PAPERWORK REDUCTION ACT SUBMISSION WORKSHEET

Part II: Information Collection Detail

1. Title of Information Collection:    FORMTEXT  NESHAP for Area Source
Standards:  Information for Lead Acid Batteries Manufacturing 



2. Is this a common form? 

  FORMCHECKBOX    Yes

  FORMCHECKBOX    No

(Select, Yes, to identify forms that EPA is willing to host for
potential use by other Federal Agencies.)

	

3. Obligation to respond (check one):

       FORMCHECKBOX    Voluntary

       FORMCHECKBOX    Required to obtain or retain benefits

       FORMCHECKBOX     Mandatory

Only one selection may be made.  

If multiple categories apply, you must create 

additional ICs to account for the burden associated 

with each category.

	

4. Frequency of reporting (only to be completed if there are reporting
requirements, check all that apply): 

    FORMCHECKBOX    Hourly

    FORMCHECKBOX    Daily

    FORMCHECKBOX    Weekly

    FORMCHECKBOX    Monthly

    FORMCHECKBOX    Quarterly 

    FORMCHECKBOX    Semi-annually

      FORMCHECKBOX    Annually

    FORMCHECKBOX    Every Decade 

    FORMCHECKBOX    Biennially

    FORMCHECKBOX    On Occasion

    FORMCHECKBOX    Once



5.  CFR Citation(s) for the information collection under review (if
applicable):

Title:   FORMTEXT  National Emission Standards for Hazardous Air
Pollutants for

Lead Acid Batteries Manufacturing Area Sources                          
      Citation:   FORMTEXT  40 CFR 63.11425(a),(b) 

Title:   FORMTEXT                                                       
                                                Citation:   FORMTEXT    
                                 

Title:   FORMTEXT                                                       
                                             Citation:   FORMTEXT 
      

Title:   FORMTEXT                                                       
                                               Citation:   FORMTEXT     
       



6.  Information Collection Instruments/Forms (if applicable):

Form/Instrument must be submitted to OEI as a separate attachment. 

Form Name

EPA Form #

URL (required if electronic)

Is this collection instrument/form available electronically?

If yes, can this collection instrument/form be submitted electronically?

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMCHECKBOX   Yes         FORMCHECKBOX    No

  FORMCHECKBOX   Yes         FORMCHECKBOX    No

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMCHECKBOX   Yes         FORMCHECKBOX    No

  FORMCHECKBOX   Yes         FORMCHECKBOX    No

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMCHECKBOX   Yes         FORMCHECKBOX    No

  FORMCHECKBOX   Yes         FORMCHECKBOX    No





7.  Federal Enterprise Architecture Business Reference Model

    

Line of Business (check one):                                           
       Subfunction (check one):

  FORMCHECKBOX    None

  FORMCHECKBOX    Environmental Management

  FORMCHECKBOX   Environmental Monitoring and Forecasting

  FORMCHECKBOX   Environmental Remediation

  FORMCHECKBOX   Pollution Prevention and Control

  FORMCHECKBOX   None

  FORMCHECKBOX    Health

  FORMCHECKBOX   Illness Prevention

  FORMCHECKBOX   Immunization Management

  FORMCHECKBOX   Public Health Monitoring

  FORMCHECKBOX   Health Care Services

  FORMCHECKBOX   Consumer Health and Safety

  FORMCHECKBOX   None

  FORMCHECKBOX    Natural Resources

  FORMCHECKBOX   Water Resource Management

  FORMCHECKBOX   Conservation, Marine and Land Management

  FORMCHECKBOX   Recreational Resource Management and Tourism

  FORMCHECKBOX   Agricultural Innovation and Services

  FORMCHECKBOX   None





IMPORTANT:  Part II must be completed for each Information Collection
(IC) activity associated with the ICR.  Please be sure that you copy
this portion of the template as many times as necessary so that each IC
has its own Part II submission.  For more information on how to break
your ICR into ICs, please see OMB’s ROCIS IC Q&A, located at:  
HYPERLINK "http://intranet.epa.gov/icrintra/download.html" 
http://intranet.epa.gov/icrintra/download.html . In addition, please
reference OEI’s ROCIS instructions at:   HYPERLINK
"http://intranet.epa.gov/icrintra/download.html" 
http://intranet.epa.gov/icrintra/download.html 

Note:  Most EPA ICRs will be aligned with the Environmental Management
FEA Line of Business.  Other likely categories are also listed.  For a
full listing of the FEA Business Reference Model categories and
definitions, see: 
http://www.whitehouse.gov/omb/egov/documents/FY07_Ref_Model_Mapping_Quic
kGuide.pdf 



8.  Privacy Act System of Records (if applicable):														

                                       	          

    Federal Register Citation:     Volume:   FORMTEXT         
           Page number:   FORMTEXT               Publication
date:   FORMTEXT         /      /                  



9. Respondents

 

Total number:   FORMTEXT  58           

Small entity number:   FORMTEXT  0        

Percentage of responses collected electronically:   FORMTEXT  0 	

Affected Public (choose one):

  FORMCHECKBOX    Individuals or households

  FORMCHECKBOX    Private Sector (if private sector, check all that
apply)

                    FORMCHECKBOX    Business or other for-profit

                    FORMCHECKBOX    Not-for-profit institutions

                    FORMCHECKBOX    Farms

  FORMCHECKBOX    State, Local, or Tribal Governments  

  FORMCHECKBOX    Federal Government

Only one selection may be made.  If multiple categories apply, you must
create additional ICs to account for the burden associated with each
category.  Note: Selecting multiple subcategories within the Private
Sector will not affect the number of ICs required.



10. Frequency: How often on average will each respondent respond 

      to the Information Collection?

      Number of Responses per Respondent:    FORMTEXT  2 one-time
notifications 

      Per (select the most appropriate time period for this collection)

        FORMCHECKBOX   Hour (24 per day, 8736 per year)

        FORMCHECKBOX    Business Hour (40 per week, 2080 per year)

        FORMCHECKBOX    Day ( 7 per week, 365 per year)

        FORMCHECKBOX    Business Day ( 5 per week, 260 per year)      

        FORMCHECKBOX    Week (52 per year)

        FORMCHECKBOX    Month (12 per year)

        FORMCHECKBOX    Semi-Annual (2 per year)

        FORMCHECKBOX    Year 

        FORMCHECKBOX    Decade (.1 per year)	

Calculated: Annual Frequency  =   FORMTEXT  0.76  

(responses per respondent, per year)

Calculated: Annual Number of Responses =   FORMTEXT  44

 

	





11. Hour and Cost Burden - Enter the hours and cost (per response)
broken out by reporting, record keeping, and third-party disclosure.

Hours per Response

Total Annual Hour Burden

Cost per Response

(Capital/Startup and O&M Costs Only)

Total Annual Cost Burden

(Capital/Startup and

O&M Costs Only)

Reporting

  FORMTEXT  15.30 

  FORMTEXT  675.00 

  FORMTEXT  $0.00 

  FORMTEXT  $0.00 

Recordkeeping

      

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

Third Party Disclosure

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

Total

  FORMTEXT  15.30 

  FORMTEXT  675.00 

  FORMTEXT  $0.00 

  FORMTEXT  $0.00 





12. Allocate the change in Burden:

Total Requested

Change Due to

New Statute

Change Due to

Agency Discretion

Due to

Agency Estimate

Change due to Violation

Currently Approved

Annual Responses

  FORMTEXT  44.00 

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT  0.00 

Annual Hour Burden

  FORMTEXT  675.00 

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT  0.00 

Annual Cost Burden (Capital/Startup and O&M costs only)

  FORMTEXT  0.0 

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT  0.00 





PAPERWORK REDUCTION ACT SUBMISSION WORKSHEET

Part II: Information Collection Detail

1. Title of Information Collection:    FORMTEXT  NESHAP for Area Source
Standards:  Information Collection for Wood Preserving 



2. Is this a common form? 

  FORMCHECKBOX    Yes

  FORMCHECKBOX    No

(Select, Yes, to identify forms that EPA is willing to host for
potential use by other Federal Agencies.)

	

3. Obligation to respond (check one):

       FORMCHECKBOX    Voluntary

       FORMCHECKBOX    Required to obtain or retain benefits

       FORMCHECKBOX     Mandatory

Only one selection may be made.  

If multiple categories apply, you must create 

additional ICs to account for the burden associated 

with each category.

	

4. Frequency of reporting

(check all that apply): 

    FORMCHECKBOX    Hourly

    FORMCHECKBOX    Daily

    FORMCHECKBOX    Weekly

    FORMCHECKBOX    Monthly

    FORMCHECKBOX    Quarterly 

    FORMCHECKBOX    Semi-annually

      FORMCHECKBOX    Annually

    FORMCHECKBOX    Every Decade 

    FORMCHECKBOX    Biennially

    FORMCHECKBOX    On Occasion

    FORMCHECKBOX    Once



5.  CFR Citation(s) for the information collection under review (if
applicable):

Title:   FORMTEXT  National Emission Standards for Hazardous Air
Pollutants

        for Wood Preserving Area Sources                                
              Citation:   FORMTEXT  40 CFR 63.11432(a),(b),(c) 

                                                              
                                   Citation:   FORMTEXT         
                  

Title:   FORMTEXT                                                   
                                                Citation:  
FORMTEXT                           

Title:   FORMTEXT                                               
                                                    Citation:  
FORMTEXT                           



6.  Information Collection Instruments/Forms (if applicable):

Form/Instrument must be submitted to OEI as a separate attachment. 

Form Name

EPA Form #

URL (required if electronic)

Is this collection instrument/form available electronically?

If yes, can this collection instrument/form be submitted electronically?

      

  FORMTEXT        

  FORMTEXT        

  FORMCHECKBOX   Yes         FORMCHECKBOX    No

  FORMCHECKBOX   Yes         FORMCHECKBOX    No

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMCHECKBOX   Yes         FORMCHECKBOX    No

  FORMCHECKBOX   Yes         FORMCHECKBOX    No

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMCHECKBOX   Yes         FORMCHECKBOX    No

  FORMCHECKBOX   Yes         FORMCHECKBOX    No





7.  Federal Enterprise Architecture Business Reference Model

    

Line of Business (check one):                                           
       Subfunction (check one):

  FORMCHECKBOX    None

  FORMCHECKBOX    Environmental Management

  FORMCHECKBOX   Environmental Monitoring and Forecasting

  FORMCHECKBOX   Environmental Remediation

  FORMCHECKBOX   Pollution Prevention and Control

  FORMCHECKBOX   None

  FORMCHECKBOX    Health

  FORMCHECKBOX   Illness Prevention

  FORMCHECKBOX   Immunization Management

  FORMCHECKBOX   Public Health Monitoring

  FORMCHECKBOX   Health Care Services

  FORMCHECKBOX   Consumer Health and Safety

  FORMCHECKBOX   None

  FORMCHECKBOX    Natural Resources

  FORMCHECKBOX   Water Resource Management

  FORMCHECKBOX   Conservation, Marine and Land Management

  FORMCHECKBOX   Recreational Resource Management and Tourism

  FORMCHECKBOX   Agricultural Innovation and Services

  FORMCHECKBOX   None





IMPORTANT:  Part II must be completed for each Information Collection
(IC) activity associated with the ICR.  Please be sure that you copy
this portion of the template as many times as necessary so that each IC
has its own Part II submission.  For more information on how to break
your ICR into ICs, please see OMB’s ROCIS IC Q&A, located at:  
HYPERLINK "http://intranet.epa.gov/icrintra/download.html" 
http://intranet.epa.gov/icrintra/download.html . In addition, please
reference OEI’s ROCIS instructions at:   HYPERLINK
"http://intranet.epa.gov/icrintra/download.html" 
http://intranet.epa.gov/icrintra/download.html 

Note:  Most EPA ICRs will be aligned with the Environmental Management
FEA Line of Business.  Other likely categories are also listed.  For a
full listing of the FEA Business Reference Model categories and
definitions, see: 
http://www.whitehouse.gov/omb/egov/documents/FY07_Ref_Model_Mapping_Quic
kGuide.pdf 



8.  Privacy Act System of Records (if applicable):														

                                       	          

    Federal Register Citation:     Volume:   FORMTEXT         
           Page number:   FORMTEXT               Publication
date:   FORMTEXT         /      /                  



9. Respondents

 

Total number:   FORMTEXT  393            

Small entity number:   FORMTEXT   1        

Percentage of responses collected electronically:   FORMTEXT  0 	

Affected Public (choose one):

  FORMCHECKBOX    Individuals or households

  FORMCHECKBOX    Private Sector (if private sector, check all that
apply)

                    FORMCHECKBOX    Business or other for-profit

                    FORMCHECKBOX    Not-for-profit institutions

                    FORMCHECKBOX    Farms

  FORMCHECKBOX    State, Local, or Tribal Governments  

  FORMCHECKBOX    Federal Government

Only one selection may be made.  If multiple categories apply, you must
create additional ICs to account for the burden associated with each
category.  Note: Selecting multiple subcategories within the Private
Sector will not affect the number of ICs required.



10. Frequency: How often on average will each respondent respond 

      to the Information Collection?

      Number of Responses per Respondent:    FORMTEXT  2 one-time
notifications 

      Per (select the most appropriate time period for this collection)

        FORMCHECKBOX   Hour (24 per day, 8736 per year)

        FORMCHECKBOX    Business Hour (40 per week, 2080 per year)

        FORMCHECKBOX    Day ( 7 per week, 365 per year)

        FORMCHECKBOX    Business Day ( 5 per week, 260 per year)      

        FORMCHECKBOX    Week (52 per year)

        FORMCHECKBOX    Month (12 per year)

        FORMCHECKBOX    Semi-Annual (.5 per year)

        FORMCHECKBOX    Year 

        FORMCHECKBOX    Decade (.1 per year)	

Calculated: Annual Frequency  =   FORMTEXT  0.67  

(responses per respondent, per year)

Calculated: Annual Number of Responses =   FORMTEXT  262 

	





11. Hour and Cost Burden - Enter the hours and cost (per response)
broken out by reporting, record keeping, and third-party disclosure.

Hours per Response

Total Annual Hour Burden

Cost per Response

(Capital/Startup and O&M Costs Only)

Total Annual Cost Burden

(Capital/Startup and

O&M Costs Only)

Reporting

  FORMTEXT  4.00 

  FORMTEXT  1055.00 

  FORMTEXT  $0.00 

  FORMTEXT  $0.00 

Recordkeeping

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

Third Party Disclosure

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

Total

  FORMTEXT  4.00 

  FORMTEXT  1055.00 

  FORMTEXT  $0.00 

  FORMTEXT  $0.00 





12. Allocate the change in Burden:

Total Requested

Change Due to

New Statute

Change Due to

Agency Discretion

Due to

Agency Estimate

Change due to Violation

Currently Approved

Annual Responses

  FORMTEXT  262.00 

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT  0.00 

Annual Hour Burden

  FORMTEXT  1055.00 

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT  0.00 

Annual Cost Burden (Capital/Startup and O&M costs only)

  FORMTEXT  $0.00 

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT  $0.00 





PAPERWORK REDUCTION ACT SUBMISSION WORKSHEET

Part II: Information Collection Detail

1. Title of Information Collection:    FORMTEXT        



2. Is this a common form? 

  FORMCHECKBOX    Yes

  FORMCHECKBOX    No

(Select, Yes, to identify forms that EPA is willing to host for
potential use by other Federal Agencies.)

	

3. Obligation to respond (check one):

       FORMCHECKBOX    Voluntary

       FORMCHECKBOX    Required to obtain or retain benefits

       FORMCHECKBOX     Mandatory

Only one selection may be made.  

If multiple categories apply, you must create 

additional ICs to account for the burden associated 

with each category.

	

4. Frequency of reporting

(check all that apply): 

    FORMCHECKBOX    Hourly

    FORMCHECKBOX    Daily

    FORMCHECKBOX    Weekly

    FORMCHECKBOX    Monthly

    FORMCHECKBOX    Quarterly 

    FORMCHECKBOX    Semi-annually

      FORMCHECKBOX    Annually

    FORMCHECKBOX    Every Decade 

    FORMCHECKBOX    Biennially

    FORMCHECKBOX    On Occasion

    FORMCHECKBOX    Once



5.  CFR Citation(s) for the information collection under review (if
applicable):

                                                                
                                  Citation:   FORMTEXT          
               

Title:   FORMTEXT                                                 
                                                  Citation:  
FORMTEXT                            

Title:   FORMTEXT                                                   
                                                Citation:  
FORMTEXT                           

Title:   FORMTEXT                                               
                                                    Citation:  
FORMTEXT                           



6.  Information Collection Instruments/Forms (if applicable):

Form/Instrument must be submitted to OEI as a separate attachment. 

Form Name

EPA Form #

URL (required if electronic)

Is this collection instrument/form available electronically?

If yes, can this collection instrument/form be submitted electronically?

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMCHECKBOX   Yes         FORMCHECKBOX    No

  FORMCHECKBOX   Yes         FORMCHECKBOX    No

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMCHECKBOX   Yes         FORMCHECKBOX    No

  FORMCHECKBOX   Yes         FORMCHECKBOX    No

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMCHECKBOX   Yes         FORMCHECKBOX    No

  FORMCHECKBOX   Yes         FORMCHECKBOX    No





7.  Federal Enterprise Architecture Business Reference Model

    

Line of Business (check one):                                           
       Subfunction (check one):

  FORMCHECKBOX    None

  FORMCHECKBOX    Environmental Management

  FORMCHECKBOX   Environmental Monitoring and Forecasting

  FORMCHECKBOX   Environmental Remediation

  FORMCHECKBOX   Pollution Prevention and Control

  FORMCHECKBOX   None

  FORMCHECKBOX    Health

  FORMCHECKBOX   Illness Prevention

  FORMCHECKBOX   Immunization Management

  FORMCHECKBOX   Public Health Monitoring

  FORMCHECKBOX   Health Care Services

  FORMCHECKBOX   Consumer Health and Safety

  FORMCHECKBOX   None

  FORMCHECKBOX    Natural Resources

  FORMCHECKBOX   Water Resource Management

  FORMCHECKBOX   Conservation, Marine and Land Management

  FORMCHECKBOX   Recreational Resource Management and Tourism

  FORMCHECKBOX   Agricultural Innovation and Services

  FORMCHECKBOX   None





IMPORTANT:  Part II must be completed for each Information Collection
(IC) activity associated with the ICR.  Please be sure that you copy
this portion of the template as many times as necessary so that each IC
has its own Part II submission.  For more information on how to break
your ICR into ICs, please see OMB’s ROCIS IC Q&A, located at:  
HYPERLINK "http://intranet.epa.gov/icrintra/download.html" 
http://intranet.epa.gov/icrintra/download.html . In addition, please
reference OEI’s ROCIS instructions at:   HYPERLINK
"http://intranet.epa.gov/icrintra/download.html" 
http://intranet.epa.gov/icrintra/download.html 

Note:  Most EPA ICRs will be aligned with the Environmental Management
FEA Line of Business.  Other likely categories are also listed.  For a
full listing of the FEA Business Reference Model categories and
definitions, see: 
http://www.whitehouse.gov/omb/egov/documents/FY07_Ref_Model_Mapping_Quic
kGuide.pdf 



8.  Privacy Act System of Records (if applicable):														

                                       	          

    Federal Register Citation:     Volume:   FORMTEXT         
           Page number:   FORMTEXT               Publication
date:   FORMTEXT         /      /                  



9. Respondents

 

Total number:   FORMTEXT               

Small entity number:   FORMTEXT           

Percentage of responses collected electronically:   FORMTEXT 
      	

Affected Public (choose one):

  FORMCHECKBOX    Individuals or households

  FORMCHECKBOX    Private Sector (if private sector, check all that
apply)

                    FORMCHECKBOX    Business or other for-profit

                    FORMCHECKBOX    Not-for-profit institutions

                    FORMCHECKBOX    Farms

  FORMCHECKBOX    State, Local, or Tribal Governments  

  FORMCHECKBOX    Federal Government

Only one selection may be made.  If multiple categories apply, you must
create additional ICs to account for the burden associated with each
category.  Note: Selecting multiple subcategories within the Private
Sector will not affect the number of ICs required.



10. Frequency: How often on average will each respondent respond 

      to the Information Collection?

      Number of Responses per Respondent:    FORMTEXT           
  

      Per (select the most appropriate time period for this collection)

        FORMCHECKBOX   Hour (24 per day, 8736 per year)

        FORMCHECKBOX    Business Hour (40 per week, 2080 per year)

        FORMCHECKBOX    Day ( 7 per week, 365 per year)

        FORMCHECKBOX    Business Day ( 5 per week, 260 per year)      

        FORMCHECKBOX    Week (52 per year)

        FORMCHECKBOX    Month (12 per year)

        FORMCHECKBOX    Semi-Annual (.5 per year)

        FORMCHECKBOX    Year 

        FORMCHECKBOX    Decade (.1 per year)	

Calculated: Annual Frequency  =   FORMTEXT         

(responses per respondent, per year)

Calculated: Annual Number of Responses =   FORMTEXT        

	





 0

1

F

G

H

I

K

L

Z

[

\

g

h

v

w

x

‚

ƒ

‘

’

“

ž

Ÿ



®

¯

»

¼

Ê

愀̤摧縡%਀Ê

Ë

Ì

Û

Ü

ê

ë

ì

:

?

S

a

e

?

½

摧棩̀e

m

n

˜

™

£

¤

¥

¦

±

»

¼

½

Ä

Å

Ï

Ð

Ñ

j†

jü

N¶

µ欀繤

@

Ì

@

Ì

@

Ì

@

j

' h9

 h9

j

$

N¶

N¶

N¶

N¶

N¶

7

N¶

N¶

N¶

@

N¶

j

@

N¶

Ê

@

N¶

Ê

@

N¶

N¶

N¶

' h9

 h9

N¶

N¶

N¶

N¶

N¶

N¶

N¶

N¶

N¶

N¶

N¶

N¶

7

N¶

N¶

N¶

Ê

@

N¶

Ê

@

N¶

Ê

@

N¶

Ê

@

N¶

N¶

N¶

' h9

 h9

N¶

 reporting, record keeping, and third-party disclosure.

Hours per Response

Total Annual Hour Burden

Cost per Response

(Capital/Startup and O&M Costs Only)

Total Annual Cost Burden

(Capital/Startup and

O&M Costs Only)

Reporting

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

Recordkeeping

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

Third Party Disclosure

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

Total

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        





12. Allocate the change in Burden:

Total Requested

Change Due to

New Statute

Change Due to

Agency Discretion

Due to

Agency Estimate

Change due to Violation

Currently Approved

Annual Responses

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

Annual Hour Burden

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

Annual Cost Burden (Capital/Startup and O&M costs only)

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        





PAPERWORK REDUCTION ACT SUBMISSION WORKSHEET

Part II: Information Collection Detail

1. Title of Information Collection:    FORMTEXT        



2. Is this a common form? 

  FORMCHECKBOX    Yes

  FORMCHECKBOX    No

(Select, Yes, to identify forms that EPA is willing to host for
potential use by other Federal Agencies.)

	

3. Obligation to respond (check one):

       FORMCHECKBOX    Voluntary

       FORMCHECKBOX    Required to obtain or retain benefits

       FORMCHECKBOX     Mandatory

Only one selection may be made.  

If multiple categories apply, you must create 

additional ICs to account for the burden associated 

with each category.

	

4. Frequency of reporting

(check all that apply): 

    FORMCHECKBOX    Hourly

    FORMCHECKBOX    Daily

    FORMCHECKBOX    Weekly

    FORMCHECKBOX    Monthly

    FORMCHECKBOX    Quarterly 

    FORMCHECKBOX    Semi-annually

      FORMCHECKBOX    Annually

    FORMCHECKBOX    Every Decade 

    FORMCHECKBOX    Biennially

    FORMCHECKBOX    On Occasion

    FORMCHECKBOX    Once



5.  CFR Citation(s) for the information collection under review (if
applicable):

                                                                
                                  Citation:   FORMTEXT          
               

Title:   FORMTEXT                                                 
                                                  Citation:  
FORMTEXT                            

Title:   FORMTEXT                                                   
                                                Citation:  
FORMTEXT                           

Title:   FORMTEXT                                               
                                                    Citation:  
FORMTEXT                           



6.  Information Collection Instruments/Forms (if applicable):

Form/Instrument must be submitted to OEI as a separate attachment. 

Form Name

EPA Form #

URL (required if electronic)

Is this collection instrument/form available electronically?

If yes, can this collection instrument/form be submitted electronically?

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMCHECKBOX   Yes         FORMCHECKBOX    No

  FORMCHECKBOX   Yes         FORMCHECKBOX    No

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMCHECKBOX   Yes         FORMCHECKBOX    No

  FORMCHECKBOX   Yes         FORMCHECKBOX    No

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMCHECKBOX   Yes         FORMCHECKBOX    No

  FORMCHECKBOX   Yes         FORMCHECKBOX    No





7.  Federal Enterprise Architecture Business Reference Model

    

Line of Business (check one):                                           
       Subfunction (check one):

  FORMCHECKBOX    None

  FORMCHECKBOX    Environmental Management

  FORMCHECKBOX   Environmental Monitoring and Forecasting

  FORMCHECKBOX   Environmental Remediation

  FORMCHECKBOX   Pollution Prevention and Control

  FORMCHECKBOX   None

  FORMCHECKBOX    Health

  FORMCHECKBOX   Illness Prevention

  FORMCHECKBOX   Immunization Management

  FORMCHECKBOX   Public Health Monitoring

  FORMCHECKBOX   Health Care Services

  FORMCHECKBOX   Consumer Health and Safety

  FORMCHECKBOX   None

  FORMCHECKBOX    Natural Resources

  FORMCHECKBOX   Water Resource Management

  FORMCHECKBOX   Conservation, Marine and Land Management

  FORMCHECKBOX   Recreational Resource Management and Tourism

  FORMCHECKBOX   Agricultural Innovation and Services

  FORMCHECKBOX   None





IMPORTANT:  Part II must be completed for each Information Collection
(IC) activity associated with the ICR.  Please be sure that you copy
this portion of the template as many times as necessary so that each IC
has its own Part II submission.  For more information on how to break
your ICR into ICs, please see OMB’s ROCIS IC Q&A, located at:  
HYPERLINK "http://intranet.epa.gov/icrintra/download.html" 
http://intranet.epa.gov/icrintra/download.html . In addition, please
reference OEI’s ROCIS instructions at:   HYPERLINK
"http://intranet.epa.gov/icrintra/download.html" 
http://intranet.epa.gov/icrintra/download.html 

Note:  Most EPA ICRs will be aligned with the Environmental Management
FEA Line of Business.  Other likely categories are also listed.  For a
full listing of the FEA Business Reference Model categories and
definitions, see: 
http://www.whitehouse.gov/omb/egov/documents/FY07_Ref_Model_Mapping_Quic
kGuide.pdf 



8.  Privacy Act System of Records (if applicable):														

                                       	          

    Federal Register Citation:     Volume:   FORMTEXT         
           Page number:   FORMTEXT               Publication
date:   FORMTEXT         /      /                  



9. Respondents

 

N¶

N¶

j

N¶

N¶

N¶

N¶

N¶

N¶

N¶

N¶

N¶

7

N¶

N¶

N¶

Ê

@

N¶

Ê

@

N¶

Ê

@

N¶

Ê

@

N¶

N¶

jâ

jl

j

j«

N¶

' h9

 h9

N¶

ਁ氃愀϶ﾸ܀number:   FORMTEXT               

Small entity number:   FORMTEXT           

Percentage of responses collected electronically:   FORMTEXT 
      	

Affected Public (choose one):

  FORMCHECKBOX    Individuals or households

  FORMCHECKBOX    Private Sector (if private sector, check all that
apply)

                    FORMCHECKBOX    Business or other for-profit

                    FORMCHECKBOX    Not-for-profit institutions

                    FORMCHECKBOX    Farms

  FORMCHECKBOX    State, Local, or Tribal Governments  

  FORMCHECKBOX    Federal Government

Only one selection may be made.  If multiple categories apply, you must
create additional ICs to account for the burden associated with each
category.  Note: Selecting multiple subcategories within the Private
Sector will not affect the number of ICs required.



10. Frequency: How often on average will each respondent respond 

      to the Information Collection?

      Number of Responses per Respondent:    FORMTEXT           
  

      Per (select the most appropriate time period for this collection)

        FORMCHECKBOX   Hour (24 per day, 8736 per year)

        FORMCHECKBOX    Business Hour (40 per week, 2080 per year)

        FORMCHECKBOX    Day ( 7 per week, 365 per year)

        FORMCHECKBOX    Business Day ( 5 per week, 260 per year)      

        FORMCHECKBOX    Week (52 per year)

        FORMCHECKBOX    Month (12 per year)

        FORMCHECKBOX    Semi-Annual (.5 per year)

        FORMCHECKBOX    Year 

        FORMCHECKBOX    Decade (.1 per year)	

Calculated: Annual Frequency  =   FORMTEXT         

(responses per respondent, per year)

Calculated: Annual Number of Responses =   FORMTEXT        

	





11. Hour and Cost Burden - Enter the hours and cost (per response)
broken out by reporting, record keeping, and third-party disclosure.

Hours per Response

Total Annual Hour Burden

Cost per Response

(Capital/Startup and O&M Costs Only)

Total Annual Cost Burden

(Capital/Startup and

O&M Costs Only)

Reporting

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

Recordkeeping

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

Third Party Disclosure

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

N¶

N¶

N¶

    

Total

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        





12. Allocate the change in Burden:

Total Requested

Change Due to

New Statute

Change Due to

Agency Discretion

Due to

Agency Estimate

Change due to Violation

Currently Approved

Annual Responses

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

Annual Hour Burden

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

Annual Cost Burden (Capital/Startup and O&M costs only)

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        

  FORMTEXT        





 PAGE   

 PAGE   4 

Revised 9/1/2006

