Document ID: EPA-HQ-OAR-2010-0690-0014
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2015-03-26T04:00Z

REPLY FORM

1 .       Owner's Name                                                  
        2. Control No.                                                 

THIS INFORMATION  REQUEST  IS AUTHORIZED BY LAW. WHILE YOU ARE NOT
REQUIRED TO RESPOND, YOUR COOPERATION IS NEEDED TO MAKE THE RESULTS OF
THIS INVESTIGATION VALID

3.        Do you own/lease a                   vehicle with the vehicle
identification number

(VIN)	___	___	___	___	___	___	___	___	___	___	___	___	___	___	___	___
___?     _____yes      _____no4.       If so, list the Make            
                                         Model                          
                                    

5.        Current odometer reading                                     
miles.

6.        Are you the original owner/lessee?         yes 	    _____no

7.        Is your  vehicle ______ automatic    ______ manual  8. 	 Are
you interested in participating in this program?

 	 yes	  _____ no 	             _______ need more information.

9. 	May we contact you at your convenience:

Home Phone: (_____) - _____________________	Best time to call:          
 a.m. ______p.m. 

Work Phone:  (_____) - _____________________	Best time to call:         
  a.m. ______p.m. 

Cell Phone:      (        ) - _____________________	 Best time to call:
_______ a.m.             p.m.

IF YOU HAVE ANY QUESTIONS, PLEASE CALL US TOLL FREE AT (855)665-1228.

WHETHER OR NOT YOU PLAN TO PARTICIPATE, PLEASE RETURN THIS FORM IN THE
POSTAGE PAID ENVELOPE.

                        

	 

                                                                        
                                          

Privacy Act Statement	

Title 42, United States Code, Section 7451, Compliance by vehicles and
engines in actual use, authorizes the collection of this information. 
The primary use is to provide an instrument by which individuals may
indicate interest in and eligibility for participating in EPA’s
Light-Duty In-Use Testing Program.  Additional disclosures of this
information may be made pursuant to published routine uses, including to
appropriate agencies for law enforcement purposes and to contractors
working for EPA who have a need to know in the course of that work.

Providing the requested information is voluntary, but failing to do so
will result in EPA’s inability to approve your participation in the
Light-Duty In-Use Testing Program.

Public reporting burden for this collection of information is estimated
to vary from 1 to 60 minutes per response, with an average of 30 minutes
per response, including time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information.  Send comments
regarding the burden estimate or any other aspect of this collection on
information,  including suggestions for reducing this burden, to Chief,
Information Policy Branch, PM-223, U.S. Environmental Protection Agency,
401 M St., S.W. Washington, DC. 20460: and to the Office of Information
and Regulatory Affairs, Office Of Management and Budget, Washington, DC.
20503.

EPA Form #5900-306									OMB No.  2060-0086 Expires (###)