative Summary Sheet Sht A
5700 20 A Aug-94 3901F Assistance Agreement/Amendment Pam A
5700 20 B Aug-94 390 IF Assistance Amendment Sht A
5700 14 Mar-94 390 iF Assistance Funding Order Sht A
R04 R265 2 Jan-94 Attorney Timesheet - Criminal Branch Sht C
R04 R265 3 Jan-94 Attorney Timesheet - OPA Branch Sht C
23
-------
Alphabetical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
R04 R265 4 Jan-94 Attorney Timesheet - RCRA/Air Branch Sht C
R04 R265 1 Jan-94 Attorney Timesheet - Water Branch Sht C
R03 R750 5 3WM55 Audit Checklist C
1480 40 Feb-84 2410 Authority for Release of Information Set A
8710 11 Oct-82 5305 Authorization for Access to RCRA CBI Sht C
2560 31 Oct-91 3303F Authorization For Change Of Address Set A
2560 4 Oct-90 3303F Authorization for Mailing Pay Checks Sht A
7610 7 Jan-95 6204J Bid Form Sht C
2505 4 Feb-94 3303F BilLfor Collection Set A
8510 14 Oct-76 7503W Biological Report of Analysis Set A,C
5180 16 May-91 3204 Business Reply Label Label C
R06 R159 Apr-92 Calling Authority Form Sht C
3115 8 E Nov-86 3610 Candidate Referral Certificate: Temporary Sht A
Position
3115 34 Jul-95 3610 Candidate Referral List Sht C
R06 R021 May-78 Car Reservation Request Set D
3550 11 Jul-95 Case Opening Checklist Sht C
2560 32 May-90 3303F Cashier Reimbursement Voucher Sht A
3115 8 D Oct-84 3610 Certificate for Upward Mobility Sht A
3130 4 Jul-82 3634 Certificate of Approval for Payment of Sht A
Suggestion Award
3130 6 Sep-90 3610 Certificate of Completion of Training Sht A
7610 1 Dec-94 6204J Certificate of Representation Set C
3130 9 Jan-88 3622 Certificate of Retirement Sht A,B,C
7610 14 Jan-93 6204J Certification Application Sht C
8570 32 May-91 7505C Certification of Attempt to Enter into an Sht C
Agreement with other Restraints for
Development of Data
8570 28 Jan-91 7505C Certification of Compliance with Data Gap Set C
Procedures
5700 49 Nov-88 390 iF Certification Regarding Debarment, Pam A
Suspension, and Other Responsibility
Matters
7610 13 Jan-93 6204J Certification Test Notice (Optional) Sht C
8570 29 May-94 7505C Certification with Respect to Citation of Set C
Data
2560 5 Sep-94 3303F Change in Fixed Account Number Sht A
1315 4 Aug-86 3610 Checklist of EPA Transmittals Sht A,C
2570 8 Jul-95 3303F Claim for Relocation Income Tax Sht A
Allowance for the Year
5040 11 Aug-90 3707 Classified Fax Cover Sheet Sht A
1300 13 Apr-86 3404 Clerical Work Request Pad A
2550 9 Apr-74 3303F Commitment Notice Sht A
3110 26 Oct-74 3610 Competitive Level Code Log Sht C
7520 9 Sep-90 4602 Completion Form for Class I Injection Sht A
Wells
24
-------
Alphabetical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
7520 10 Sep-90 4602 Completion Report for Brine Disposal, Sht A
Hydrocarbon Storage, or Enhanced
Recovery Well
7710 52 7405 Comprehensive Assessment Information Pam C
Rule (CAIR) Report
R06 R139 Oct-93 Compressed Work Schedule Pay Period Sht C
Schedule Change
R06 R140 Compressed work Schedule Request Sht C
1320 1 A Jan-90 3204 Concurrence Sheet (Official File Copy) Set A,B
(Single Sheet)
2570 7 Jul-95 3303F Conference Planning -- Cost Comparison Sht
for Site Selection
R09 R5 17 1 May-92 Conference Room Reservation Form
8570 4 Aug-94 7505C Confidential Statement of Formula Set C
8710 14 Oct-82 5305 Confidentiality Agreement for Contractor Slit C
Employees Upon Termination/Transfer
7740 16 Oct-85 7407 Confidentiality Agreement for US Set A
Employees Upon Relinquishing TSCA CBI
Access Authority
8710 10 Oct-82 5305 Confidentiality Agreement for US Sht C
Employees Upon Termination/Transfer
7710 19 Sep-81 7407 Confidentiality Agreement--TSCA Slit A
Contractor Employee
7610 11 Mar-93 6204J Conservation Verification Protocol Set C
7610 10 Jan-93 6204J ConservationtRenewables Reserve Sht C
1900 20 Apr-85 380 IF Contract Checklist Sht A
1900 19 Aug-88 3801F Contract Memorandum of Transmittal and Sht A
Checklist
1900 44 B Jul-96 3801F Contract Summary of Significant Sht A
Performance Obser
1900 26 Apr-85 3801F Contracting Officer’s Evaluation of Set A
Contractor Performance
7740 27 Sep-92 7407 Contractor Information Sheet Sht A
1900 5 Jun-71 3801F Contractor’s Assignment of Refunds, Set A
Rebates, and Credits
1900 10 Feb-91 3801F Contractor’s Cumulative Claim and Sht A,B
Reconciliation
1900 6 Feb-81 3801F Contractor’s Release Set A
5700 41 Nov-90 3901F Cost or Price Summary Pam A
R06 R060 Mar-89 Court Reporter Checklist Sht C
1900 41 B Jun-79 380 iF CPAF Contract Individual event Sht A
Performance Observation
1900 41 A Jun-79 3801F CPAF Contract Summary of Significant Sht A
Performance Observation
1950 1 Credit Card Requisition
2560 22 Jul-81 3303F Cumulative Pay Adjustment Sht C
25
-------
Alphabetical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
2560 23 Jul-81 3303F Current Pay Adjustment Sht C
5180 18 Aug-88 3204 Custom Designed Mail Special Envelope Env A
5180 17 Mar-87 3204 Daily Record of Postage Meter Register Sht C
Readings
4920 3 Mar-94 3204 Daily Vehicle Utilization Report Sht A
R03 R280 1 3ES3 1 Data Acceptance or Rejection Forms C
R03 R280 2 3ES3 I Data Acceptance or Rejection Tracking C
Reports
8570 20 Jan-91 7505C Data Reference Sheet Set C
3560 4 Feb-80 2223-A Deficiency Notice Set A
R03 R280 3 3ES3 1 Delivery of Analytical Services Request C
Forms
1900 59 Jul-94 380 iF Delivery Order for Emergency Response Set A
1900 65 Jun-94 380 iF Designation & Appointment of Project Sht A
Officer/Work Assignment
Manager/Delivery Order
7710 45 Sep-81 7407 Destruction Log Sht A
8710 7 Oct-82 5305 Destruction Log (RCRA CBI) Sht C
7500 54 Sep-80 5202G Detailed SPCC Documentation for Set A
Inspection
1900 62 Feb-84 380 iF Determination and Findings: Authority To Sht C
Use a Letter Contract
1900 53 Apr-84 3801 F Determination and Findings: Authorization Sht C
To Use a Time and Materials Contract
8500 22 Jan-89 7502C Dinoseb Products: Claim for Pam C
Indemnification, Request for Federal
Disposal
7710 51 Jul-87 7405 DioxinsfFurans Report Pam C
2560 18 Sep-77 3303F DIPS Payroll Master Input Data Sht A
7610 9 Apr-94 6204J Direct Sale Application Sht C
1315 10 Dec-79 3610 Directive Number Assignment Card A,C
1315 17 Jan-95 3610 Directives Clearance Record Sht A,C
1315 5 Jul-82 3610 Directives Processing Worksheet Sht A
3320. 1 Dec-91 4203 Discharge Monitoring Report Set
7610 4 Nov-92 6204J Dispatch System Set C
R06 R070 Nov-77 DMR Calculation Check Set C
R03 R210 I 3ES31 Document Distribution Form C
R04 R2 17 2 Mar-95 4PM- iF Dun & Bradstreet Request Tracking Form Sht C
4700 14 May-84 1201 EEO Contractor Invoice Set C
1320 8 Apr-73 3204 EGD Contractor’s 4th Class Mailing Label Label
3550 21 Jul-95 Electronic Surveillance Authorization Sht C
2560 29 Apr-89 2410 Eligibility & Rate Determination Schedule Sht A,C
for Administratively Uncontrollable
Overtime (AUO) Pay
3155 8 Apr-94 3634 Emergency Designation and Authorization Sht
for an Exemption to Bi-Weekly Limitation
26
-------
Alphabetical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
2560 21 Oct-78 3303F Emergency Salary Payment Voucher Sht C
2620 1 Dec-86 3303F Employee Application for Reimbursement Sht A
of Expenses
3370 1 Jan-84 2376 Employee Claim for Loss or Damage to Sht C
Personal Property
3340 1 Aug-72 2310 Employee Report of Invention Set A
3110 1 Aug-92 3610 Employee Separation or Transfer Checklist Set A
3550 14 Jul-95 Employe&s Monthly Activity Report Sht C
8500 7 Feb-73 7505C Enforcement Case Review Set C
8500 7 A Feb-73 7505C Enforcement Case Review Set C
R03 R750 9 3WM55 Enforcement Response Plan Checklist C
1480 36 Jul-96 3204 EPA Bomb Data Info Sht A,C
3110 47 Sep-93 3610 EPA Direct Hire Announcement Sht C
5770 7 Jun-73 390 iF EPA Fellowship Activation Notice Set A
5770 9 Jul-73 390 iF EPA Fellowship Termination Notice Sht A
5100 9 May-94 3204 EPA Headquarters Transit Subsidy Sht C
Enrollment Form.
5100 10 May-94 3204 EPA Headquarters Transit Subsidy Sht
Recertification
3160 7 Nov-89 3610 EPA Leave Recipient Action Form Sht
4920 19 Jul-93 3204 EPA Motor Vehicle Master Record Sht A
4920 18 Jul-93 3204 EPA Motor Vehicle Status Change Notice D
1315 12A May-86 3610 EPAOrder Sht A
9350 1 Dec-94 7408 EPA Toxic Chemical Release Inventory Pam A,C
Reporting - Form R
R04 R3 16 8 Episodic Flexiplace Assignment Form Sht C
3115 7 Feb-92 3610 Evaluation and Rating Worksheet Slit A
2720 6 Mar-87 2410 Evidence Custody Set A
R06 R136 May-85 Exemption Certificate Card C
3110 15 Aug-91 3610 Expert or Consultant Supplemental Sht A
Information
5100 8 Aug-94 3303F Facilities Services Request Set
3150 21 Dec-77 3622 Factor Evaluation System Evaluation Sht
Statement
1480 6 Jun-71 2441 FBI Record Check Request Sht C
7740 24 Sep-92 7407 Federal Agency, Congress and Federal Sht A
Court Sign Out Log
8710 4 Oct-82 5305 Federal Agency, Congress, and Federal Sht C
Court Sign-Out Log (RCRA CBI)
2340 15 Aug-94 3303F Federal Register Typesetting Request Set A
7740 6 A Jan-92 7407 Federal TSCA CBI Access Request, Sht A
Agreement, & Approval:
Contractor/Subcontractor Employee
7740 6 Sep-92 7407 Federal TSCA CBI Access Request. Sht A
Agreement, and Approval (Document &
Computer)
27
-------
Alphabetical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
5770 8 Jul-73 3901F Fellowship Agreement Sht A
5770 6 Sep-90 390ff Fellowship Amendment Sht A
5770 4 Feb-77 3901F Fellowship Applicant Qualifications Sht A,C
Inquiry
5770 2 Feb-91 390 iF Fellowship Application Pam A
5770 3 Aug-90 3901F Fellowship Facilities and Commitment Sht A,C
Statement
R03 R750 12 3ES3 I Field Inspection Checklist C
R03 R850 3 FIFRA Enforcement Case
Recommendation Worksheet
R03 R850 2 FIFRA Investigation Referral Form
R03 R850 I 3AT1 I FIFRA Section 27 Case Referral
Disposition Worksheet
8580 1 Oct-82 7505C FIFRA Section 3(CX2XB) Sht C
8500 24 Feb-88 7502C FIFRA Sensitive Information Transmittal Set C
7610 25 Mar-94 6204-J Final Alternative Emission Limitation Sht C
2550 23 Sep-94 3303F Financial and Accounting Data Sht A
Continuation Sheet
R04 R316 7 Fiexiplace Application Form Sht C
R04 R3 16 5 Flexiplace Program - Employee Self- Sht C
Certification Safety Checklist
R04 R3 16 4 Flexiplace Program - Employee Self- Sht C
Certification Time and Attendance Report
R04 R3 16 3 Fiexiplace Program - Participation Sht C
Termination Form for Termination Prior to
Project Completion
R04 R3 16 6 Flexiplace Program - Supervisor-Employee Sht C
Checklist
R04 R3 16 1 Flexiplace Program - Work Agreement for Sht C
Episodic Participants
R04 R3 16 2 Flexiplace Program - Work Agreement for Sht C
Routine Participants
R04 R155 2 Jan-94 FOJA Exemption Sht C
R04 R155 1 Jan-94 FOIA Work Request Sht C
1335 4 Nov-80 3404 Forms Number Assignment Sheet Sht B,C
8570 27 Jul-91 7505C Formulator’s Exemption Statement Set C
R06 R144 Jul-90 Freedom of Information File Review Form Sht C
1550 9 Feb-94 7506C Freedom of Information Request Response Set C
R03 R850 4 FYI’S Data Input Forms
3520 13 Mar-90 6406J Fuel Additive Manufacturer Notification Sht C
3520 12 Mar-90 6406J Fuel Manufacturer Notification for Motor Sht C
Vehicle Fuel
3510 1 Aug-90 4203 General information Consolidated Permits Set A
Program (Form 1)
5700 29 Jul-82 390 IF Grant Audit Request Sht A
5700 42 Feb-85 3901F Grant Record Adjustment Notice Set A
28
-------
Alphabetical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
R06 R163 Mar-94 Grants Document Cover Sheet Sht C
3150 15 Dec-73 3622 Group Action Request List Sht
1900 34 A Apr-83 380 iF Guide for Preparation of Contractor’s Claim Pam A
1900 34 Apr-83 3801F Guide for Preparation of Contractor’s Pam A
Claims
8700 13 Al Aug-93 5301 Hazardous Waste Report Pam D
B
5040 13 Jun-93 3707 Headquarters Express Locator Form Card
5040 14 Feb-92 3707 Headquarters Subject Directory Change Card
Form
5000 1 HQ Data Communications Quality Service
Survey
1325 4 Jan-87 2136 ICRClearance Control Set C
3520 1 Sep-94 6401 Importation of Motor Vehicles and Motor Mult A,D
Vehicle Engines Subject to Federal Air Sht
Pollution Requirements
3520 21 Oct-94 6401 Importation of Non-Road Vehicles and Sht A,D
Equipment Subject to Federal Air Pollution
Regulations
R06 R148 Apr-91 In-House Conference Room Service Set C
Request
R06 Ri 54 Sep-94 Individual Issue Form Set C
R03 R750 7 3W1v155 Industrial User Oversight Checklist C
2635 1 Nov-72 3303F information for Authorization of Moving Sht A
and Related Travel Expenses
7520 8 Sep-90 4602 Injection Well Monitoring Report Sht A
9110 1 Nov-90 5201 inorganic Traffic Report Set C
5700 12 A Nov-90 3903F Instructions for Completing EPA Form Pam A
5700- 12
7550 6 A Oct-90 4203 Instructions for EPA 75 50-06 Sht A
R04 R2 17 1 4PM- IF Inter Library Loan Request Sht C
1610 1 Oct-88 3303F Interagency Agreement Pam
4550 5 Apr-93 2610 International Travel Plan Set A
4550 1 Aug-94 2610 International Trip Report Set A
2550 4 Dec-79 3303F Interoffice Transfer Voucher Set A
3115 17 Oct-84 3610 interview Rating Sheet for Upward Sht C
Mobility Positions
3340 2 Aug-72 2310 Invention Rights Questionnaire Set C
8710 1 Oct-82 5305 Inventory Log (RCRA CBI) Sht C
7740 11 Oct-85 7407 Inventory Log: TSCA CBI Sht A
7500 48 Sep-94 4602 Inventory of Injection Wells Sht
2720 17 Jul-86 2410 Investigation Cover Sheet Sht A
2720 13 Apr-83 2410 Investigative Report Cover A
2550 22 Mar-90 3303F Invoice Summary Report Set D
3115 28 Sep-84 3610 Job Analysis Record Sht A
29
-------
Alphabetical List of EPA Forms
Con-
struc-
tion
Sht
Stock
Code
C
C
Card C
Sht C
Sht C
Sht C
Sht
Sht
Sht
Sht
Pam
Sht
Sht
Sht
Label
Label
Label
Pam
Date of
Current Origin-
Form No. Edition ator Title
3115 18 Oct-84 3610 Job Element Rating Sheet for Upward
Mobility Positions
R03 R750 13 3ES3 1 Laboratory Inspection Checklist
3300 4 Jun-93 2312 Law Library (Charge-Out)
3520 5 May-90 6406J Lead Additive Report for Gasoline
Importer
3520 2 Feb-88 6406J Lead Additive Report for Refinery
3520 6 B May-85 6406J Lead Additive Report Supplement B:
Transfers of Lead
R03 R750 8 3WM55 Legal Authority Checklist
3130 7 A Jul-86 3622 Length of Service Certificate-- 10 Years
3130 7 B Jul-86 3622 Length of Service Certificate -- 20 Years
3130 7 C Jul-86 3622 Length of Service Certificate -- 30 Years
3130 7 D Jul-86 3610 Length of Service Certificate --40 Years
1900 56 Apr-85 3801F Letter Contract for State/Local Government
Response to Emergency Hazardous
Substance Release
7610 7 A Jan-95 6204J Letter of Credit
R04 RI 71 1 Loan Request for Computer Equipment
R06 R03 I Sep-77 Long Distance Phone Record
5180 14 May-79 3204 Mail Label - Fourth Class
5180 12 May-79 3204 Mail Label - Third Class
1320 3 Mar-84 3204 Mailing Label
7710 35 May-82 7405 Manufacturer’s Report: Preliminary
Assessment Information
3100 13 Jan-78 3610 Medical Report
3550 8 Jul-95 Memorandum of interview
3550 8 A Jul-95 Memorandum of Interview (Continuation
Sheet)
7740 12 Oct-85 7407 Memorandum of TSCA CBI Telephone
Conversation -
1900 54 Apr-85 3801F Memorandum to the File: Synopsis
Exemption
3115 14 Feb-92 3610 Merit Promotion Application Rating Sheet
3115 8 Sep-84 3610 Merit Promotion Certificate
3115 8 A Sep-84 3610 Merit Promotion Certificate (Continuation)
3115 9 Sep-84 3610 Merit Promotion Information Record
3115 13 Sep-84 3610 Merit Promotion Program Checklist
3115 15 Sep-84 3610 Merit Promotion Rating Plan Specifications
3115 3 A Dec-94 3610 Merit Promotion Vacancy Announcement
(Upward Mobility)
8500 12 Apr-75 7503W Microbiological Laboratory Report
8550 11 Apr-75 7503W Microbiological Laboratory Report
2550 10 Oct-94 3303F Miscellaneous Obligation Document
7610 12 Jan-93 6204J Monitoring Plan
C
A
A
A
A
C
C
C
C
C
C
A
C
Sht C
Sht C
Sht C
Sht A
Sht C
Sht
Sht
Sht
Set
Sht
Sht
Sht
Sht
Sht
Sht
Sht
A
A
A
A
A,C
A
C
C
C
A
C
30
-------
Alphabetical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
1900 63 Sep-94 380 iF Monthly Requisition and/or Receiving Set A
Report for Blanket Purchase Orders
5700 34 Mar-74 390 iF Multipurpose Wastewater Treatment
Reimbursement
R06 R138 Name Plate Card C
R03 R850 5 NARS Data Input Form
R03 R850 6 NESHAP Inspection Checklist
7610 19 Jan-94 6204J New Unit Exemption Sht C
1900 65 A Nomination and Appointment of
Contracting Officer’s Representative (COR)
3115 8 C Sep-84 3610 Noncompetitive Candidate Referral Sht A
Certificate
3115 8 B Sep-84 3610 Nonstatus Candidate Referral List Sht A
1315 11 May-86 3610 Notice Sht A
7710 56 Sep-94 7405 Notice of Commencement of Manufacture Pam C
or Import
1900 68 Notice of Contract Costs Suspended and/or
Disallowed
R06 R065 A Aug-89 Notice of Deficiency Set C
3510 6 Aug-92 4203 Notice of Intent (NOl) Sht A.C,D
2340 17 May-84 3204 Notice of Pending Delivery/Shipment Set C
8570 6 May-76 7505C Notice of Registration Set C
2720 2 May-83 2410 Notice of Scheduled Investigation Sht A
8570 5 Aug-94 7505C Notice of Supplemental Registration of Set C
Distribution of a Registered Pesticide
Product
3510 7 Aug-92 4203 Notice of Termination (NOT) Sht A,C,D
1900 58 Apr-84 380 IF Notice Regarding Work Stoppage Sht C
2720 19 Oct-84 2410 Notice to a Federal Employee: Duty To Sht C
Respond to Questions
1900 49 Sep-94 380 IF Notice To Proceed with Emergency Pam C
Response to Hazardous Substance Release
7530 l Feb-92 5401W Notification for Underground Storage Pam C
Tanks
7710 53 Sep-89 7404 Notification of PCB Activity Sht C
8700 12 Nov-93 5301 Notification of Regulated Waste Activity Pam A
1900 60 A Apr-90 3801F Notification of Work Assignment For Sht A
Superfund Remedial Action Construction
7610 22 Mar-94 6204-i NOx Averaging Plan Set C
7610 23 Mar-94 6204-J NOx Compliance Extension Sht C
7500 55 Jan-93 2225A NPDES Laboratory Performance Pam A,D
Evaluation
7550 6 Nov-90 4203 NPDES--Application for Permit To Sht A
Discharge (Form A)
7550 22 Aug-90 4203 NPDES-Application for Permit To Set A
Discharge Wastewater (Form A)
31
-------
Alphabetical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
5170 5 Off-Site Conference Room Rental
R06 R016 Nov-77 Office Machines Repair Form Set C
2720 4 Apr-90 2410 Office of Investigations Monthly Report Sht A
7500 2 Jul-75 7201 Official Sample Seals Label A,B,C
1900 48 Jul-94 380 iF Order for Services-Emergency Response to Pam C
Hazardous Substance Release
9110 2 Nov-90 5201 Organic Traffic Report Set C
9110 5 Mar-93 5204G Organic Traffic Report/Chain of Custody Set C
Form
3110 43 Jul-86 3610 Organization Code Sheet Sht A
3155 2 Apr-73 2376 Overpayment Investigation Report Sht A
1740 9 Aug-94 3303F Owned Personal Property System Input Sht A,B
Data
9110 3 5201 Packing List/Chain of Custody
R06 R162 Jun-94 Parking Permit Application Sht C
5160 1 Jan-95 3204 Parking Permit Application Sht A
4920 15 Nov-92 3204 Parking Violation Set C
7520 2 A Sep-90 4602 Part II- A: Compliance Evaluation Set A
7520 2 B Sep-90 4602 Part II- B: Compliance Set A
Evaluation/Significant Noncompliance
7520 3 Sep-90 4602 Part Ill-A: Inspections/Mechanical Set A
Integrity Testing
7520 4 Sep-90 4602 Part IV: Quarterly Exceptions List Set A
7520 5 Sep-90 4602 Part V: Summary of UIC Grant Utilization Set A
7740 8 Feb-94 7407 Partial Updating of TSCA Inventory Data Set C
Base: Production and Site Report
4550 7 Nov-80 2610 Passport Log Card C
2560 28 Aug-94 3303F Payroll Distribution Time Sheet Set A
2560 28 A Aug-94 3303F Payroll Distribution Time Sheet Set A
(Continuation)
2560 2 Nov-86 3303F Payroll Error Notice Set A
R03 R750 6 3WM55 PCI Checklist C
3140 32 Sep-92 3634 Performance Agreement, Appraisal and Set A
Certification for Supervisors, Managers,
and Executives
3115 24 Aug-87 3634 Performance Agreement, Appraisal, and Sht A
Certification
R06 R042 Sep-93 Periodical Log Card C
7740 26 Sep-92 7407 Permanent Transfer Receipt for TSCA Sht A
CBI
3100 18 May-84 3610 Personnel Action Tickler Notice
1480 2 Jan-80 2410 Personnel Security Action Request Sht A
8570 30 Oct-93 7502C Pesticide Registration Maintenance Fee Set C
Filing
8500 6 Nov-72 7503W Pesticide Sample Record Card C
7610 16 P Apr-93 6204J Petition Submittal Notice (Optional) Sht
32
-------
Alphabetical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
7610 21 Mar-94 6204-J Phase 1, Permit Application NOx Sht C
Compliance Plan
7610 3 A Nov-92 6204J Phase I Extension Plan Set C
7610 3 Nov-92 6204J Phase I Permit Set C
7610 16 Dec-94 6204J Phase II Permit Application Set C
7520 14 Sep-90 4602 Plugging and Abandonment Plan Sht A
3150 1 Feb-87 3622 Position Description Sht
3150 5 Sep-73 3622 Position Description Amendment Sht
2070 12 Jul-81 5201 Potential Hazardous Waste Preliminary Pam C
Assessment
2070 14 Sep-91 5201 Potential Hazardous Waste Site Current Pam C
Disposition
2070 11 Jul-81 5201 Potential Hazardous Waste Site Sht C
Identification
2070 13 Jul-81 5201 Potential Hazardous Waste Site--Site Pam C
Inspection Report
R06 R153 Aug-91 POV Comparison to Airport Sht C
R06 R151 Aug-91 POV Cost Comparison Sht C
R03 R750 I 3WM55 PPETS Annual Report Form - 1994 C
R03 R750 2 3WM55 PPETS Audit Form C
R03 R750 3 3WM55 PPETS Pretreatment Compliance C
Inspection
R03 R750 4 3WM55 PPETS Update C
5700 30 Nov-90 3901F Preapplication for Federal Assistance Pam A
4700 4 Jan-90 1201 Preaward Compliance Review Report for Sht A
All Applicants Requesting Federal
Assistance
7710 25 Jan-91 7405 Premanufacture Notice for New Chemical Set D
Substances
2200 9 Jul-93 3204 Printing, Distribution, and Inventory
3100 17 Jan-84 3622 Probationary Period Sht A
1900 8 Aug-94 380 iF Procurement Request/Order Set A
5700 48 Nov-90 3 Q1F Procurement System Certification Sht A
8580 4 May-88 7505C Product Specific Data Report Sht C
1900 2 Dec-81 3801F Profit/Fee Objectives Sht A
2550 19 Sep-94 3303F Project Officer Invoice Approval Set D
1900 27 Apr-84 3801F Project Officer’s Evaluation of Contractor Set A
Performance
2550 21 Oct-94 3303F Project Officer’s Interagency Agreement Set A,D
Invoice Approval
3115 32 Dec-94 3610 Promotion and Career Opportunities Sheet Sht C
3550 15 Jul-95 Property Inventory/Chain of Custody Sht C
3550 15 A Jul-95 Property Inventory/Chain of Custody Sht C
(Continuation Sheet)
1700 9 Jul-96 3204 Property Pass Request Order Sht C
1700 7 Oct-74 3204 Property Receipt and Transfer Document Set A
33
-------
Alphabetical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
1900 61 Feb-84 3801F Proposal Technical Evaluation Sht A
2360 1 Feb-84 3204 PublicationsfForms Request Set A
R04 R190 I Purchase Justification Sht C
1900 44 May-94 380 IF Purchase Order Register Sht A,C
R03 R750 15 3ES3 I QA Project Plan Review Checklist C
R03 R750 11 3ES3 1 Quality Assurance Project Plan and C
Sampling Plan Review Checklists
7610 15 Jan-93 6204J Quarterly Reports C
R04 R261 I Quick Trip Permit Sht C
8710 13 Oct-82 5305 RCRA Confidential Business Information Sht C
8710 6 Oct-82 5305 RCRA Confidential Business Information Sht C
Meeting Sign-in Sheet
8710 9 Oct-82 5305 RCRA Contractor Employee Sht C
Confidentiality Agreement
8700 23 Nov-93 5301 RCRA Part A Permit Application Pam A
7740 10 Oct-85 7407 Receipt Log: TSCA CBJ Sht A
3130 1 A Aug-94 3303F Recommendation for Incentive Award Set A
3130 1 Aug-94 3610 Recommendation for Monetary Award Set A
R04 R134 4 Record Checkout Form for Regional Sht C
Records Tracking System
R04 R134 3 Jan-94 Record Inventory Sht C
R06 RI23 Feb-84 Record of Communication Set C
1480 41 Jan-86 2410 Record of Communication (Records Sht C
Checks/Clearances)
2720 26 Feb-92 2410 Record of Non-Cost Training Activity Sht C
1900 37 Apr-85 3801F Record of Procurement Request Review Sht A
2505 2 May-81 3303F Record of Public Funds Received Set A
R04 R134 I Record Transfer Inventory Form Sht C
R04 R134 2 Jan-94 Records Checkout Form Sht C
3155 5 Apr-94 3634 Recruitment or Relocation Bonus Request Pam A,C
and Approval
3155 6 Apr-94 3634 Recruitment or Relocation Bonus Service Sht A,C
Agreement
2550 6 Mar-80 3303F Redistribution of Payroll Charges Set A
7610 3 C Nov-92 6204J Reduced Utilization Plan Set C
R06 R027 Jan-83 Reference File Material Sht C
3520 20 E Feb-95 6406J Reformulated Gasoline and Anti-Dumping Sht C
Annual Compliance Designation
3520 20 D Feb-95 6406J Reformulated Gasoline and Anti-Dumping Sht C
Quarterly Certification
3520 20 A Jun-94 6406J Reformulated Gasoline Company Sht C
Registration
3520 20 C Jun-94 6406.1 Reformulated Gasoline Facility Batch Sht C
Report
3520 20 B Jun-94 6406J Reformulated Gasoline Facility Sht C
Registration
34
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Alphabetical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
R03 R750 14 3ES31 Regional Sample Control Center’s Monthly C
Reports
2635 2 Aug-77 3303F Relocation Expenses Payment Record Set A
2720 15 Nov-84 2431 Report of Interview Sht A
2720 16 Jul-83 2431 Report of Investigation Sht A
3550 9 Jul-95 Report of Investigation Sht C
2720 14 Nov-84 2410 Report of Investigation-Narrative Sht A
3550 22 Jul-95 Report of Use - Electronic Surveillance Sht C
7610 17 Dec-94 6204J Repowering Extension Plan Set C
7610 18 Repowering Technology Petition
7740 17 Sep-92 7407 Request for Approval of Contractor Access Sht A
to TSCA Confidential Bus. Info.
2545 2 Mar-92 3303F Request and Receipt for Cash Advance Set A
R06 RI 52 Aug-91 Request for Actual Lodging Costs
2560 7 Aug-94 3303F Request for and Authorization of Overtime Set A
Work
8710 5 Oct-82 5305 Request for Approval of Contractor Access Sht C
to RCRA Confidential Business
Information
3155 9 Apr-94 3634 Request for Approval of Superior
Qualifications Appointment
8710 12 Oct-82 5305 Request for Approval of Temporary Sht C
Employee for Access to RCRA CBI
1110 1 Jul-83 3610 Request for Change in Organization Sht A
Structure
1900 7 Apr-85 3801F Request for Cost Analysis Sht A,B
R06 R160 Dec-92 Request for Delegation of Authority Sht C
8500 23 Jun-90 7502C Request for Document Center Services Set C
R06 R035 Mar-90 Request for Duplication Set C
4920 8 Nov-83 3204 Request for EPA Driver Service Set C
1900 35 Jul-84 3801F Request for Equal Opportunity Clearance Sht A
of Contract Award
3160 3 Nov-76 3634 RequestforFlexibleHours Sht A
R06 R150 Dec-91 Request for Goods and Services Sht C
3550 13 Jul-95 Request for Laboratory/Technical Support Sht C
R06 RI 56 Apr-93 3 Request for Non-FTE Position Sht C
R04 R217 3 Mar-95 4PM-IF Request for Services Sht C
1700 4 Jul-94 3303F Request for Shipping Service Set A
R06 RI 55 Jul-93 Request for Space Alterations Sht C
R06 R124 Sep-93 Request for Special Mail Handling Card C
3155 1 Apr-77 2376 Request for Waiver of Claim for Erroneous Sht A
Payment
3155 10 Apr-94 3634 Request, Approval, and Agreement for Sht
Advance in Pay
‘2170 6 Feb-88 3404 Response to Request for Publication Card C
3160 2 Oct-82 3634 Restoration of Forfeited Annual Leave Sht
35
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Alphabetical List of EPA Forms
Date of Con-
Current Origin- sfruc- Stock
Form No. Edition ator Title tion Code
3155 4 Apr-94 3634 Retention Allowance Request and Pam A,C
Approval
7610 20 Dec-94 6204J Retired Unit Exemption Sht C
R06 R061 Apr-89 Room Rental Checklist Sht D
R03 R750 16 3ES31 RSCC Sample Projection Form C
R06 R161 Jun-95 Sample Analysis Tag Label C
R04 R148 I Secured Hours Building Access Sht C
1480 7 Mar-80 2410 Security File Review Sht C
1480 27 2410 Security Investigation Review/Analysis Sht C
1480 19 Feb-74 2410 Security Termination Statement Sht A
3110 11 Feb-92 3610 Service Computation Date Worksheet Sht C
R06 R059 Apr-91 Service Request Set C
5040 10 Aug-90 3707 Signature Card Card A
1265 93 Dec-93 6205J SNAP Information Notice for Significant Set C
Activity
7610 8 Jan-95 6204J S02 Allowance Offer Sht C
R03 R750 10 3WM55 SPCC Facility Inspection C
7500 53 Sep-80 5202G SPCC Inspection Field Sheet Sht A
3130 10 Sep-88 3610 Special Achievement Award Certificate Sht A
3115 4 Sep-84 3622 Staffing Requisition Sht A
3550 4 C Jul-95 Statement (Conclusion, with signature) Sht C
3550 4 B Jul-95 Statement (Continuation Sheet) Sht C
3550 4 A Jul-95 Statement (Initial page, no signaturc) Sht C
3550 4 Jul-95 Statement (Initial page, with signature) Sht C
2560 25 Oct-88 3303F Statement of Earnings and Leave Set A,C
7600 5 Jan-94 6205J Stratospheric Ozone Protection Program Set
Controlled Substance Report
9510 1 Jul-88 5101 Substantiation To Accompany Claims of Pam A,C
Trade Secrecy: Emergency
Planning/Community Right-To-Know Act
7610 3 B Nov-92 6204J Substitution Plan Set C
3140 20 Jun-95 3633 Supervisor’s Evaluation of EPA’S IPA Sht C
Personnel Exchange Program
3520 16 Aug-94 6406J Supplemental Notification for a Fuel or Sht C
Fuel Additive Manufacturer - Registration
of Fuel and Fuel Additives
3155 3 Jul-94 3033F Supplemental Pay for Federal and Non- Set A
Federal IPA Detailees
5040 12 Jul-92 3707 Telecommunications Quality Survey Card C
R06 Rl49 Nov-91 Telephone Service Request Sht C
7740 14 Oct-85 7407 Temporary Loan Receipt for TSCA CBI Set A
1900 64 Jul-84 3801F Termination Settlement Memorandum of Sht A,C
Transmittal and Checklist
7710 30 Jan-94 7502C Time Accounting Information System Set
Record
2565 1 Sep-94 3303F Time and Attendance Card Card D
36
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Alphabetical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
2565 2 Jul-94 3303F Time and Attendance Card (Salmon) Card A
2565 3 Jan-92 3303F Time and Attendance Card (Yellow) Card A
2560 12 Jul-74 3303F Time and Attendance Chargeout Card Card C
2560 30 May-89 2410 Time Report for Administratively Sht A,C
Uncontrollable Overtime (AUO)
2560 1 Oct-71 3303F Timekeeper Signature Card Card A
9350 2 New 7408 Toxic Chemical Release Inventory Sht A,C,D
Certification Statement
2610 1 Aug-94 3303F Travel Authorization Set A
2610 1 A Aug-94 3303F Travel Authorization - Permanent Change Set A
of Station
R09 R257 1 Jul-94 Travel Request Form
2570 6 Dec-80 3303F Treasury Financial Communication System Card A
(TFLS) Ticket
7740 23 Sep-92 7407 TSCA Security Manual Update Sht A
Transmittal Sheet
7740 25 Sep-92 7407 TSCA CB1 ADP User Registration Sht A
7740 15 Oct-85 7407 TSCA CBI Meeting Sign-in Sheet Sht A
7740 13 Oct-85 7407 TSCA CBI Visitors Log Sht A
7740 9 Oct-92 7407 TSCA Confidential Business Information Card A
(Cover Sheet)
7740 28 Sep-92 7407 TSCA Confidential Business Information Sht A
Document Reconciliation Certification
7740 2 Oct-96 7201 TSCA Declaration of CBI Set
1265 94 Dec-93 6205J TSCA/SNAP Addendum for Significant Set C
Activity
7740 1 Dec-82 7201 TSCA Receipt for Samples and Documents Set
7520 1 Sep-90 4602 UIC Federal Reporting System Part 1: Set A
Permit Review and Issuance/Wells in Area
of Review
7520 6 Sep-90 4602 Underground injection Control Permit Sht A
Application
8700 22 Sep-88 5301 Uniform Hazardous Waste Manifest Sht
8700 22 A Sep-88 5301 Uniform Hazardous Waste Manifest Sht
(Continuation)w
8710 2 Oct-82 5301 User Sign-Out Log (RCRA CBI) Sht C
3110 38 Dec-94 3610 Vacancy Announcement Sht C
3110 46 Dec-94 3610 Vacancy Announcement (Headquarters) Sht C
4920 17 Jul-93 3204 Vehicle Operations Report (Monthly) Sht A
4920 16 Jul-93 3204 Vehicle Operations Summary (Quarterly) Sht A
2545 1 Nov-71 3303F Verification of Imprest Fund Sht A
R09 RI 71 1 Video Monitor Request
3100 14 May-80 3610 Volunteer Service Program Participation Sht A
Agreement
1700 8 Jul-94 2376 Voucher for Payment and Release Sht C
3300 14 Jan-93 2233 Voucher For Payment To informants Set C
37
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Alphabetical List of EPA Forms
Date of Con-
Current Origin- struc- Stock
Form No. Edition ator Title tion Code
5020 1 Jul-94 3707 Washington Telecommunications Service Sht
Request
3560 3 Sep-94 2223-A Water Compliance inspection Report Sht A
7520 12 Sep-90 4602 Well Rework Record Sht A
3550 5 A Jul-95 Witness Narrative Statement (Continuation Sht C
page)
3550 5 C Jul-95 Witness Narrative Statement (Includes Sht C
signature, conclusion page)
3550 5 B Jul-95 Witness Narrative Statement (initial page, Sht C
no signature)
3550 5 Jul-95 Witness Narrative Statement (Initial page, Sht C
with signature)
1900 13 Apr-85 3801F Worksheet for Small Purchases Sht A
38
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EPA Forms Available in Electronic Format
Beginning in 1992, EPA began an initiative to incorporate electronic forms into the
workplace. This effort was designed to broaden delivery of administrative support
services to employee computer workstations, improve productivity of forms processing
workflow activities, and reduce the volume of paper forms used by the Agency.
That initiative evolved into the Next Generation electronic fonns application, now
managed by the Enterprise Systems Division within the Office of Information Resources
Management (OIRM). Two types of “Next Generation” forms have been developed and
made available on Agency local area networks.
“Workflow Forms” can be electronically filled, “signed,” and routed for approval and
processing using the Agency’s electronic mail system. These Workflow Forms are
available now: -
Procurement Request EPA 1900-8
Application for Leave SF 71
In addition, 23 “Fill and Print Forms” currently are available. These forms may be
filled at a personal computer workstation, printed on a local laser printer, then manually
routed in paper format using existing procedures. Fill and Print Forms include:
EPA 1700-9 Property Pass
EPA 1900-65A Nomination and Appointment of Contracting
Officer’s Representative (COR)
EPA 2550-9 Commitment Notice
EPA 2560-28 Payroll Distribution Time Sheet
EPA 2200-9 Printing, Distribution and Inventory
EPA 2610-3 Approval to Accept Travel (eth. Ref. Act 1989)
EPA 3110-1 Employee Separation or Transfer Checklist
EPA 3115-24 Performance Appraisal & Certification
EPA 3130-lA Recommendation for Incentive Award
EPA 3140-32 Individual Development Plan
EPA 3 150-1 Position Description
EPA 3 160-6 Application to Contribute to EPA Leave Bank
EPA 5040-13 Changes in Telephone Listing
EPA 5100-8 Facilities Service Request
FMS 2231 Direct Deposit (Fastart)
OF 41 Routing Slip
OGE 450 Financial Disclosure (Confidential)
SF 52 Request for Personnel Action
Electronic-I
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EPA Forms Available in Electronic Format
SF 182 Request, Authorization, Agreement and
Certification of Training
SF 278 Financial Disclosure (Public)
SF 1164 Claim for Reimbursement
SF 2801 Application for Retirement (CSRS)
SF 3107 Application for Retirement (FERS)
For further information regarding the Next Generation Electronic Forms application,
please contact Tony Studer at (202) 260-5621 or Chris Bullock at (202) 260-3298. For
Electronic Forms support, please contact the Next Generation support hot line at (703)
734-2338.
Electronic-2
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Numerical List of EPA Public-Use Forms
Date of
Current 0MB
Form No. Edition Originator Title Number
1265 93 Nov-89 6205J SNAP Information Notice for
Significant Activity
1265 94 Nov-89 6205J TSCA/SNAP Addendum for
Significant Activity
1900 10 Jan-87 380 IF Contractor’s Cumulative Claim and 2030-00 16
Reconciliation
2070 11 Jun-77 5201 Potential Hazardous Waste Site
Identification
2070 12 Jun-77 5201 Potential Hazardous Waste Preliminary 2050-0095
Assessment
2070 13 Jun-77 5201 Potential Hazardous Waste Site--Site 2050-0095
Inspection Report
2070 14 Aug-87 5201 Potential Hazardous Waste Site Current 2050-0095
Disposition -
2170 6 Jan-84 3404 Response to Request for Publication
3510 1 Jul-86 4203 General Information Consolidated 2040-0086
Permits Program (Form 1)
3510 2 B Mar-87 4203 Application for Permit To Discharge 2040-0086
Wastewater (Form 2B) Concentrated
Animal Feeding Ops.
3510 2 C Jul-86 4203 Application Form 2C - Wastewater 2040-0086
Discharge Information
3510 2 D Jul-86 4203 Application Form 2D-New Sources & 2040-0086
New Dischargers: Application for
Permit To Discharge Process Waste
3510 2 E Jul-86 4203 Application Form 2E--Facilities Which 2040-0086
Do Not Discharge Process Wastewater
3510 2 F Dec-87 4203 Application for Permit to Discharge 2040-0086
Stormwater
3510 3 A Nov-76 5302W Acknowledgment of Application for a
Hazardous Waste Permit
3510 6 Jul-88 4203 Notice of Intent (NOl) 2040-0086
3510 7 Jul-88 4203 Notice of Termination (NOT) 2040-0086
3520 1 Aug-90 6401 Importation of Motor Vehicles and 2060-0095
Motor Vehicle Engines Subject to
Federal Air Pollution Requirements
3520 2 Jan-84 6406J Lead Additive Report for Refinery 2060-0066
3520 5 Apr-86 6406J Lead Additive Report for Gasoline 2060-0066
Importer
3520 6 B Apr-81 6406J Lead Additive Report Supplement B: 2060-0066
Transfers of Lead
3520 8 Sep-86 6401 Application for Final Admission of 2060-0095
Nonconforming Imported Vehicle
3520 9 Aug-90 6401 Application for Final Admission - U.S. 2060-0095
Version Vehicle
0MB-i
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Numerical List of EPA Public-Use Forms
Date of
Current 0MB
Form No. Edition Originator Title Number
3520 12 Feb-86 6406J Fuel Manufacturer Notification for 2060-0150
Motor Vehicle Fuel
3520 13 Feb-86 6406J Fuel Additive Manufacturer 2060-0150
Notification
3520 14 Aug-90 6101 Application for EPA Prior Written 2060-0095
Approval
3520 15 Aug-90 6101 Application for Final Admission - 2060-0095
Plumbtesmo Test Report
3520 16 Jul-90 6406J Supplemental Notification for a Fuel or 2060-0150
Fuel Additive Manufacturer -
Registration of Fuel and Fuel Additives
3520 20 A May-90 6406J Reformulated Gasoline Company 2060-0277
Registration
3520 20 B May-90 6406J Reformulated Gasoline Facility 2060-0277
Registration
3520 20 C May-90 6406J Reformulated Gasoline Facility Batch 2060-0277
Report
3520 20 D Jan-91 6406J Reformulated Gasoline and Anti- 2060-0277
Dumping Quarterly Certification
3520 20 E Jan-91 6406J Reformulated Gasoline and Anti- 2060-0277
Dumping Annual Compliance
Designation
3520 21 Oct-90 6401 Importation of Non-Road Vehicles and 2060-0320
Equipment Subject to Federal Air
Pollution Regulations
3550 4 A Jun-91 Statement (Initial page, no signature)
3550 4 B Jun-91 Statement (Continuation Sheet)
3550 4 C Jun-91 Statement (Conclusion, with signature)
3550 4 Jun-91 Statement (Initial page, with signature)
3550 5 A Jun-91 Witness Narrative Statement
(Continuation page)
3550 5 B Jun-91 Witness Narrative Statement (Initial
page, no signature)
3550 5 C Jun-91 Witness Narrative Statement (Includes
signature, conclusion page)
3550 5 Jun-91 Witness Narrative Statement (Initial
page, with signature)
3550 8 A Jun-91 Memorandum of Interview
(Continuation Sheet)
3550 8 Jun-91 Memorandum of Interview
3550 9 Jun-91 Report of Investigation
3550 11 Jun-91 Case Opening Checklist
3550 13 Jun-91 Request for Laboratory/Technical
Support
3550 14 Jun-91 Employee’s Monthly Activity Report
OMB-2
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Numerical List of EPA Public-Use Forms
Form No. Edition Originator Title
3550 15 A Jun-91 Property Inventory/Chain of Custody
(Continuation Sheet)
Property Inventory/Chain of Custody
Electronic Surveillance Authorizaiton
Report of Use - Electronic Surveillance
2223-A Water Compliance Inspection Report
1201 Preaward Compliance Review Report
for All Applicants Requesting Federal
Assistance
5700 12 A Oct-86 3903 F Instructions for Completing EPA Form
5700- 12
5700 12 Dec-86 3903F Application for Federal Assistance
5700 20 A Jul-90 390 IF Assistance Agreement/Amendment
5700 20 B Jul-90 390 iF Assistance Amendment
5700 30 Oct-86 390 IF Preapplication for Federal Assistance
5700 3 1 Oct-75 390 IF Application for Federal Assistance
(Short Form)
5700 33 A Aug-86 390 IF Application for Federal Assistance,
Narrative Statement
5700 33 B Aug-86 390 iF Application for Federal Assistance,
Narrative Statement
5700 33 C Apr-70 390 IF Application for Federal Assistance
(Water Pollution Control Areawide
Waste Treatment Management
Planning Grants)
5700 33 F Aug-86 390 iF Application for Federal Assistance,
Narrative Statement
5700 33 G Aug-86 390 IF Application for Federal Assistance,
Narrative Statement
5700 33 H Jul-82 3901F Pesticide Enforcement Cooperative
Agreement
5700 33 I Nov-75 390 iF Application for Federal Assistance,
Narrative Statement
5700 33 Aug-86 390 iF Application for Federal Assistance
5700 34 Feb-70 390 IF Multipurpose Wastewater Treatment
Reimbursement
5700 41 Oct-86 3901F Cost or Price Summary
5700 48 Oct-86 3901F Procurement System Certification
5720 12 Jul-86 390 IF Application for Federal Assistance
(Construction Grants/Cooperative
Agreements)
5770 2 Jan-87 3901F Fellowship Application
5770 3 Jul-86 3901F Fellowship Facilities and Commitment
Statement
Date of
Current 0MB
3550
3550
3550
3560
4700
15 Jun-91
21 Jun-91
22 Jun-91
3 Aug-90
4 Dec-85
Number
2040-0057
2090-0014
2030-0020
2030-0020
2030-0020
2030-0020
2030-0020
2030-0020
2030-0020
2030-0020
2030-0020
2030-0020
2030-0020
2030-0020
2030-0020
2030-0020
2030-0020
2030-0020
2030-0018
2030-0020
2030-0020
OMB-3
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Numerical List of EPA Public-Use Forms
Date of
Current 0MB
Form No. Edition Originator Title Number
5770 4 Jan-73 3901F Fellowship Applicant Qualifications 2030-0020
Inquiry
5770 5 Apr-74 390 IF Agency Fellowship Certificate 203 0-0020
5770 6 Aug-86 390 IF Fellowship Amendment 2030-0020
5770 7 May-69 3901F EPA Fellowship Activation Notice 2030-0020
5770 8 Jun-69 3901F Fellowship Agreement 2030-0020
5770 9 Jun-69 390 iF EPA Fellowship Termination Notice 2030-0020
7500 48 Aug-90 4602 Inventory of Injection Wells 2040-0042
7500 55 Dec-88 222SA NPDES Laboratory Performance 2080-0021
Evaluation
7520 1 Aug-86 4602 UIC Federal Reporting System Part I: 2040-0042
Permit Review and Issuance/Wells in
Area of Review
7520 2 A Aug-86 4602 Part II- A: Compliance Evaluation 2040-0042
7520 2 B Aug-86 4602 Part II- B: Compliance 2040-0042
Evaluation/Significant Noncompliance
7520 3 Aug-86 4602 Part 111-A: Inspections/Mechanical 2040-0042
Integrity Testing
7520 4 Aug-86 4602 Part IV: Quarterly Exceptions List 2040-0042
7520 5 Aug-86 4602 Part V: Summary of UIC Grant 2040-0042
- Utilization
7520 6 Aug-86 4602 Underground Injection Control Permit 2040-0042
Application
7520 7 Aug-86 4602 Application To Transfer Permit 2000-0042
7520 8 Aug-86 4602 Injection Well Monitoring Report 2000-0042
7520 9 Aug-86 4602 Completion Form for Class I Injection 2000-0042
Wells
7520 10 Aug-86 4602 Completion Report for Brine Disposal. 2040-0042
Hydrocarbon Storage, or Enhanced
Recovery Well
7520 11 Aug-86 4602 Annual Disposal/Injection Well 2000-0042
Monitoring Report
7520 12 Aug-86 4602 Well Rework Record 2000-0042
7520 14 Aug-86 4602 Plugging and Abandonment Plan 2040-0042
7530 1 Jan-88 540 1W Notification for Underground Storage 2050-0068
Tanks
7550 6 A Sep-86 4203 Instructions for EPA 7550-06 2040-0086
7550 6 Oct-86 4203 NPDES--Application for Permit To 2040-0086
Discharge (Form A)
7550 22 A Jul-86 4203 Application for Permit to Discharge 2040-0086
Wastewater. Supplementary
Instructions for Standard Form A -
Municipal
7550 22 Jul-86 4203 NPDES-Application for Permit To 2040-0086
Discharge Wastewater (Form A)
OMB-4
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Numerical List of EPA Public-Use Forms
Date of
Current 0MB
Form No. Edition Originator Title Number
7600 5 Dec-89 6205J Stratospheric Ozone Protection 2060-0170
Program Controlled Substance Report
7610 1 Nov-90 6204J Certificate of Representation 2060-0221
7610 3 A Oct-88 6204J Phase I Extension Plan 2060-0221
7610 3 B Oct-88 6204J Substitution Plan 2060-0221
7610 3 C Oct-88 6204J Reduced Utilization Plan 2060-022 1
7610 3 Oct-88 6204J Phase I Permit 2060-0221
7610 4 Oct-88 6204J Dispatch System 2060-0221
7610 5 Dec-88 6204J Allowance Account Information 2060-025 8
7610 6 Dec-88 6204J Allowance Transfer Form 2060-0258
7610 7 A Dec-90 6204J Letter of Credit 2060-022 1
7610 7 Dec-90 6204J Bid Form 2060-0221
7610 8 Dec-90 6204J S02 Allowance Offer 2060-0221
7610 9 Mar-90 6204J Direct Sale Application 2060-0221
7610 10 Dec-88 6204J Conservation/Renewables Reserve 2060-0258
7610 11 Feb-89 6204J Conservation Verification Protocol 2060-0258
7610 12 Dec-88 6204J Monitoring Plan 2060-0258
7610 13 Dec-88 6204J Certification Test Notice (Optional) 2060-0258
7610 14 Dec-88 6204J Certification Application 2060-0258
7610 15 Dec-88 62O4J Quarterly Reports 2060-0258
7610 16 P Mar-89 6204J Petition Submittal Notice (Optional) 2060-0258
7610 16 Nov-90 6204J Phase II Permit Application 2060-0258
7610 17 Nov-90 6204i Repowering Extension Plan 2060-025 8
7610 19 Dec-89 6204i New Unit Exemption 2060-0258
7610 20 Nov-90 6204J Retired Unit Exemption 2060-0258
7610 21 Feb-90 6204-i Phase 1, Permit Application NOx 2060-0258
Compliance Plan
7610 22 Feb-90 6204-i NOx Averaging Plan 2060-0258
7610 23 Feb-90 6204-i NOx Compliance Extension 2060-0258
7610 24 Feb-90 6204-J Alternative Emission Limitation 2060-025 8
Demonstration Period Petition
7610 25 Feb-90 6204-i Final Alternative Emission Limitation 2060-0258
7710 25 Dec-86 7405 Premanufacture Notice for New 2070-574
Chemical Substances
7710 35 Apr-78 7405 Manufacturer’s Report: Preliminary 2070-0054
Assessment Information
7710 51 Jul-83 7405 Diäxins/Furans Report 2070-0017
7710 52 Dec-85 7405 Comprehensive Assessment 2010-0019
Information Rule (CAIR) Report
7710 53 Aug-85 7404 Notification of PCB Activity 2070-0112
7710 56 Aug-90 7405 Notice of Commencement of 2070-003 8
Manufacture or Import
7740 6 Aug-88 7407 Federal TSCA CBI Access Request, 2070-0075
Agreement, and Approval (Document
& Computer)
OMB-5
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Numerical List of EPA Public-Use Forms
Date of
Current 0MB
Form No. Edition Originator Title Number
7740 8 Jan-90 7407 Partial Updating of TSCA Inventory 2070-0070
Data Base: Production and Site Report
8500 22 Dec-84 7502C Dinoseb Products: Claim for 2070-0071
Indemnification, Request for Federal
Disposal
8570 1 Jul-90 7505C Application for Pesticide 2070-0060
AniendmentlRegistration
8570 4 Jul-90 7505C Confidential Statement of Formula 2070-0060
8570 5 Jul-90 7505C Notice of Supplemental Registration of 2070-0044
Distribution of a Registered Pesticide
Product
8570 17 Dec-89 7505C Application for an Experimental Use 2070-0040
Permit
8570 20 Dec-86 7505C Data Reference Sheet 2070-0060
8570 25 Dec-89 7505C Application for/Notification of State 2070-0055
Registration of a Pesticide To Meet a
Special Local Need
8570 27 Jun-87 7505C Formulator’s Exemption Statement 2070-0060
8570 28 Dec-86 7505C Certification of Compliance with Data 2070-0060
Gap Procedures
8570 29 Apr-90 7505C Certification with Respect to Citation 2070-0060
of Data
8570 30 Sep-89 7502C Pesticide Registration Maintenance Fee 2070-0 100
Filing
8570 32 Apr-87 7505C Certification of Attempt to Enter into 2070-0 106
an Agreement with other Restraints for
Development of Data
8580 1 Sep-78 7505C FJFRA Section 3(C)(2XB) 2070-0057
8580 4 Apr-84 7505C Product Specific Data Report 2070-0057
8700 12 B Jun-86 5301 Acknowledgment of Notification of
Hazardous Waste Activity
(Verification)
8700 12 Nov-89 5301 Notification of Regulated Waste 2050-0028
Activity
8700 13 Jul-89 5301 Hazardous Waste Report 2000-0024
8700 23 Nov-89 5301 RCRA Part A Permit Application 2050-0034
9310 1 Jun-87 5201 Application for Reimbursement to 2050-0077
Local Governments for Emergency
Response
9350 1 Nov-90 7408 EPA Toxic Chemical Release 2070-0093
inventory Reporting - Form R
9350 2 New 7408 Toxic Chemical Release Inventory
Certification Statement
OMB-6
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Numerical List of EPA Public-Use Forms
Date of
Current 0MB
Form No. Edition Originator Title Number
9510 1 Jun-84 5101 Substantiation To Accompany Claims 2050-0078
of Trade Secrecy: Emergency
Planning/Community Right-To-Know
Act
OMB-7
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EPA Public-Use Forms by 0MB Number
Date of
0MB Current
Number Form No. Edition Originator Title
1265 93 Nov-89 6205J SNAP Information Notice for Significant
Activity
1265 94 Nov-89 6205J TSCA/SNAP Addendum for Significant
Activity
2070 11 Jun-77 5201 Potential Hazardous Waste Site Identification
2170 6 Jan-84 3404 Response to Request for Publication
3510 3 A Nov-76 5302W Acknowledgment of Application for a
Hazardous Waste Permit
3550 4 A Jun-91 Statement (Initial page, no signature)
3550 4 B Jun-91 Statement (Continuation Sheet)
3550 4 C Jun-91 Statement (Conclusion, with signature)
3550 4 Jun-91 Statement (Initial page, with signature)
3550 5 A Jun-91 Witness Narrative Statement (Continuation
page)
3550 5 B Jun-91 Witness Narrative Statement (Initial page, no
signature)
3550 5 C Jun-91 Witness Narrative Statement (Includes
signature, conclusion page)
3550 5 Jun-91 Witness Narrative Statement (Initial page, with
signature)
3550 8 A Jun-91 Memorandum of Interview (Continuation
Sheet)
3550 8 Jun-91 Memorandum of Interview
3550 9 Jun-91 Report of Investigation
3550 11 Jun-91 Case Opening Checklist
3550 13 Jun-91 Request for Laboratory/Technical Support
3550 14 Jun-91 Employee’s Monthly Activity Report
3550 15 A Jun-91 Property Inventory/Chain of Custody
(Continuation Sheet)
3550 15 Jun-91 Property Inventory/Chain of Custody
3550 21 Jun-91 Electronic Surveillance Authorizaiton
3550 22 Jun-91 Report of Use - Electronic Surveillance
5700 34 Feb-70 390 IF Multipurpose Wastewater Treatment
Reimbursement
8700 12 B Jun-86 5301 Acknowledgment of Notification of Hazardous
Waste Activity (Verification)
9350 2 New 7408 Toxic Chemical Release Inventory Certification
Statement
2000-0024 8700 13 Jul-89 5301 Hazardous Waste Report
2000-0042 7520 7 Aug-86 4602 Application To Transfer Permit
2000-0042 7520 8 Aug-86 4602 Injection Well Monitoring Report
2000-0042 7520 9 Aug-86 4602 Completion Form for Class I Injection Wells
2000-0042 7520 11 Aug-86 4602 Annual Disposal/Injection Well Monitoring
Report
OMBNo.-1
-------
EPA Public-Use Forms by 0MB Number
Date of
0MB Current
Number Form No. Edition Originator Title
2000-0042 7520 12 Aug-86 4602 Well Rework Record
2010-0019 7710 52 7405 Comprehensive Assessment Information Rule
(CAIR) Report
2030-0016 1900 10 Jan-87 3801F Contractor’s Cumulative Claim and
Reconciliation
2030-0018 5720 12 Jul-86 390 iF Application for Federal Assistance
(Construction Grants/Cooperative Agreements)
2030-0020 5700 12 A Oct-86 3903F Instructions for Completing EPA Form 5700-12
2030-0020 5700 12 Dec-86 3903F Application for Federal Assistance
2030-0020 5700 20 A Jul-90 3901F Assistance Agreement/Amendment
2030-0020 5700 20 B Jul-90 3901F Assistance Amendment
2030-0020 5700 30 Oct-86 3901F Preapplication for Federal Assistance
2030-0020 5700 31 Oct-75 3901F Application for Federal Assistance (Short
Form)
2030-0020 5700 33 A Aug-86 3901 F Application for Federal Assistance, Narrative
Statement
2030-0020 5700 33 B Aug-86 3901F Application for Federal Assistance, Narrative
Statement
2030-0020 5700 33 C Apr-70 3901F Application for Federal Assistance (Water
Pollution Control Areawide Waste Treatment
Management Planning Grants)
2030-0020 5700 33 F Aug-86 390 iF Application for Federal Assistance, Narrative
Statement
2030-0020 5700 33 G Aug-86 3901F Application for Federal Assistance, Narrative
Statement
2030-0020 5700 33 H Jul-82 390 iF Pesticide Enforcement Cooperative Agreement
2030-0020 5700 33 1 Nov-75 390 IF Application for Federal Assistance, Narrative
Statement
2030-0020 5700 33 Aug-86 3901F Application for Federal Assistance
2030-0020 5700 41 Oct-86 390 iF Cost or Price Summary
2030-0020 5700 48 Oct-86 3901F Procurement System Certification
2030-0020 5770 2 Jan-87 3901F Fellowship Application
2030-0020 5770 3 Jul-86 3901F Fellowship Facilities and Commitment
Statement
2030-0020 5770 4 Jan-73 3901F Fellowship Applicant Qualifications Inquiry
2030-0020 5770 5 Apr-74 390 IF Agency Fellowship Certificate
2030-0020 5770 6 Aug-86 3901F Fellowship Amendment
2030-0020 5770 7 May-69 390 IF EPA Fellowship Activation Notice
2030-0020 5770 8 Jun-69 3901F Fellowship Agreement
2030-0020 5770 9 Jun-69 390 iF EPA Fellowship Termination Notice
2040-0042 7500 48 Aug-90 4602 Inventory of Injection Wells
2040-0042 7520 1 Aug-86 4602 UIC Federal Reporting System Part 1: Permit
Review and Issuance/Wells in Area of Review
2040-0042 7520 2 A Aug-86 4602 Part Ii- A: Compliance Evaluation
OMBNo.-2
-------
EPA Public-Use Forms by 0MB Number
Date of
0MB Current
Number Form No. Edition Originator Title
2040-0042 7520 2 B Aug-86 4602 Part II- B: Compliance EvaluationlSignificant
Noncompliance
2040-0042 7520 3 Aug-86 4602 Part 111-A: inspections/Mechanical Integrity
Testing
2040-0042 7520 4 Aug-86 4602 Part IV: Quarterly Exceptions List
2040-0042 7520 5 Aug-86 4602 Part V: Summary of UIC Grant Utilization
2040-0042 7520 6 Aug-86 4602 Underground Injection Control Permit
Application
2040-0042 7520 10 Aug-86 4602 Completion Report for Brine Disposal,
Hydrocarbon Storage, or Enhanced Recovery
Well
2040-0042 7520 14 Aug-86 4602 Plugging and Abandonment Plan
2040-005 7 3560 3 Aug-90 2223-A Water Compliance Inspection Report
2040-0086 3510 1 Jul-86 4203 General Information Consolidated Permits
Program (Form 1)
2040-0086 3510 2 B Mar-87 4203 Application for Permit To Discharge
Wastewater (Form 2B) Concentrated Animal
Feeding Ops.
2040-0086 3510 2 C Jul-86 4203 Application Form 2C - Wastewater Discharge
Information
2040-0086 3510 2 D Jul-86 4203 Application Form 2D-New Sources & New
Dischargers: Application for Permit To
Discharge Process Waste
2040-0086 3510 2 E Jul-86 4203 Application Form 2E--Facilities Which Do Not
Discharge Process Wastewater
2040-0086 3510 2 F Dec-87 4203 Application for Permit to Discharge
Stormwater
2040-0086 3510 6 Jul-88 4203 Notice of Intent (NOl)
2040-0086 3510 7 Jul-88 4203 Notice of Termination (NOT)
2040-0086 7550 6 A Sep-86 4203 Instructions for EPA 7550-06
2040-0086 7550 6 Oct-86 4203 NPDES--Application for Permit To Discharge
(Form A)
2040-0086 7550 22 A Jul-86 4203 Application for Permit to Discharge
Wastewater. Supplementary Instructions for
Standard Form A - Municipal
2040-0086 7550 22 Jul-86 4203 NPDES-Application for Permit To Discharge
Wastewater (Form A)
2050-0028 8700 12 Nov-89 5301 Notification of Regulated Waste Activity
2050-0034 8700 23 Nov-89 5301 RCRA Part A Permit Application
2050-0068 7530 1 Jan-88 540 1W Notification for Underground Storage Tanks
2050-0077 9310 1 Jun-87 5201 Application for Reimbursement to Local
Governments for Emergency Response
2050-0078 9510 1 Jun-84 5101 Substantiation To Accompany Claims of Trade
Secrecy: Emergency Planning/Community
Right-To-Know Act
OMBNo.-3
-------
EPA Public-Use Forms by 0MB Number
Date of
0MB Current.
Number Form No. Edition Originator Title
2050-0095 2070 12 Jun-77 5201 Potential Hazardous Waste Preliminary
Assessment
2050-0095 2070 13 Jun-77 5201 Potential Hazardous Waste Site--Site
Inspection Report
2050-0095 2070 14 Aug-87 5201 Potential Hazardous Waste Site Current
Disposition
2060-0066 3520 2 Jan-84 6406J Lead Additive Report for Refinery
2060-0066 3520 5 Apr-86 6406J Lead Additive Report for Gasoline Importer
2060-0066 3520 6 B Apr-81 6406J Lead Additive Report Supplement B: Transfers
of Lead
2060-0095 3520 1 Aug-90 6401 Importation of Motor Vehicles and Motor
Vehicle Engines Subject to Federal Air
Pollution Requirements
2060-0095 3520 8 Sep-86 6401 Application for Final Admission of
Nonconforming Imported Vehicle
2060-0095 3520 9 Aug-90 6401 Application for Final Admission - U.S. Version
Vehicle
2060-0095 3520 14 Aug-90 6101 Application for EPA Prior Written Approval
2060-0095 3520 15 Aug-90 6101 Application for Final Admission - Plumbtesmo
Test Report
2060-0150 3520 12 Feb-86 6406J Fuel Manufacturer Notification for Motor
Vehicle Fuel
2060-0150 3520 13 Feb-86 6406J Fuel Additive Manufacturer Notification
2060-0150 3520 16 Jul-90 6406J Supplemental Notification for a Fuel or Fuel
Additive Manufacturer - Registration of Fuel
and Fuel Additives
2060-0170 7600 5 Dec-89 6205J Stratospheric Ozone Protection Program
Controlled Substance Report
2060-0221 7610 1 Nov-90 6204J Certificate of Representation
2060-0221 7610 3 A Oct-88 6204J Phase I Extension Plan
2060-022 1 7610 3 B Oct-88 6204J Substitution Plan
2060-0221 7610 3 C Oct-88 6204J Reduced Utilization Plan
2060-0221 7610 3 Oct-88 6204J Phase I Permit
2060-0221 7610 4 Oct-88 6204J Dispatch System
2060-0221 7610 7 A Dec-90 6204J Letter of Credit
2060-0221 7610 7 Dec-90 6204J Bid Form
2060-0221 7610 8 Dec-90 6204J S02 Allowance Offer
2060-0221 7610 9 Mar-90 6204J Direct Sale Application
2060-0258 7610 5 Dec-88 6204J Allowance Account Information
2060-0258 7610 6 Dec-88 6204J Allowance Transfer Form
2060-0258 7610 10 Dec-88 6204J ConservationlRenewables Reserve
2060-025 8 7610 11 Feb-89 6204J Conservation Verification Protocol
2060-0258 7610 12 Dec-88 6204J Monitoring Plan
2060-0258 7610 13 Dec-88 6204J Certification Test Notice (Optional)
2060-0258 7610 14 Dec-88 6204J Certification Application
0MB No.-4
-------
EPA Public-Use Forms by 0MB Number
Date of
0MB Current
Number Form No. Edition Originator Title
2060-0258 7610 15 Dec-88 6204J Quarterly Reports
2060-025 8 7610 16 P Mar-89 6204J Petition Submittal Notice (Optional)
2060-0258 7610 16 Nov-90 6204J Phase 11 Permit Application
2060-0258 7610 17 Nov-90 6204J Repowering Extension Plan
2060-0258 7610 19 Dec-89 6204J New Unit Exemption
2060-0258 7610 20 Nov-90 6204J Retired Unit Exemption
2060-0258 7610 21 Feb-90 6204-J Phase 1, Permit Application NOx Compliance
Plan
2060-0258 7610 22 Feb-90 6204-J NOx Averaging Plan
2060-0258 7610 23 Feb-90 6204-J NOx Compliance Extension
2060-0258 7610 24 Feb-90 6204-J Alternative Emission Limitation Demonstration
Period Petition
2060-0258 7610 25 Feb-90 6204-J Final Alternative Emission Limitation
2060-02 77 3520 20 A May-90 6406J Reformulated Gasoline Company Registration
2060-0277 3520 20 B May-90 6406J Reformulated Gasoline Facility Registration
2060-0277 3520 20 C May-90 6406J Reformulated Gasoline Facility Batch Report
2060-0277 3520 20 D Jan-91 6406J Reformulated Gasoline and Anti-Dumping
Quarterly Certification
2060-0277 3520 20 E Jan-91 6406J Reformulated Gasoline and Anti-Dumping
Annual Compliance Designation
2060-0320 3520 21 Oct-90 6401 Importation of Non-Road Vehicles and
Equipment Subject to Federal Air Pollution
Regulations
2070-0017 7710 51 Jul-83 7405 Dioxins/Furans Report
2070-0038 7710 56 Aug-90 7405 Notice of Commencement of Manufacture or
Import
2070-0040 8570 17 Dec-89 7505C Application for an Experimental Use Permit
2070-0044 8570 5 Jul-90 7505C Notice of Supplemental Registration of
Distribution of a Registered Pesticide Product
2070-0054 7710 35 Apr-78 7405 Manufacturer’s Report: Preliminary
Assessment Information
2070-0055 8570 25 Dec-89 7505C Application for/Notification of State
Registration of a Pesticide To Meet a Special
Local Need
2070-0057 8580 1 Sep-78 7505C FIFRA Section 3(C)(2)(B)
2070-005 7 8580 4 Apr-84 7505C Product Specific Data Report
2070-0060 8570 1 Jul-90 7505C Application for Pesticide
AmendmentlRegistration
2070-0060 8570 4 Jul-90 7505C Confidential Statement of Formula
2070-0060 8570 20 Dec-86 7505C Data Reference Sheet
2070-0060 8570 27 Jun-87 7505C Formulator’s Exemption Statement
2070-0060 8570 28 Dec-86 7505C Certification of Compliance with Data Gap
Procedures
2070-0060 8570 29 Apr-90 7505C Certification with Respect to Citation of Data
OMBNo.-5
-------
EPA Public-Use Forms by 0MB Number
Date of
0MB Current
Number Form No. Edition Originator Title
2070-0070 7740 8 Jan-90 7407 Partial Updating of TSCA Inventory Data Base:
Production and Site Report
2070-0071 8500 22 Dec-84 7502C Dinoseb Products: Claim for Indemnification,
Request for Federal Disposal
2070-0075 7740 6 Aug-88 7407 Federal TSCA CBI Access Request,
Agreement, and Approval (Document &
Computer)
2070-0093 9350 1 Nov-90 7408 EPA Toxic Chemical Release Inventory
Reporting - Form R
2070-0100 8570 30 Sep-89 7502C Pesticide Registration Maintenance Fee Filing
2070-0 106 8570 32 Apr-87 7505C Certification of Attempt to Enter into an
Agreement with other Restraints for
Development of Data
2070-0112 7710 53 Aug-85 7404 Notification of PCB Activity
2070-574 7710 25 Dec-86 7405 Premanufacture Notice for New Chemical
Substances
2080-0021 7500 55 Dec-88 2225A NPDES Laboratory Performance Evaluation
2090-0014 4700 4 Dec-85 1201 Preaward Compliance Review Report for All
Applicants Requesting Federal Assistance
OMBNo.-6
-------
List of EPA Forms Declared Obsolete Since September 1, 1995
Form No.
1130- 1
1130-3
1130-4
1130-5
1250-50
1250-51
1300- 1
1300-2
1300-5
1 300-5A
1300-6
1300-11
1300- 12
1300-15
1300-19
1300-2 1
1300-22
1300-24
13 15-IC
1315-iD
13 15-15
13 15-16
1315-16A
13 15-17
1320-1
1320-2
1320-3A
I 320-3B
1320-5
I 320-5A
1320-6
1320-9
1320-11
1320-12
1320-15
1320- 17
13 20-18
1320-20
1320-21
1320-22
1320-23
in
I., -
Request for Approval of Nominees for Public
Advisory Committees
Notification of Advisory Committee Meeting
Committee Inventory Record
Committee Authorization Form
Tank & Container Internal Cleaning Screener
Aircraft and Pavement Screener
Stock Reorder Notice
Clearance Record
Request for Reprint of Article
Request for Reprint for Article (No Bird)
Record of Communication
011 Document Clearance Form
Case Docketing Sheet
OA Personnel Action Routing Slip
Things To Do Today
Assignment Form
Productivity Measurement Data
Vacation & Training Schedule
EPA Issuances Guide Sheet (odd number
pages)
EPA Issuances Guide Sheet (even number
pages)
Red Border Planning Guide
Clearance/Approval Record
Clearance/Approval Record (Continuation)
OSWER Directive Initiation Request
Concurrence Sheet (Official File Copy)
(Manifold Set)
Correspondence Signature Tab
EPA Postcard (Headquarters)
Special Mail Label
OA Priority Correspondence Folder
Postal Card--Contractor’s 4th Class
EPA Memorandum
EPA Postcard (Field Elements)
Executive Communications Transmittal
OL Priority Correspondence Folder
OPTS Routing Slip
OFA Routing Slip/Assignment Form
Correspondence Action Request
Information Transmittal
Typing Instruction Sheet
White House Correspondence Request
Priority Executive Correspondence
Form Action Request
Originator
3203
3203
3203
1102
4101
4101
3404
2131
3404
AMAM
7407
3203
M&O
M&O
3203
3203
3203
5101
3404
1102
3204
3203
1102
3204
3204
1102
1102
7101
2251
1102
7405
2312
1102
1101
3404
Title
Date
Obsolete
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Sep-95
Obsolete-i
-------
List of EPA Forms Declared Obsolete Since September 1, 1995
Date
Form No. Title Obsolete Originator
1335-5 Printing Specification Sheet Sep-95 3404
1335-8 Request/Receipt of Accountable Forms Sep-95 3404
1335-9 Forms Distribution Guide Sep-95 3404
1335-11 Forms Workload Diary/Catalog Source Sep-95 3203
1335-13 Forms Catalogue Typing Guide (Master) Sep-95 3203
1335-13A Forms Catalogue Typing Guide (New) Sep-95 3203
1335-13B Forms Catalogue Typing Guide (Obsolete) Sep-95 3203
1335-17 FonnsfPublications Shipping Label Sep-95 3204
1335-18 Form Approval Sep-95 3404
1335-20 Agreement Regarding Forms Design Service Sep-95 3404
1340-1 Vital Records Transmittal Sep-95 3404
1340-4 Files Maintenance Plan Sep-95 3404
1340-7 Records Control Schedules Sep-95 3404
1345-1 Jacket Locator Card Sep-95 7505C
1350-2 Classified Document Accountability Record Sep-95 3204
1350-3 Top Secret Access Acknowledgment List Sep-95 3204
1350-4 Official US Government Identification Sep-95 3204
1350-5 Official Office Use (Cover Sheet) Sep-95 3204
1400-1 Credential Acknowledgment Statement Sep-95 3204
1440-6 Report of Unhealthful or Unsafe Conditions Sep-95 3207
1440-9 Supervisor’s Report of Accident/Illness Sep-95 3207
1440-12 Driver’s ID Card Sep-95 3207
1480-26 Name Check Request Sep-95 3201
1480-33 EPA Headquarters Building Pass Sep-95 3204
1480-36 EPA Bomb Data Information Sep-95 3204
1480-38 Incident Report Sep-95 3204
1480-39 Official US Government Identification Sep-95 3204
1480-42 Enforcement Credential Sep-95 3204
1480-43 Inspector’s Credential Sep-95 6101
1480-44 Contract Guard Duty Register Sep-95 3204
1480-45 Visitor and Employee Sign-in Register Sep-95 3204
1480-46 Officer’s Operations Log Sep-95 3204
1480-47 Record of Keys Issued Sep-95 3204
1480-48 Guard Inspection Report Sep-95 3204
1480-49 Guard Post Orders Sep-95 3204
1480-49A Guard Post Orders (Continuation Sheet) Sep-95 3204
1480-49B Guard Post Orders (Continuation Sheet: Sep-95 3204
Schedule of Activities)
1480-50 Alarm Monitor Log Sep-95 3204
1480-51 Key Issuance Register Sep-95 3204
1480-52 Special Order Sep-95 3204
1480-53 Request for Lock Work Sep-95 3204
1480-55 AARP Inspector’s Credential Sep-95 7201
1540-9 8 1/2 X 11 Layout Sheet Sep-95 1701
1550-2 FOIA Request Acknowledgment (HQ) Sep-95 1102
1550-3 FOl Request Acknowledgment (Regions) Sep-95 1102
Obsolete-2
-------
List of EPA Forms Declared Obsolete Since September 1, 1995
Date
Form No. Title Obsolete Originator
1550-4 Acknowledgment Receipt for FOl Appeal Sep-95 1102
1550-5 EPA Journal Subscription Notice Sep-95 1701
1550-7 FOl Case Status Report Sep-95 TS-75 7
1550-8 FOl Subject Files Sep-95 TS-757
1 550-9A FOl Request Response Sep-95 7502C
1550-12 Freedom of Information Request Log Sep-95 1102
1640-1 Section 309 Actions Log Sep-95
1700-1 Notification of Designation of Shipping Sep-95 3204
Officer
1700-2 Personal Property Loan Agreement Sep-95 3204
1700-3 Store Room Request and Issue Record Sep-95
1710-1 Audio-Visual Equipment Loan Record Sep-95 3204
1710-2 Office Equipment Repair Record Sep-95 3204
1730-I Report of Nonexpendable Government Sep-95 3204
Property Acquired by Contracto
1740-10 Property Action Request and Memorandum Sep-95 3204
Receipt
1740-12 Report of Survey Sep-95 3204
1740-13 Adjustment Voucher Sep-95 3204
1740-15 Leased Personal Property System Input Data Sep-95 3204
1740-16 Stock Record Sep-95 3204
1740-17 Voucher Register Sep-95 3204
1740-18 Simplified Stock Record Sep-95
1740-22 Personal Property Custody Card Sep-95 3204
1750-7 Equipment Maintenance Record Sep-95 3204
1780-1 Personal Property Loan Agreement Sep-95 ISMD
(Electronic)
1900-8B Procurement Request/Order Sep-95 2376
1900-14 Abstract of Bids Sep-95
1900-1 4A Abstract of Bids (continuation) Sep-95
1900-22 General Provisions For Use in Fixed Price Sep-95 AMAC
Research and Developmen
1900-24 General Provisions to SF-32 Sep-95 AMAC
1900-28 General Instructions For Use in Cost Sep-95 AMAC
Reimbursement Contracts with
1900-30 Additional General Provisions to Standard Sep-95 AMAC
Form 253 for Procuremen
1900-32 Additional General Provisions to SF 23-A and Sep-95 AMAC
General Conditions f
1900-33 Additional General Provisions to SF32 Sep-95 AMAC
1900-3 8 Procurement Information Notice Sep-95 2376
1900-41 C WCC Quarterly Performance Report Sep-95 3403
1900-45 Request for Proposal Sep-95
1900-46 FIT Workplan/Sample Allocation Request Sep-95 WFI-548
1900-51 Worksheet for Order for Services Sep-95 2376
Obsolete-3
-------
List of EPA Forms Declared Obsolete Since September 1, 1995
Date
Form No. Title Obsolete Originator
1900-52 D&F Authority to Negotiate an Individual Sep-95
Contract
1900-55 Hazardous Substance Response Fund Sep-95 2376
1900-55A Hazardous Substance Response Fund Sep-95
Contractor Report (Set) Page 1
1900-55B Contractor-Owned Equipment/Materials Sep-95
Report (Set)
1900-55C Subcontractor Report (Set) Page 3 of 4 Part 4 Sep-95
Included
1900-57 Determination and Findings: Method of Sep-95 2376
Contracting
1900-66 Purchase Order Record (Small Purchases) Sep-95 2376
1900-67 Purchase Order/Subcontract Record Sep-95 2376
2070-15 Potential Hazardous Waste Site Preliminary Sep-95
Assessment Score Sheet
2075-1 Application for Claim for Natural Resource Sep-95 5101
Action
2075-2 Application for Preauthorization for Natural Sep-95 5101
Resource Action
2075-3 Application for Claim for CERCLA Response Sep-95 5101
Action
2075-4 Application for Preauthorization of CERCLA Sep-95 5101
Response Action
2075-5 Application for Reimbursement Under Sep-95 WH-548B
CERCLA S123
2075-8 Confidential Information Claim Submission Sep-95 5101
2100-4 Film/Videotape Library Catalog Record Sep-95 1701
2 130-1 Translation Service Request Sep-95 3404
2170-6 Response to Request for Publication Sep-95 3404
2 170-7 Photocopying Receipt Sep-95
2190-1 Request for Computer Match Sep-95 3404
2200- 1 Reply to Request for Publications Sep-95 3204
2200-lA Reply to Request for Publication Sep-95 390 IF
2200-2 Publication Review/Clearance Request Sep-95
2200-4 Mailing List Update (OSW) Sep-95 5305
2200-5 Public Information -Product Inventory Form Sep-95 1701
2200-6 Concept Notification - Public Oriented Sep-95 1701
Products
2200-7 Final Draft Review - Public- Oriented Products Sep-95 1701
2200-8 National Environmental Education Awards Sep-95
Application
2220-1 Technical Report Data Sep-95
2340-1 Publication Review/Printing Request Sep-95 3204
2340-6 Requisition for Local Duplicating Service Sep-95 AMAF
2340-Il Production Control Record Sep-95 3204
2340-18 Revised Estimate Sep-95 3204
Obsolete-4
-------
List of EPA Forms Declared Obsolete Since September 1, 1995
Date
Form No. Title Obsolete Originator
2350-1 Cue Sheet for Multiprojection Sep-95 AMAD
2350-2 Audiovisual Service Request Sep-95 1701
2350-3 Photographic Services Work Order Sep-95 3204
2360-2 Publications Distribution Record Sep-95 3204
2360-3 Form/Publication Stockage Information Sep-95 3204
24 10-7 Financial Support to State and Local Agencies Sep-95 PM-228
D.U.
2410-8 Summary of Control Agency Funding by Sep-95 PM-228
Source of Funds
2410-9A Contract Planning Submission (FY) Annual Sep-95
Plan (Sheet)
241 0-9B Contract Planning Submission Quarterly Plan Sep-95
(Sheet)
24 10-10 Decision Unit Overview Sep-95 PM-228
2410-13 Continuation Form (Form BUD-O) Sep-95 PM-228
24 10-14 Decision Unit Level Analysis (Short Form) Sep-95 PM-228
24 10-15 Decision Unit Level Analysis Sep-95 PM-228
24 10-17 Projected Program Accomplishments Sep-95 PM-228
(Suggested Format)
2410-20 Change Request/Notification-Funding Sep-95 3301
24 10-23 Regional Decision Unit Program Sep-95 3301
Contract/Grant Dollar Allocations
24 10-24 Regional Decision Unit Work Year Proposal Sep-95 3301
2500-I Notice of Administrative Exception Sep-95 3303
2500-2 Accounting Code Sheet Sep-95 3303
2500-3 General Ledger Code Sheet Sep-95 3303
2500-4 Advance Travel Code Sheet Sep-95 3303
2500-5 Accounts Receivable General Ledger Code Sep-95 3303
Sheet
2505-1 Register of Collections Sep-95 3303
2505-3 Schedule of Collections Sep-95 3303
2505-5 Collection Officer Designation Sep-95 3303
2550-5 Paid Purchase Order Register Sep-95 3303
25 50-8 Report of Reimbursable Services Rendered Dec-96
2550-11 Document Control Register Sep-95 3303
2550-15 Letter of Credit History Sep-95 3303
2550-20 Adjustment of Pay Status Codes in Financial Sep-95 3303
Management Systems
2560-3 Application and Account for Emergency Sep-95
Salary Advance
2560-6 Authorized Compensatory Time Record Sep-95 3303
2560-8 Payroll Special Label Sep-95 3303
2560-10 Commissioned Corps Labor Distribution Sep-95 AMRF
Worksheet
2560-15 Employee Statement of Leave Balances Sep-95 3303
2560-16 Leave Overpayment Remittance Request Sep-95 3303
Obsolete-5
-------
List of EPA Forms Declared Obsolete Since September 1, 1995
Date
Form No. Title Obsolete Originator
2560-17 Payroll Commitment Adjustment Notice Sep-95 3303
2560-26 Organization Data Code Sheet Sep-95
2570-3 Substitute Memorandum of US Transportation Sep-95 3303
Request
2570-4 Payment Record Sep-95 3303
26 10-2 Notice of Leave To Be Charged While on Sep-95 3303
Travel
2615-1 Outstanding Travel Advance Sep-95 3303
2615-2 Travel Advance Balance Sep-95 3303
2620-3 Employee Acknowledgment of Diners Club Sep-95 3303
Credit Card Program
2700-I Audit Control Card Sep-95 AMU
2720-1 Investigative Control and Assignment Record Sep-95 2410
2720-8 Report of Interview Sep-95 EN-329
2720-8A Report of Interview (Continuation) Sep-95 EN-329
2720-9 Report of Investigation Sep-95 EN-329
2720-10 Report of Information Received Sep-95 EN-329
2720-12 Quarterly Verification of Administratively Sep-95 EN-329
Uncontrollable Hours
2720-21 PATS Biweekly Time Distribution Report Sep-95 2410
2 720-22 Office of Inspector General Workpaper Sep-95 2410
2 720-23 PATS Control Document (page 1) Sep-95 2410
2720-23A PATS Control Document (page 2) Sep-95 2410
2720-23B PATS Control Document (page 3) Sep-95 2410
2720-23C PATS Control Document (page 4) Sep-95 2410
2720-23D PATS Control Document (page 5) Sep-95 2410
2720-24 PATS HQ Assignment Control Document Sep-95 2410
2720-25 PATS Biweekly Time Distribution Report Sep-95 2410
(Contract Monitoring)
2720-27 Statement Sep-95 2231
2720-27A Statement Continuation Form Sep-95 2231
2720-27B Statement Conclusion Form Sep-95 2231
2720-28 Witness Narrative Statement Sep-95 2231
2720-29 Individual Fitness Profile Evaluation Sep-95 2231
2800-1 80-Column Keypunch Code Sheet Sep-95 3403
2800-3 ED!’ Services Registration Sep-95 3403
2800-4 Data Elements and Code Sep-95 3403
2800-5 Transmittal of Proposed Changes to Data Sep-95 3403
Standards
2 800-8 Application Receipt and Acceptance Sep-95 5301
2800-9 Program Change Sep-95 5301
2800-14 Facility - ID Update Maintenance Form Sep-95 5301
2800-15 Confidentiality Claim Sep-95 5301
2800-16 Facility Inventory Maintenance Form Sep-95 5301
2800-17 Waste Definition Maintenance Form Sep-95 5301
Obsolete-6
-------
List of EPA Forms Declared Obsolete Since September 1, 1995
Date
Form No. Title Obsolete Originator
2800-18 Ad Hoc Report Request (Hazardous Waste Sep-95 5301
Data Management System)
2800-22 Approved Operating Plan Sep-95 3403
2800-23 System Modernization Fund Project Proposal Sep-95 3403
3100-16 Position Control Transmittal Sep-95
3100-19 Retirement Questionnaire Sep-95 3622
3100-20 Individual Fitness Profile Sep-95
3110-13 Merit Promotion Application Sep-95 AMAP
3110-17 Consultant Certificate Sep-95
3110-18 Expert Certificate Sep-95
3110-20 Review of Employment of Experts and Sep-95 3622
Consultants
3110-21 Summary of Review of Experts and Sep-95 3622
Consultants
3110-34 Database Integrity Form Sep-95 3622
3110-35 Senior Executive Service Vacancy Sep-95 3 103
Announcement
3110-44 Senior Executive Service Recertification CY Sep-95 3 103
3110-45 Expert or Consultant Certificate Sep-95 3 103
3115-3 Merit Promotion Announcement Sep-95 3622
311 S-3C Temporary Vacancy Announcement Sep-95 3622
3115-3D Career Management System Vacancy Sep-95 3 103
Announcement
311 5-21 SES Staffing Request Sep-95 3622
3115-23 SES Candidate Program Supervisory Appraisal Sep-95 3622
311 5-24E Performance Standard Sep-95
3115-26 Certificate of Eligible Voluntary Assignment Sep-95 3622
Program
3115-29 Cumulative Merit Promotion Evaluation Sheet Sep-95 3622
3115-31 Basic Qualifications Determination Worksheet Sep-95 3622
3120-1 Confidential Statement of Employment and Sep-95 2312
Financial Interests
3130-2 Employee Suggestion Form Sep-95 3622
3130-3 Suggestion Record and Evaluation Sep-95 3622
3130-5 Cash Award Notice Sep-95 3622
3130-8 Suggestion Award Certificate Sep-95 3622
3140-1 1 Upward Mobility Trainee Evaluation Sep-95 3622
3 140-24A Project Officer Certificate (Interim Sep-95 2376
Appointment)
3140-27 Project Officer Certification Program Sep-95 2376
(Contract Administration Co
3140-28 Project Officer Certification Program (Basic Sep-95 2376
Course)
3140-29 Career Management System Qualification Sep-95 3103
Worksheet
31 40-29A Career Management Plan Sep-95 3 103
Obsolete-7
-------
List of EPA Forms Declared Obsolete Since September 1, 1995
Date
Form No. Title Obsolete Originator
3140-30 Education Center Agreement Sep-95 3103
3140-31 Individual Development Plan Sep-95 3103
3140-33 Shortage Determination Form Sep-95 3103
3 150-6 Evaluation Statement for Supervisors of Two- •Sep-95 3622
Grade-Interval Positi
3150-7 Evaluation Statement for Supervisors of Sep-95
Subprofessional and Cleri
3150-9 Evaluation Statement Sep-95 3622
3 150-10 Desk Audit Report Sep-95 3622
3150-11 Position Description for Regional Two-Grade- Sep-95
Interval Professional
3150-12 Position Description for Clerk - Typist Sep-95 AMAP
3150-13 Position Description for Clerk - Dictating Sep-95 AMAP
Machine Transcriber
3150-14 Position Description for Clerk - Stenographer Sep-95 AMAP
3150-16 Position Description for Supervisors of Two- Sep-95
Grade-Interval Positi
3150-22 Position Description (Factor Evaluation Sep-95
System)
3150-24 Final Performance Guide Sep-95 3622
3150-27 Position Description for Regional Sep-95
Nonsupervisory Two-Grade-Intern
3150-28 Position Description for Regional Sep-95
Nonsupervisory Professional Pro
3150-29 Position Description for Regional Sep-95
Nonsupervisory Non-Professional
3 155-7 Justification for Appointment of Retiree Sep-95 3634
Without Reduction in Ann
3155-11 Manager or Supervisor Buyout Application Sep-95 3634
3 155-12 Nonsupervisory Employee Buyout Application Sep-95 3634
3155-13 Buyout Agreement Sep-95 3634
3160-4 Performance Appraisal Worksheet Sep-95 3203
31 60-4A Appraisal for Merit Promotion - Short Version Sep-95 3622
3 160-5 Record of Excused Absence for Employee Sep-95 3622
3 300-2 Notice of State Certification Sep-95
3300-11 Enforcement Data Management Form Sep-95 2211
3300-12 CERCLA Enforcement Data Management Sep-95 2211
Form
3300- 15 Tracking Form for Packages Sent From OE - Sep-95 2243
Water
3300-16 National Environmental Policy Act NEPA Sep-95 2211
Review
3300-17 Approval to Accept Travel Expenses from Sep-95 2379
EPA
3320-IT NPDES Discharge Monitoring Report Sep-95 4203
3500-5 Fuels Field Inspection Sep-95 6101
Obsolete-8
-------
List of EPA Forms Declared Obsolete Since September 1, 1995
Date
Form No. Title Obsolete Originator
3500-6 Routing Slip/Assignment Form Sep-95 EN-329
351 0-2A Application Form 2A - NPDES (Municipal Sep-95 4203
Wastewater Plants)
3510-3 Application Form 3 - RCRA Sep-95 WH-563
3520-3 Lead Additive Report for Manufacturing Sep-95 6101
Facility or Site
3520-6A Lead Additive Report Supplement A: Sep-95 6101
Constructive Allocations.
3520-7 Notice of Violation of Section 211 of the Clean Sep-95 6101
Air Act
3540-1 Notice of Arrival of Pesticides and Devices Sep-95 7201
3540-2 Notice of Inspection Sep-95 7201
3 540-3 Receipt for Samples Sep-95 7201
3 540-4 Sample Record Jacket Sep-95 7201
3 540-5 Report of Analysis Sep-95 7201
3540-5A Report of Analysis Continuation Sep-95 7201
3 540-7 Collection Report Sep-95 AGGP
3540-9 Authorization To Administer Oaths, Sep-95 7201
Affidavits, and Affirmations
3540-10 Revocation of Authorization to Administer Sep-95 AGGP
Oaths, Affidavits, and
3540-11 Affidavit Sep-95 7201
3540-13 Copy of Invoice and Shipping Record Sep-95 7201
3540-14 Poison Gas Label Sep-95 EG-333
3540-15 Poison Label Sep-95 EG-333
3540-17 History of Official Sample Sep-95 7201
3540-19 Dealer’s Statement Sep-95 EG-342
3540-20 Use Investigation Report Sep-95 7201
3540-2 1 Establishment Inspection Report Sep-95 7201
3540-22 Corrective Action Report Sep-95 7201
3540-24 EPA Inspector’s Credential FIFRA Sep-95 7201
3540-25 Notice of Pesticide UseIMisuse Inspection Sep-95 7201
3540-26 Receipt for Pesticide Use/Misuse Inspection Sep-95 7201
3540-27 Notice of Stop Sale. Use, or Removal Order Sep-95 7201
3540-28 State Inspector’s Credential Sep-95 7201
3 540-29 Sample Container Tag Sep-95 7201
3540-30 Contractor’s Credential Sep-95 7201
3540-31 Inspector’s Credential Sep-95 7201
3540-32 F1FRA!TSCA Administration Inspection Sep-95 7201
Schedule Description
3540-33 Case Management Sep-95 7201
3540-34 State Inspectors Credential Sep-95 7201
3540-35 Notice of Inspection Sep-95 7201
3 540-40 Good Laboratory Practice Notice of Inspection Sep-95 7204
3 560-2 Authorization to Discharge Under the National Sep-95 EG-326
Pollutant Discharge
Obsolete-9
-------
List of EPA Forms Declared Obsolete Since September 1’, 1995
Date
Form No. Title Obsolete Originator
3560-3ADD Addendum for Form 3560-03 Sep-95
3710-4 Information Request Record Sep-95 2121
3720-6 Cost Analysis Worksheet Sep-95 PM-228
3720-7 Government Commercial or Industrial Activity Sep-95 PM-228
Report
3720-10 Start Action Request Sep-95 2131
3720-1 OA Workgroup Membership Invitation Sep-95 2131
3720-11 Federalism Review Sep-95 2131
3720-12 Start Action Request Sep-95 6101
3720-13 Takings Implication Assessment (TIA) for Sep-95 2136
Proposed Administrative
4510-2 International Visitor(s) Alert Sep-95 2610
4540-1 Clearance of Foreign Research Award Sep-95 2610
4700-5 Minority Business Enterprise Information Sep-95 1201
4850-2 Maintenance Job Order Sep-95 3204
4850-3 Fume Hood Certification Sep-95 3204
4920-1 Application for Motor Vehicle Operator’s Sep-95 3204
License
4920-4 Motor Pool Assignment Sep-95 3204
4920-6 Accumulative Daily Requests--Dispatcher Sep-95 3204
4920-7 Key and Credit Card Log Sep-95 3204
4920-9 Daily Schedule Chart Sep-95 3204
4920-10 Accident Report Sep-95 3204
4920-11 Monthly Vehicle Report Sep-95 3204
4920-12 Procedure in Case of Theft or Accident Sep-95 3204
4940-1 Motor Vehicle Record Sep-95 3204
4940-2 Driver’s Daily and Weekly Preventive Sep-95 3204
Maintenance Checklist
5020-2 Telephone Key System Worksheet Sep-95 3707
5040-1 Message Receipt Log Sep-95 3707
5040-2 Facsimile Log Sep-95 3707
5040-3 Originating Traffic Log Sep-95 3707
5040-4 Terminating Traffic Log Sep-95 3707
5040-5 Facsimile Request and Cover Sheet Sep-95 3707
5040-5A Facsimile Transmission Record (Nonoriginal Sep-95 3204
Copy)
5040-8 Message for Transmission Sep-95 3707
5 100-1 Building Modification Services Request Sep-95
51 00-2A Labor Services Request Receipt Log Sep-95 3204
5100-4 Relocation Worksheet Sep-95 3204
5100-4A Relocation Worksheet Sep-95 3204
5100-6 Facilities Status Record Sep-95 3204
5100-7 EPA Facility NEPA Review Sep-95
5100-11 Facilities Quality Survey Sep-95 3204
5110-1 EPA Identification Card Acknowledgment Sep-95 3204
5 130-1 Self Service-Store Void Slip Sep-95 3204
Obsolete- 10
-------
List of EPA Forms Declared Obsolete Since September 1, 1995
Date
Form No. Title Obsolete Originator
5130-lA Self Service-Store Void Slip (Continuation) Sep-95 3204
5130-2 EPA Self-Service Store Request/Sales Slip Dec-96
5 130-2A EPA Self-Service Store Request/Sales Slip Sep-95 3204
Continuation
5130-3 Application for EPA Supply Store Shopping Dec-96
Plate
5140-1 Office Equipment Repair Log Sep-95 3204
5140-3 Office Equipment Repair Records Sep-95 3204
5160-2 Physician’s Statement in Support of Handicap Sep-95 3204
Parking
5160-3 Supervisor’s Report in Support of Handicap Sep-95
Parking Assignment
51 70-4T Conference Room Schedule Sep-95 3204
5180-1 Mail Control Schedule Sep-95 3404
5180-3 Record of Registered and Certified Mail Sep-95 3204
5180-4 Sampled Mail Report Sep-95 3204
5180-5 Supplemental Mail Report Sep-95 3204
5180-8 U.S. Government Shipment Label Sep-95 3204
5180-10 Express Mail Register Sep-95 3204
5180-11 Mail Label - First Class Sep-95 3204
5180-13 Special Fourth-Class Book Rate Sep-95 3204
5180-15 Mail Label - Third-Class Bulk Sep-95 3204
5300-23 Environmental Review for Extramural Projects Sep-95 8102
5300-24 Time Sheet (Hours) Sep-95 8601
5320-5 ORDIS Project Data Form Sep-95 8102
5700-7C Application Kit for Assistance (Fellowship) Sep-95 390 iF
5700-7D Application Kit for Assistance (Training) Sep-95 390 iF
5700-7E Application Kit for Assistance (Research) Sep-95 390 W
5700-20C EPA Assistance Agreement’Amendment Sep-95 390 IF
5700-43 Final Report Status Sep-95 3901F
5700-44 Request for information Omitted from Group Sep-95 390 IF
Application
5 700-45 Programming Request Sep-95 390 IF
5700-46 GICS Transaction Verification/Discrepancy Sep-95 390 IF
Listing
5720-4 Labor Standards Provisions for Federal & Sep-95 1201
Federally Assisted Contr
5 720-9 Required Provisions Consulting Engineering Sep-95 390 IF
Agreements
5720-10 Required Provisions Construction Contracts Sep-95 3901F
6005-2 Quarterly MBE/WBE Consolidation Report Sep-95 A- 149
6005-3 Superfund Minority Contractors Utilization Sep-95 A-149
Report
6005-3A Superfund Minority Contractors Utilization Sep-95 A- 149
Report--Part 2
7500-3 SB Postcard/PreliminarY Assessment Information Sep-95 7408
Obsolete-Il
-------
List of EPA Forms Declared Obsolete Since September 1, 1995
Date
Form No. Title Obsolete Originator
7500-42 Federal Reporting Data System-Violations Sep-95
7500-43 Federal Reporting Data System-Variance and Sep-95
Exemptions
7500-48 inventory of Injection Wells Sep-95 4602
7500-51 Organics Laboratory Chronicle Sep-95 4101
7500-52 SPCC Inspection Summary Sheet Sep-95 5201
7500-56 Request for Wetlands Related Material Sep-95 4501 F
7500-59 Industrial User Baseline Monitoring Report Sep-95
7500-60 Civil Referral Review Sep-95
7500-61 Office of Water IRM Outreach Documents Sep-95 4101
7520-13 Plugging Record Sep-95 4601
7550-8 NPDES Application for Permit to Discharge Sep-95
(Form C)
7550-8A Instructions for EPA Form 7550-08 Sep-95
75 50-221 Section 1: Applicant and Facility Description Sep-95
Standard Form A - M
7550-2211 Section II: Basic Discharge Description Sep-95
Standard Form A - Municip
7550-22111 Section III: Scheduled Improvements and Sep-95
Schedules of Implementati
7550-22W Section 4: Industrial Waste Contribution to Sep-95
Municipal System Stan
7550-23 NPDES-Application for Permit To Discharge Sep-95 4203
Wastewater (Form C)
7550-23A Application for Permit to Discharge Sep-95
Wastewater: Supplementary Ins
7550-231 Applicant and Facility Description Sep-95
7550-2311 Basic Discharge Description Sep-95
7550-23111 Waste Abatement Requirements, etc. Sep-95
7550-23 SET NPDES/Application for Permit to Discharge Sep-95
Wastewater - Standard F
7550-24 National Pollutant Discharge Elimination Sep-95 AG
System Application for P
7550-25 Application for Permit to Discharge Municipal Sep-95 4305
or Industrial Waste
7600-4 Fuel Economy Rating Sep-95
7600-6 Application For An IPP Written Guarantee For Sep-95 ANR-445
So2 Allowances
7600-7 Application For An IPP Written Guarantee For Sep-95 ANR-445
So2 Allowances Suppl
76 10-2 Phase I Extension Early Ranking Sep-95 6204J
771 0-3C TSCA Inventory Report Form C Sep-95 7101
7710-3E Chemical Substance Inventory Report Form E Sep-95 7407
7710-6 TSCA Confidential Business Information Sep-95 7407
Cover Sheet
7710-8 Interoffice Applicant Form Sep-95 7407
Obsolete- 12
-------
List of EPA Forms Declared Obsolete Since September 1, 1995
Date
Form No. Title Obsolete Originator
77 10-9 Request for Word Processing Sep-95 7502C
7710-13 Federal Agency, Congress, and Federal Court Sep-95 7407
Sign-Out Log
7710-15 Request for Access to TSCA - C.B.I. Sep-95 7407
7710-16 Confidentiality Agreement for EPA Employees Sep-95 7407
7710-22 Library Request Index Sep-95 7407
7710-23 Meeting Registration Card Sep-95 7101
7710-24 ICS Data Request Sep-95 TS-757
7710-26 Premanufacture Notice (importers) Sep-95
7710-27 Premanufacture Notice (Exporters) Sep-95
7710-34 Trade Name Product Identity Report Sep-95 7407
7710-42 Processing of 1,2 - Dichiorbethane (Ethylene Sep-95 TS-778
Dichloride, EDC)
77 10-47 Authorization for Access to TSCA-CBI Sep-95 7407
77 10-48 HERD Action Report Sep-95 7403
7710-49 Structure Activity Relationship Database Sep-95 7403
7710-54 Substantiation to Accompany Claims of Trade Sep-95
Secrecy Under the Eme
77 10-55 Polymer Exemption Form Sep-95 7405
7720-1 Detailed Review PMN Tracking Record Sep-95 7405
7720-2 Initial Review PMN Tracking Record Sep-95 7405
7720-3 Initial Review PMN Tracking Summary Sep-95 7405
7720-4 PMN Information Summary Sep-95 7405
7720-5 TMEA Tracking Record Sep-95 7405
7720-6 TMEA Tracking Summary Sep-95 7405
7720-7 PMN/TMEA Data Summary Sep-95 7405
7720-8 Detailed Review Summary Sep-95 7405
7720-9 TMEA Information Summary Report Sep-95 7405
7720-10 TMEA Case Record Sep-95 7405
7720-11 Detailed Review Case Record Sep-95 7405
7730-4 Notice to EPA Employees Sep-95 3207
7730-5 Asbestos School Hazardous Abatement Act Sep-95 7408
Forms
7740-3 TSCA Notice of Inspection Sep-95 7201
7740-4 TSCA Inspection Confidentiality Notice Sep-95 7201
7740-5 TSCA Investigation Summary Sep-95 7201
7740-19 CBI Document Receipt Sep-95
7740-20 Toxic Chemical Release Inventory Sep-95
7740-21 Mercury Reporting Sep-95 7407
8500-1 Investigation Request Sep-95 7201
8500-21 SilvexI2,4,5-T Products: Claim for Sep-95 7505C
Indemnification, Request for
8550-5A Pesticide Incident Report Update Sep-95
8550-10 Specimen Label Sep-9S 7407
8560-5 Document Sign-Out Sheet Sep-95 OPP/HED
CETS
Obsolete- 13
-------
List of EPA Forms Declared Obsolete Since September 1, 1995
Date
Obsolete Originator
Form No. Title
8570-13 Data Review Record Sep-95 7505C
8570-26 Certification with Respect to Citation of Data Sep-95 TS-767
8570-31 Certification with Respect to Data Sep-95 7502C
Compensation Requirements
8580-3 Generic Data Exemption Statement Sep-95 7505C
8580-6 Certificate of Attempt To Enter into an Sep-95 7505C
Agreement with Other Regi
8580-7 FIFRA Investigation Summary Sep-95 7201
8580-8 Authorization for Access to FIFRA Trade Sep-95
Secrets and CBI
8580-11 Docket Control Slip Sep-95 5301
8700-11 Docket Control Slip Sep-95 WH-562
8700-12A Acknowledgment of Notification of Hazardous Sep-95 5301
Waste Activity
8700-12S Notification of Regulated Waste Activity Sep-95
8710- 16A 1990 Inventory of Federal Hazardous Waste Sep-95 5301
Activity at Formerly Ow
9100-1 Technical Enforcement Support at Hazardous Sep-95 5201
Waste Sites
9 100-2 Superfiind Document Center-Inventory Card Sep-95 5501
9110-3 Packing List/Chain of Custody Sep-95 5201
9110-4 QTM Traffic Report Sep-95 5201
9510-2 SPMS and SCAP Report: Fiscal Year 1989 Sep-95 5101
Obsolete- 14
-------
Source Information for EPA Forms
Form No. Mail Originator Source Source Phone
Code
1110-1 3601 OARM Cincinnati 513-489-8190
EPA FonnSmart Center (HQ)
Originating Office 260-6654
1265-93 6205J OAR Originating Office 233-9152
1265-94 620Sf OAR Originating Office 233-9152
1300-6
1300-13 3408 OARM 260-2866
1315-4 3610 OAR.M Originating Office 260-5000
1315-5 3610 OARM Originating Office 260-5000
1315- 10 3610 OARM Originating Office 260-5000
13)5-) 1 3610 OARM Originating Office 260-5000
1315-12 3203 OARM Cincinnati 513-489-8190
1315-12A 3601 OARM 260-4229
1315-17 3610 OARM Originating Office 260-5000
1320-lA 3204 OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
1320-3 3204 OARM EPA FormSmart Center (HQ)
Originating Office 260-2096
1320-8 3204 OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office. 260-2096
1325-4 2136 OPPE Originating Office 260-2740
1335-4 3408 OARM EPA ForrnSmart Center (HQ)
Originating Office . 260-2866
1480-2 2410 O IG Originating Office 260-4115
1480-6 2441 OIG Originating Office 260-4115
1480-7 2410 O IG Originating Office 260-4115
1480-19 24)0 010 Cincinnati 513-489-8190
1480-27 2410 O(G Originating Office 260-4)15
1480-36 3204 OARM Cincinnati 513-489-8190
Originating Office 260-2019
1480-40 2410 O IG Cincinnati 513-489-8190
1480-41 2410 O G Originating Office 260-4115
1550-9 7506C OPPTS . 703-305-5454
1610-i 3303F OARM Cincinnati 513-489-8190
EPA Form Smart Center (HQ)
Originating Office 260-5658
1700-4 3303F OARM Cincinnati 513-489-8190
EPA ForrnSmart Center (HQ)
Originating Office 260-5658
1700-7 3204 OARM Cincinnati 5)3-489-8)90
EPA ForrnSmart Center (1-IQ)
Originating Office 260-6354
1700-8 2376 OGC Cincinnati 5)3-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-7512
Source-I
-------
Source Information for EPA Forms
1700-9 3204 OARM EPA FormSmart Center (HQ)
Originating Office 260-2138
1740-9 3303F OARM Cincinnati 513-489-8190
1900-2 3801F OARM Cincinnati 513-489-8190
1900-3 3801F OARM Cincinnati 513-489-8190
1900-5 3801F OARM Cincinnati 513-489-8190
1900-6 3801F OARM Cincinnati 513-489-8190
1900-7 3801F OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
1900-8 3801F OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-9948
1900-10 3801F OARM Cincinnati 513-489-8190
EPA FoimSmart Center (HQ)
1900-13 3801F OARM Cincinnati 513-489-8190
1900-19 3801F OARM Cincinnati 513-489-8190
1900-20 3801F OARM Cincinnati 513-489-8190
1900-26 3801F OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-9948
1900-27 3801F OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-9948
1900-34 3801F OARM Cincinnati 513-489-8190
1900-34A 3801 F OARM Cincinnati 513-489-8190
1900-35 3801F OARM Cincinnati 513-489-8190
1900-37 3801F OARM Cincinnati 513-489-8190
1900-41A 3801F OARM Cincinnati 513-489-8190
1900-41B 3801F OARM Cincinnati 513-489-8190
1900-44 3801F OARM Originating Office 260-9948
1900-44B 3801F OARM Cincinnati 513-489-8190
1900-48 380 IF OARM Originating Office 260-9786
1900-49 3801F OARM Originating Office 260-9786
1900-53 3801F OARM Originating Office 260-9786
1900-54 380 iF OARM Originating Office 260-9786
1900-56 380 IF OARM Originating Office 475-8671
1900-58 380ff OARM Originating Office 475-8671
1900-59 3801F OARM Cincinnati 513-489-8190
1900-60 3801F OARM Cincinnati 513-489-8190
1900-60A 3801F OARM Cincinnati 513-489-8190
1900-61 380 1F OARM Cincinnati 513-489-8190
1900-62 3801F OARM Originating Office 475-8671
1900-63 380 1F OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-2355
1900-64 3801F OARM Originating Office 260-9948
1900-65 3801 F OARM Cincinnati 51 3-489-8190
Source-2
-------
Source Information for EPA Forms
1900-65A 3801F OARM Cincinnati 513-489-8190
EPA Form Smart Center (HQ)
Originating Office 260-5020
1900-68 3801F OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-6482
1900-69 38O1F OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-9032
1900-69A 3801F OARM Cincinnati 513-489-8190
EPA FormSmart Center (HO)
Originating Office 260-9032
2070-11 5201G OSWER 703-603-8960
2070-12 5201G OSWER 703-603-8960
2070-13 5201G OSWER 703-603-8960
2070-14 5201G OSWER 703-603-8960
2200-9 3204 OARM Cincinnati 513-489-8190
EPA Form Smart Center (HQ)
Originating Office 260-2128
2340-15 3303F OARM Cincinnati 513-489-8190
EPA Form Smart Center (HQ)
Originating Office 260-5658
2340-17 3204 OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-8019
2360-1 3204 OARM Cincinnati 513-489-8190
2505-2 3303F OARM Cincinnati 513-489-8190
2505-4 3303F OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-5658
2545-1 3303F OARM Cincinnati 513-489-8190
2545-2 3303F OARM Cincinnati 513-489-8190
2550-4 3303F OARM Cincinnati 513-489-8190
2550-6 3303F OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-5658
2550-9 3303F OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-5658
2550-10 3303F OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-5658
2550-19 3303F OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
2550-21 3303F OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-5658
2550-22 3303F OARM Originating Office 260-5658
Source-3
-------
Source Information for EPA Forms
2550-23 3303F OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-5658
2560-1 3303F OARM Cincinnati 513-489-8190
2560-2 3303F OARM Cincinnati 513-489-8190
2560-4 3303F OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
2560-5 3303F OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-5658
2560-7 3303F OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office
2560- 12 3303F OARM Originating Office 260-5658
2560-18 3303F OARM Cincinnati 513-489-8190
2560-21 3303F OARM Originating Office 260-5658
2560-22 3303F OARM Originating Office 260-5658
2560-23 3303F OARM Originating Office 260-5658
2560-25 3303F OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-5658
2560-28 3303F OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-5658
2560-28A 3303F OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-5658
2560-29 2410 OIG Originating Office 260-1109
2560-30 2410 OIG Originating Office 260-1109
2560-31 3303F OARM Cincinnati 513-489-8190
2560-32 3303F OARM Originating Office 260-5658
2565-1 3303F OARM Cincinnati 513-489-8190
EPA Form Smart Center (HQ)
Originating Office 260-5658
2565-2 3303F OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-5658
2565-3 3303F OARM Cincinnati 513-489-8190
EPA Form Smart Center (HQ)
Originating Office 260-5658
2570-6 3303F OARM Cincinnati 513-489-8190
2570-7 3303F OARM Originating Office 260-5658
25 70-8 3303f OARM Originating Office 260-5658
2610-1 3303F OARM Cincinnati 513-489-8190
EPA Form Smart Center (HQ)
Originating Office 260-5658
2610-IA 3303F OAR.M Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-5658
Source-4
-------
Source Information for EPA Forms
2620-1
3303F
OARM
Cincinnati
2620-2
3303F
OARM
Cincinnati
513-489-8190
2635-1
3303F
OARM
Cincinnati
513-489-8190
2635-2
3303F
OARM
Cincinnati
513-489-8190
2720-2
2410
OIG
Cincinnati
513-489-8190
2720-4
2410
OIG
Cincinnati
513-489-8190
2720-6
2410
OIG
Cincinnati
513-489-8190
2720-13
2410
010
Cincinnati
513-489-8190
2720-14
2410
OIG
Cincinnati
513-489-8190
2720-15
2431
OIG
Cincinnati
513-489-8190
2720-16
2431
010
Cincinnati
513-489-8190
2720-17
2410
OIG
Cincinnati
513-489-8190
2720-18
2410
OIG
Cincinnati
513-489-8190
2720-19
2410
OIG
Cincinnati
513-489-8190
2720-20A
2410
010
Cincinnati
513-489-8190
2720-20B
2410
010
Cincinnati
513-489-8190
2720-26
2410
010
Originating Office
260-2187
513-489-8190
3100-i
3100-13
3622
3610
OARM
OARM
Cincinnati
EPA Form Smart Center (HQ)
Originating Office
Originating Office
260-3192
260-9686
260-3308
3100-14
3601
OARM
3 100-17
3622
OARM
260-3289
3100-18
3601
OARM
31 10-i
3110-11
3601
3601
OARM
OARM
Cincinnati
EPA FormSmart Center (HQ)
Originating Office
513-489-8190
260-3308
260-3285
3110-15
3110-26
3601
3610
OARM
OARM
Cincinnati
EPA FormSmart Center (HQ)
Originating Office
Originating Office
260-3308
260-3352
513-489-8190
3110-38
3610
OARM
Cincinnati
3110-43
3110-46
3601
3610
OARM
OARM
Cincinnati
EPA FormSmart Center (HQ)
Originating Office
Originating Office
260-3314
260-3280
260-2962
3110-47
3610
OARM
Originating Office
513-489-8190
3115-4
3622
OARM
Cincinnati
513-489-8190
3115-7
3115-8
3115-8A
3601
3601
3610
OARM
OARM
OARM
Cincinnati
EPA Form Smart Center (HQ)
Originating Office
Cincinnati
EPA FormSmart Center (HQ)
Originating Office
Cincinnati
260-3308
513-489-8190
260-3308
513-489-8190
260-3308
3115-88
3601
OARM
513-489-8190
3115-8C.
3610
OARM
Cincinnati
Source-5
-------
Source Information for EPA Forms
3115-SD 3601 OARM Cincinnati 513-4894190
EPA FormSmart Center (HQ)
Originating Office 260-3308
3115-SE 3610 OARM Cincinnati 513-489-8190
3115-9 3601 OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-3308
3115-13 3610 OARM Cincinnati 513-489-8190
3115-14 3610 OARM Cincinnati 513-489-8190
3115-15 3610 OARM Cincinnati 513-489-8190
3115-17 3610 OARM Cincinnati 513-489-8190
3115-18 3610 OARM Originating Office 260-3308
3115-22 3601 OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-3308
3115-24 3634 OARM Cincinnati 513-489-8190
3115-28 3610 OARM Cincinnati 513-489-8190
3115-31 3610 OARM Cincinnati 513-489-8190
3115-32 3610 OARM Originating Office 260-2962
3115-34 3610 OARM Originating Office 260-2962
3 130-1 3601 OARM Cincinnati 513-489-8190
EPA Form Smart Center (HQ)
Originating Office 260-3341
3130-IA 3303F OARM Cincinnati 513-489-8190
EPA Form Smart Center (HQ)
Originating Office 260-5658
3130-4 3634 OARM Cincinnati 513-489-8190
3130-6 3610 OARM Cincinnati 513-489-8190
3130-7A 3622 OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-3341
3130-7B 3622 OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-3341
3 130-7C 3622 OARM Cincinnati 513-489-8190
EPA Form Smart Center (HQ)
Originating Office 260-3341
3130-7D 3601 OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-3341
3130-9 3606 OARM Cincinnati 513-489-8190
EPA Form Smart Center (HQ)
Originating Office 260-3309
3130-10 3601 OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-3341
3140-18 3633 OARM Cincinnati 513-489-8190
3140-20 3633 OARM Cincinnati 513-489-8190
Source-6
-------
Source Information for EPA Forms
3140-32 3634 OARM Cincinnati 513-489-8-190
EPA Form Smart Center (HQ)
Originating Office 260-3308
3150-1 3622 OARM Cincinnati 513-489-8190
3150-5 3622 OARM Cincinnati 513-489-8190
3150-15 3622 OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-6241
3150-21 3622 OARM Cincinnati 513-489-8190
3155-1 2376 OGC Cincinnati 513-489-8190
3155-2 2376 OGC Cincinnati 513-489-8190
3155-3 3033F OARM Cincinnati 513-489-8190
3155-4 3634 OARM Originating Office 260-3308
3155-5 3634 OARM Originating Office 260-3308
3 155-6 3634 OARM Originating Office 260-3308
3155-8 3634 OARM Originating Office 260-3308
3155-9 3634 OARM Originating Office
3 155-10 3634 OARM Originating Office 260-3308
3160-2 3634 OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-3341
3160-3 3634 OARM Cincinnati 513-489-8190
EPA Form Smart Center (HQ)
Originating Office 260-3341
3 160-6 3601 OARM Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-1630
513-489-8190
3160-7 3601 OARM Cincinnati
EPA Form Smart Center (HQ)
Originating Office 260-3341
3300-1 7401 OPPTS 260-3810
3300-4 2312 OGC Originating Office 260-5919
3300-14 2233 OECA Originating Office 260-5262
564-5036
3320-1 4203 OW
3340-1 2310 OGC Cincinnati 513-489-8190
3340-2 2310 OGC originatingOffice 260-1339
3370-1 2376 OGC Originating Office 260-7512
260-5850
35 10-2B 4203 OW 260-5850
3510-2C 4203 OW 260-5850
3510-2D 4203 OW 513-489-8190
3510-2E 4203 OW Cincinnati 513-489-8190
3510-2F 4203 OW Cincinnati 703-308-8414+
3510-3A 5302W OSWER 513-489-8190
3510-6 4203 ow Cincinnati 202-233-9240
3520-1 6401 OAR
3 520-8 6401 OAR Originating Office 202-233-9281
3 520-9 6401 OAR Originating Office 202-233-9281
3 520-12 6406J OAR Originating Office 202-233-9303
3520-13 6406J OAR Originating Office 202-233-9303
Source-7
-------
Source Information for EPA Forms
3520-14 6101 OAR Originating Office 202-233-9281
3520-15 6101 OAR Originating Office 202-233-9281
3520-,1 6 6406J OAR Originating Office 202-233-9303
3520-20A 6406J OAR Originating Office 202-233-9028
3520-20B 6406J OAR Originating Office 202-233-9028
3520-20C 6406J OAR Originating Office 202-233-9028
3520-20D 6406J OAR Originating Office 233-9028
3520-20E 6406J OAR Originating Office 233-9028
3520-21 6401 OAR Cincinnati 513-489-8190
Originating Office
3 540-8 7201 OPPTS Originating Office 564-5008
3540-8A 6118-AR OPPTS 564-5008
3540-16 6118-AR OPPTS Originating Office 564-5008
3540-38 2225A Originating Office 202-564-4202
3550-8A OECA Originating Office
3550-9 OECA Originating Office
3550-11 OECA Originating Office
3550-13 OECA Originating Office
3550- 14 OECA Originating Office
3550-15 OECA Originating Office
3550-15A OECA Originating Office
3550-2 1 OECA Originating Office
3550-22 OECA Originating Office
3560-3 2223-A OECA Cincinnati 513-489-8190
3560-4 2223-A OECA Cincinnati 513-489-8190
4550-1 2610 OIA Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-4898
4550-5 2610 OIA Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 260-4898
45 50-7 2610 OIA Originating Office 260-4898
4700-4 1201 AO Cincinnati 260-4582
4700-14 1201 AO Originating Office 260-4582
4920-3 3204 OARM Cincinnati 513-489-8190
4920-5 3204 OARM Originating Office 260-2088
4920-15 3204 OARM Originating Office 260-6232
4920-16 3204 OARM Originating Office 260-2088
4920-17 3204 OARM Originating Office 260-2088
4920-18 3204 OARM Originating Office 260-2088
4920-19 3204 OARM Originating Office 260-2088
4920-8 3204 OARM Originating Office 260-2088
5000-1 OARM 260-8554
5020-1 3707 OARM EPA FormSmart Center (HQ)
Originating Office 260-8345
5040-10 3707 OARM Originating Office 260-2077
5040-1 1 3707 OARM Originating Office 260-2077
5040-12 3707 OARM Originating Office 260-8345
Source-8
-------
Source information for EPA Forms
5040-13 3707 OARM EPA FormSmart Center (HQ)
Originating Office 260-2082
5040-14 3707 OARM EPA FormSmart Center (HQ)
Originating Office 260-2082
5100-8 3303F OARM Cincinnati 513-489-8190
EPA Form Smart Center (HQ)
Originating Office 260-5658
5100-9 3204 OARM Originating Office 260-2088
5100-10 3204 OARM Originating Office 260-2088
5160-1 3204 OARM Cincinnati 513-489-8190
5 180-12 3204 OARM Originating Office 260-2096
5 180-14 3204 OARM Originating Office 260-2096
5180-16 3204 OARM Originating Office 260-6682
5180-17 3204 OARM Originating Office 260-2096
5180-18 3204 OARM Cincinnati 513-489-8190
5700-12 3903F OARM Cincinnati 513-489-8190
5700-12A 3903F OARM Originating Office 260-6580
5700-14 3903F OARM Cincinnati 513-489-8190
5700-20A 3901F OARM Cincinnati 513-489-8190
5700-20B 3901F OARM Cincinnati 513-489-8190
5700-29 3901F OARM Cincinnati 513-489-8190
5700-30 3901F OARM Cincinnati 513-489-8190
5700-31 3901F OARM Cincinnati 513-489-8190
5700-33 3901F OARM Cincinnati 513-489-8190
5700-33A 3901F OARM Cincinnati 513-489-8190
5700-33B 3901F OARM Cincinnati 513-489-8190
5700-33C 390 IF OARM Originating Office 202-260-5296
5700-33F 3901F OARM Cincinnati 513-489-8190
5700-33G 3901F OARM Cincinnati 513-489-8190
5700 -33H 3901F OPPTS Cincinnati 513-489-8190
5700-331 3901F OARM Cincinnati 513-489-8190
5700-34 3901F OARM Originating Office 202-260-5296
5700-41 3901F OARM Cincinnati 513-489-8190
5700-42 3901F OARM Cincinnati 513-489-8190
5700-48 390 1F OARM Cincinnati 513-489-8190
5700-49 3901F OARM Cincinnati 513-489-8190
5700-5 1 3901F OARM Originating Office 202-260-2795
5720-12 3901F OARM Cincinnati 513-489-8190
5 770-2 3901F OARM Originating Office 260-6580
5770-3 3901F OARM Cincinnati 513-489-8190
5770-4 3901F OARM Cincinnati 513-489-8190
5770-5 3901F OARM 260-6580
5770-6 3901F OARM Cincinnati 513-489-8190
5770-7 3901F OARM Cincinnati 260-6580
5770-8 3901F OARM Cincinnati 260-6580
5770-9 3901F OARM Cincinnati 260-6580
7500-2 2221A OE Cincinnati 513-489-8190
EPA FormSmart Center (HQ)
Originating Office 202-564-2280
Source-9
-------
Source Information for EPA Forms
7500-53 5202G OSWER Cincinnati 513-489-8.190
7500-54 5202G OSWER Cincinnati 513-489-8190
7500-55 2225A OECA Originating Office 564-4159
7520-1 4602 OW Cincinnati 513-489-8190
7520-2A 4602 OW Cincinnati 513-489-8190
7520-2B 4602 OW Cincinnati 513-489-8190
7520-3 4602 OW Cincinnati 513-489-8190
7520-4 4602 OW Cincinnati 513-489-8190
7520-5 4602 OW Cincinnati 513-489-8190
7520-6 4602 OW Cincinnati 513-489-8190
7520-7 4602 OW Cincinnati 513-489-8190
7520-8 4602 OW Cincinnati 513-489-8190
7520-9 4602 OW Cincinnati 513-489-8190
7520-10 4602 OW Cincinnati 513-489-8190
7520-11 4602 OW Cincinnati 513-489-8190
7520-12 4602 OW Cincinnati 513-489-8190
7520-14 4602 OW Cincinnati 513-489-8190
7520-16 4602 OW Cincinnati 513-489-8190
7530-1 5401W OSWER Cincinnati 513-489-8190
7550-6 4203 OW Cincinnati 513-489-8190
7550-6A 4203 OW Cincinnati 513-489-8190
7550-22 4203 OW Originating Office 260-9530
7550-22A 4203 OW Cincinnati 513-489-8190
7600-5 6205J OAR Originating Office 233-9192
76 10-1 6204J OAR Originating Office 202-233-9194
7610-3 6204J OAR Originating Office 202-233-9175
7610-3A 6204J OAR Originating Office 202-233-9175
7610-3B 6204J OAR Originating Office 202-233-9175
7610-3C 6204J OAR Originating Office 202-233-9175
7610-4 6204J OAR Originating Office 202-233-9175
7610-5 6204J OAR Originating Office 202-233-9194
76 10-6 6204J OAR Originating Office 202-233-9194
7610-7 6204J OAR Originating Office 202-233-9194
7610-7A 6204J OAR Originating Office 202-233-9194
76 10-8 6204J OAR Originating Office 202-233-9194
7610-9 6204J OAR Originating Office 233-9164
7610-10 6204J OAR Originating Office 233-9125
7610-11 6204J OAR Originating Office 233-9166
7610-12 6204J OAR Originating Office 233-9156
7610-13 6204J OAR Originating Office 233-9156
7610-14 6204J OAR Originating Office 233-9156
7610-15 6204J OAR Originating Office 233-9156
7610-16 6204J OAR Originating Office 202-233-9077
7610-16P 6204J OAR Originating Office 233-9156
7610-17 6204J OAR Originating Office 202-233-9077
7610-18 Originating Office
7610-19 6204J OAR Originating Office 233-9175
7610-20 6204J OAR Originating Office 233-9118
7610-21 6204-i OAR Originating Office 233-9133
Source- 10
-------
Source Information for EPA Forms
7610-22 6204-J OAR Originating Office 233-9133
76 10-23 6204-J OAR Originating Office 233-9133
7610-24 6204-J OAR Originating Office 233-9133
7610-25 6204-J OAR Originating Office 233-9133
7610-28 6204J 202-33-9077
7620-8 6204j OW 202-233-9584
7620-9 6204j OW 202-233-9164
7710-19 7407 OPPTS Cincinnati 513-489-8190
77 10-25 7405 OPPTS Originating Office 260-3725
77 10-30 7502C OPPTS Originating Office 703-305-7190
77 10-35 7405 OPPTS Originating Office 260-8130
7710-45 7407 OPPTS Cincinnati 513-489-8190
7710-51 7405 OPPTS Originating Office 260-8154
77 10-52 7405 OPPTS Originating Office 260-8130
77 10-53 7404 OPPTS Originating Office 260-3933
7710-56 7405 OPPTS 260-3749
7720-12 7404 OPPTS Originating Office 202-260-3992
7740-1 7201 OPPTS 202-564-7037
7740-2 7201 OPPTS 564-7037
7740-6 7407 OPPTS Cincinnati 513-489-8190
7740-6A 7407 OPPTS Cincinnati 513-489-8190
7740-8 7407 OPPTS Originating Office 260-3480
7740-9 7407 OPPTS Cincinnati 513-489-8190
7740-10 7407 OPPTS Cincinnati 513-489-8190
7740-11 7407 OPPTS Cincinnati 513-489-8190
7740-12 7407 OPPTS Cincinnati 513-489-8190
7740-13 7407 OPPTS Cincinnati 513-489-8190
7740-14 7407 OPPTS Cincinnati 513-489-8190
7740-15 7407 OPPTS Cincinnati 513-489-8190
7740-16 7407 OPPTS Cincinnati 513-489-8190
7740-17 7407 OPPTS Cincinnati 513-489-8190
7740-23 7407 OPPTS Cincinnati 513-489-8190
7740-24 7407 OPPTS Cincinnati 513-489-8190
7740-25 7407 OPPTS Cincinnati 513-489-8190
7740-26 7407 OPPTS Cincinnati 513-489-8190
7740-2 7 7407 OPPTS Cincinnati 513-489-8190
7740-28 7407 OPPTS Cincinnati 513-489-8190
8500-6 7503W OPPTS Cincinnati 513-489-8190
8500-7 7505C OPPTS Originating Office 703-305-6250
8500-7A 7505C OPPTS Originating Office 703-305-6250
8500-12 7503W OPPTS Originating Office 301-504-8363
8500-22 7502C OPPTS Originating Office 703-557-5190
8500-23 7502C OPPTS Originating Office 703-305-5259
8500-24 7502C OPPTS Originating Office 703-305-5259
8510-14 7503W OPPTS Cincinnati 513-489-8190
8550-11 7503W OPPTS Originating Office 301-504-8363
8570-1 7505C OPPTS 703-308-8340
8570-4 7505W OPPTS 703-308-8340
8570-5 7505C OPPTS Originating Office 703-305-6250
Source-li
-------
Source Information for EPA Forms
8570-6 7505C OPPTS Originating Office 703-305-6250
8570-17 7505C OPPTS Originating Office 703-305-6250
8570-20 7505C OPPTS Originating Office 703-308-8340
8570-25 7505C OPPTS Cincinnati 513-489-8190
8570-27 7505C OPPTS Originating Office 703-305-6250
8570-28 7505C OPPTS Originating Office 703-305-6250
8570-29 7505C OPPTS Originating Office 703-305-6250
8570-30 7502C OPPTS Originating Office 703-305-6426
8570-32 7505C OPPTS Originating Office 703-305-6250
8580- 1 7505C OPPTS Originating Office 703-308-8009
8580-4 7505C OPPTS Originating Office 703-305-6250
8700-12 5301 OSWER Cincinnati ‘513-489-8190
8700-12B 5301 OSWER Cincinnati 513-489-8190
8700-I3AIB 5301 OSWER Cincinnati 513-489-8190
8700-22 5301 OSWER 703-308-8825
8700-22A 5301 OSWER 703-308-8825
8700-23 5301 OSWER Cincinnati 513-489-8190
8710-1 5305 OSWER Originating Office 260-4697
87 10-2 5301 OSWER Originating Office 260-4697
8710-4 5305 OSWER Originating Office 260-4697
8710-5 5305 OSWER Originating Office 260-4697
8710-6 5305 OSWER Originating Office 260-4697
8710-7 5305 OSWER Originating Office 260-4697
8710-9 5305 OSWER Originating Office 260-4697
8710-10 5305 OSWER Originating Office 260-4697
8710-11 5305 OSWER Originating Office 260-4697
8710-12 5305 OSWER Originating Office 260-4697
8710-13 5305 OSWER Originating Office 260-4697
8710-14 5305 OSWER Originating Office 260-4697
8710-16 5301 OSWER Originating Office 308-8759
8799-22 5301 OSWER 703-308-8825
9100-3 5501 Originating Office
9110-1 5201 OSWER Originating Office 703-603-8827
9110-2 5201 OSWER Originating Office 703-603-8827
9110-5 5204G OSWER Originating Office 703-603-9046
9310-1 5201 OSWER Cincinnati 513-489-8190
9350-1 7408 OPPTS Originating Office 260-1024
93 50-2 7408 OPPTS Originating Office 260-1715
9510-1 5104 OSWER Cincinnati 513-489-8190
R016 -1 6M-AF R06 Other Facilities 214-665-6423
R021-1 6M-AF R06 Other Facilities 214-665-6423
R027-1 6M-A1 R06 Originating Office 214-665-6521
R031-1 6M-AF R06 Originating Office 214-665-8350
R035-1 6M-AF R06 Originating Office 214-665-8599
R042-1 6M-AI R06 Originating Office 214-665-6521
R059-1 6M-AF R06 Originating Office 214-665-7268
R060-1 6M-H R06 Originating Office 214-665-6563
R061-1 6M-AF R06 Other Facilities 214-665-7268
R065- IA 6E R06 Originating Office
Source- 12
-------
Source Information for EPA Forms
R070- I 6E R06 Originating Office
R123-1 6M-AF R06 Originating Office 214-665-8599
R124-1 6M-AF R06 Originating Office 214-665-8599
RI 34-I Originating Office 404-347-2316
R 134-2 Originating Office 404-347-2316
RI 34-3 Originating Office 404-347-2316
R134-4 Originating Office 404-347-2316
R136-1 6M-FD R06 Originating Office 214-665-6510
R138-1 6M-AF R06 Originating Office 214-665-8599
R139-1 6M-HP R06 Originating Office 214-665-6563
Ri 40-1 6M-HP R06 Originating Office 214-665-6563
R 144-1 6M-A1 R06 Cincinnati 513-489-8190
Originating Office
R145-1 6M-AI R06 Originating Office 214-665-6521
R148-1 6M-AF R06 Originating Office 214-665-7268
RI 48-i Originating Office 404-347-3814
Ri49-l 6M-AF R06 Originating Office 214-665-8350
Ri 50-1 6M-AF R06 Originating Office 214-665-8599
Ri 51-1 6M-F R06 Originating Office
RI 52-i 6M-F R06 Originating Office
Ri53-i 6M-F R06 Originating Office
Ri 54-I 6M-AF R06 Originating Office 214-665-8599
Ri 55-1 6M-AF R06 Originating Office 214-665-6592
RI 55-1 Originating Office 404-347-2316
RI 55-2 Originating Office 404-347-2316
RI 56-1 GM-1-IP R06 Originating Office 6563
R159-1 6M-AF R06 Originating Office 214-665-6510
R160-i 6M-AI R06 Originating Office 214-665-2634
Ri61-1 6E-5H R06 Originating Office
RI 62-1 6M-AF R06 Originating Office 214-665-8599
R163-1 6M-A1 R06 Originating Office 665-6566
K 171-1 Originating Office 404-347-2316
R171-1 R09 415-744-1180
RI 90-1 Comptroller Originating Office 404-347-2140
R2IO-I 3ES3 1 Originating Office 410-573-6834
R217-1 4PM- IF Originating Office 404-357-3555
R2 17-2 4PM- iF Originating Office 404-347-3555 ext. 6017
R2 1 7-3 4PM- IF Originating Office 404-357-3555
R257-I R09 415-744-1180+
R26 1-1 Comptroller Originating Office 404-347-2140
R265- I OECA Originating Office 404-347-2641 ext. 2228
R265-2 OECA Originating Office 404-347-2641 ext. 2228
R265-3 OECA Originating Office 404-347-2641 ext. 2228
R265-4 OECA Originating Office 404-347-2641 ext. 2228
R280-1 3ES31 Originating Office 410-573-6834
R280-2 3ES31 Originating Office 4 1 0.573 .6834
R280-3 3ES3 i Originating Office 410-573-6834
R3 16-1 OPM Originating Office 4Q4347..3555
R3 16-2 OPM Originating Office 404-347-3555
Source- 13
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Source Information for EPA Forms
R3 16-3 OPM Originating Office 404-347-3555
R316-4 OPM Originating Office 404-347-3555
R3 16-5 OPM Originating Office 404-347-3555
R316-6 OPM Originating Office 404-347-3555
R316-7 OPM Originating Office 404-347-3555
R3 16-8 OPM Originating Office 404-347-3555
R510-1 R09 415-744-1180
R517-1 R09 415-744-1180
R750-1 3WM55 OW Originating Office 215-597-6279
R750-10 3WM55 Originating Office 215-597-1395
R750-1 I 3ES31 Originating Office 410-573-6834
R750-12 3ES31 Originating Office ‘410-573-6834
R750-13 3ES31 Originating Office 410-573-6834
R750-14 3ES31 Originating Office 410-573-6834
R750-15 3ES31 Originating Office 410-573-6834
R750-16 3ES31 Originating Office 410-573-6834
R750-2 3WM55 OW Originating Office 215-597-6279
R750-3 3WM55 OW Originating Office 215-597-6279
R750-4 3WM55 OW Originating Office 215-597-6279
R750-5 3WM55 OW Originating Office 215-597-6279
R750-6 3WM55 OW Originating Office 215-597-6279
R750-7 3WM55 OW Originating Office 215-597-6279
R750-8 3WM55 OW Originating Office 215-597-6279
R750-9 3WM55 OW Originating Office 215-597-6279
R850-1 3ATII ROS 303-312-6352
R850-2 Originating Office
R850-3 Originating Office
R850-4 Originating Office
R850-5 Originating Office
R850-6 Originating Office
Source- 14
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CEP4
United States Environmental Protection Agency
Washington, DC 20460
PUBLICATION/FORMS REQUEST
Requested By Requesting Office
I Date
Bldg and Room
No.
Special Shipping Instructions
(If special shipping is requested. please fax your request to 513-489-8695 or phone in publication order request to 1-800-490-9198,1
NOTE: Items will not be shipped Federal Express unless a FedEx number is provided. Fourth class mail is the normal method used.
SHIP TO: NAME. COMPLETE MAILING ADDRESS AND TELEPHONE NUMBER
Publication
Form Number
Warehouse
Use
TITLE
Unit of
Issue
Quantity
Requested —
EPA Form 3b0-l (REV (‘97) PrevioUs editions may be used until supplies are exhausted
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