Document ID: EPA-HQ-OPPT-2009-0929-0004
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2010-03-24T04:00Z

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<SPAN STYLE="color:#000000;background-color:#ffffff;position:absolute;left:72.00pt;top:96.75pt;z-index:2;"><IMG WIDTH=100 HEIGHT=41 style="width:52pt;height:24pt;" SRC="outputfile1255347701.htm_files\outputfile1255347701_p0.png"></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:71.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><b><FONT COLOR="000000"><FONT STYLE="font-size: 12.00pt">Appendix A  </FONT></FONT><FONT COLOR="000000"><FONT STYLE="font-size: 9.00pt">Please read Privacy Act Statement and instructions on reverse before completing this form.</FONT></FONT></b></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:254.25pt;top:87.75pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 8.25pt">United States Environmental Protection Agency</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:295.50pt;top:97.50pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 8.25pt">Washington, DC 20460</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:137.25pt;top:107.40pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><b><FONT COLOR="000000"><FONT STYLE="font-size: 14.25pt">TSCA CBI Access Request, Agreement, and Approval</FONT></FONT></b></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:67pt;top:85pt;width:477pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:85pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:243.75pt;top:131.10pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><b><FONT COLOR="000000"><FONT STYLE="font-size: 9.75pt">Section I. – Access Request</FONT></FONT></b></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:73.50pt;top:152.25pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">1.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:79.50pt;top:152.25pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Name (Last, First, MI)</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:293.25pt;top:152.25pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">2. 9-Digit ID Number (e.g., SSN)</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:432.75pt;top:152.25pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">3. Telephone Number</FONT></FONT></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:287pt;top:151pt;width: 1pt;height:19pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:426pt;top:151pt;width: 1pt;height:19pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:73.50pt;top:172.50pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">4. Requestor (Agency/Office/Division/Branch)</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:293.25pt;top:172.50pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">5. Document Control Officer (DCO)</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:432.75pt;top:172.50pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">6. DCO Telephone Number</FONT></FONT></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:67pt;top:171pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:69pt;top:171pt;width:218pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:287pt;top:171pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:288pt;top:171pt;width:138pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:426pt;top:171pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:427pt;top:171pt;width:117pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:171pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:287pt;top:171pt;width: 1pt;height:20pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:426pt;top:171pt;width: 1pt;height:20pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:73.50pt;top:193.50pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">7.TSCA Sections for which access is</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:80.25pt;top:204.00pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">required. Check all that apply. Use blank               ALL       _____</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:250.50pt;top:204.00pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">-</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:253.50pt;top:204.00pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">OR-</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:275.25pt;top:204.00pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">4  ___    5  ___    6  ___    8  ___    12  ___    13  ___    21  ___    _________</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:80.25pt;top:215.25pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">space to request other sections not listed.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:67pt;top:192pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:69pt;top:192pt;width:218pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:287pt;top:192pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:288pt;top:192pt;width:138pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:426pt;top:192pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:427pt;top:192pt;width:117pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:192pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:73.50pt;top:227.25pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">8. Justification for TSCA CBI access.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:409.50pt;top:227.25pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Other</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:79.50pt;top:237.75pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Select appropriate code from instructions on</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:410.25pt;top:237.75pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">List Justification on reverse side</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:79.50pt;top:249.00pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">reverse side. (Check one for all that apply).                   A     ______         B     ______          C     ______          D</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:354.75pt;top:249.00pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">______</FONT></FONT></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:67pt;top:225pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:69pt;top:225pt;width:475pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:225pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:162.00pt;top:265.35pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><b><FONT COLOR="000000"><FONT STYLE="font-size: 9.75pt">Section II. – Contract Information</FONT></FONT></b></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:327.75pt;top:263.25pt;z-index:3;"><FONT FACE ="Times New Roman" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 12.00pt">-</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:338.25pt;top:266.75pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><b><FONT COLOR="000000"><FONT STYLE="font-size: 8.25pt">Contractor Employees Only</FONT></FONT></b></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:73.50pt;top:284.25pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">9.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:80.25pt;top:284.25pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Employer’s Name</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:185.25pt;top:284.25pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">10a. Employer’s Address</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:356.25pt;top:284.25pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">10b. City</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:441.75pt;top:284.25pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">10c. ST</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:477.75pt;top:284.25pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">10d. Zipcode</FONT></FONT></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:67pt;top:282pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:69pt;top:282pt;width:110pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:179pt;top:282pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:180pt;top:282pt;width:170pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:350pt;top:282pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:351pt;top:282pt;width:84pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:435pt;top:282pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:436pt;top:282pt;width:35pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:471pt;top:282pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:472pt;top:282pt;width:72pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:282pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:179pt;top:283pt;width: 1pt;height:21pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:350pt;top:283pt;width: 1pt;height:21pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:435pt;top:283pt;width: 1pt;height:21pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:471pt;top:283pt;width: 1pt;height:21pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:73.50pt;top:306.00pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">11. Contract Number</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:185.25pt;top:306.00pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">12. EPA Project Officer</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:419.25pt;top:306.00pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">13. EPA Project Officer Telephone</FONT></FONT></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:67pt;top:304pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:69pt;top:304pt;width:110pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:179pt;top:304pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:180pt;top:304pt;width:170pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:350pt;top:304pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:351pt;top:304pt;width:62pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:413pt;top:304pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:414pt;top:304pt;width:21pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:435pt;top:304pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:436pt;top:304pt;width:35pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:471pt;top:304pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:472pt;top:304pt;width:72pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:304pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:179pt;top:305pt;width: 1pt;height:21pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:413pt;top:305pt;width: 1pt;height:21pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:103.50pt;top:330.55pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><b><FONT COLOR="000000"><FONT STYLE="font-size: 9.00pt">Section III. – OPPT Secure Storage Area Access – HQ Federal and HQ Contractor Employees Only</FONT></FONT></b></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:73.50pt;top:351.75pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">14. Check if EPA ID Badge. Badge is required.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:103.50pt;top:367.50pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Yes (New)</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:169.50pt;top:367.50pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Need Replacement</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:255.00pt;top:367.50pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">No (List Present EPA ID Badge Number ___________________________)</FONT></FONT></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:67pt;top:350pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:69pt;top:350pt;width:475pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:350pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:73.50pt;top:388.50pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">15. List OPPT Restricted areas by Division to which physical access is required.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:67pt;top:387pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:69pt;top:387pt;width:475pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:387pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:73.50pt;top:408.00pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Home Division (24 hour access)</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:198.75pt;top:408.00pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Other Divisions (6A.M. – 6P.M. only)</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:329.25pt;top:408.00pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Access to CBIC Only</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:410.25pt;top:408.00pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">IMD (DCO and IMD Computer Rms.)</FONT></FONT></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:67pt;top:406pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:69pt;top:406pt;width:123pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:192pt;top:406pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:193pt;top:406pt;width:129pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:323pt;top:406pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:324pt;top:406pt;width:80pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:404pt;top:406pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:405pt;top:406pt;width:139pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:406pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:192pt;top:407pt;width: 1pt;height:21pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:323pt;top:407pt;width: 1pt;height:21pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:404pt;top:407pt;width: 1pt;height:21pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:73.50pt;top:430.50pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">16. List OPPT areas by Division and Room Number for which Alarm Activation/Deactivation Authority is requested.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:67pt;top:429pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:69pt;top:429pt;width:123pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:192pt;top:429pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:193pt;top:429pt;width:129pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:323pt;top:429pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:324pt;top:429pt;width:80pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:404pt;top:429pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:405pt;top:429pt;width:139pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:429pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:215.25pt;top:455.85pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><b><FONT COLOR="000000"><FONT STYLE="font-size: 9.75pt">Section IV. – Confidentiality Agreement</FONT></FONT></b></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:73.50pt;top:475.60pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.00pt">I understand that I will have access to certain Confidential Business Information submitted under the Toxic Substances Control Act (TSCA, 15 USC 2601 et seq.). This access has been granted in accordance with</FONT></FONT></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:69pt;top:474pt;width:475pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:73.50pt;top:483.10pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.00pt">my official duties relating to Environmental Protection Agency programs.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:73.50pt;top:497.35pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.00pt">I understand that TSCA CBI may be used only in connection with my official duties and may not be disclosed except as authorized by TSCA and Agency regulations. I have received a copy of, and understand the</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:73.50pt;top:504.10pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.00pt">procedures set forth in, the TSCA CBI Protection Manual. I agree that I will treat any TSCA CBI furnished to me as confidential and that I will follow these procedures.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:73.50pt;top:517.60pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.00pt">I understand that under section 14(d) of TSCA (15 USC 2513(d)), I am liable for a possible fine of up to $5,000 and/or imprisonment for up to one year if I willfully disclose TSCA CBI to any person not authorized to</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:73.50pt;top:524.35pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.00pt">receive it. In addition, I understand that I may be subject to disciplinary action for violation of this agreement with penalties ranging up to and including dismissal.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:73.50pt;top:538.60pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.00pt">I understand that my obligation to protect TSCA CBI, which has been disclosed to me as part of my official job duties, continues after either termination of my assignment or termination of my employment.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:73.50pt;top:552.10pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.00pt">I certify that the statements I have made on this form and all attachments thereto are true, accurate, and complete.  I acknowledge that any knowingly false or misleading statement may be punishable by fine or</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:73.50pt;top:558.85pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.00pt">imprisonment or both under applicable law.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:69pt;top:568pt;width:475pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:67pt;top:474pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:69pt;top:474pt;width:475pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:474pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:73.50pt;top:570.85pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.00pt">17. Signature of Employee</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:405.75pt;top:570.85pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.00pt">18. Date</FONT></FONT></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:67pt;top:569pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:69pt;top:569pt;width:330pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:399pt;top:569pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:400pt;top:569pt;width:144pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:569pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:399pt;top:570pt;width: 1pt;height:19pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:208.50pt;top:593.85pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><b><FONT COLOR="000000"><FONT STYLE="font-size: 9.75pt">Section V. – Requesting Official Approval</FONT></FONT></b></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:216.75pt;top:615.00pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">20. Name and Signature of Requesting Official. (Immediate Supervisor – EPA Project Officer for Contractors)  As the</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:216.75pt;top:623.25pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">immediate supervisor of (or the EPA Project Officer for) the above mentioned employee, I certify he/she has successfully</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:216.75pt;top:631.50pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">completed a TSCA CBI Security Briefing on the date shown.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:210pt;top:614pt;width: 1pt;height:30pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:73.50pt;top:615.00pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">19. TSCA CBI Security Briefing Date</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:216.75pt;top:645.75pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Name</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:348.00pt;top:645.75pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Signature</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:464.25pt;top:645.75pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">21. Date</FONT></FONT></FONT></SPAN>
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<SPAN STYLE="color:#000000;position:absolute;left:180.75pt;top:669.75pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">23. Approved (TSCA Security Official Signature)</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:428.25pt;top:669.75pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">24. Approval Date</FONT></FONT></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:174pt;top:669pt;width: 1pt;height:21pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:422pt;top:669pt;width: 1pt;height:21pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:73.50pt;top:692.25pt;z-index:3;"><FONT FACE ="Arial Narrow" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">DCO Code</FONT></FONT></FONT></SPAN>
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<SPAN STYLE="color:#000000;position:absolute;left:228.10pt;top:865.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><b><FONT COLOR="000000"><FONT STYLE="font-size: 9.75pt">Paperwork Reduction Act Notice</FONT></FONT></b></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:97.75pt;top:884.15pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">The public reporting burden for the collection of information is estimated to average .84 hours per response. This estimate includes time for</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:71.35pt;top:892.40pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">reviewing instructions, gathering and maintaining the needed data, and completing and reviewing the collection of information.  Send comments</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:71.35pt;top:899.90pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">regarding the burden estimate or any other aspect of this collection of information to the Director, Collection Strategies Division, US Environmental</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:71.35pt;top:908.15pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington DC 20460, and to the Office of Information and Regulatory Affairs, Office of</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:71.35pt;top:916.40pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Management and Budget, Washington, DC 20503, marked ATTENTION: Desk Officer for EPA.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:378.10pt;top:916.40pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Include the OMB No. identified on page 1 in any</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.65pt;top:929.15pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">correspondence.  Do not send the completed form to this address.  Submit the form in accordance with the instructions in the CBI Manual.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:66pt;top:864pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:66pt;top:864pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:66pt;top:864pt;width:477pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:864pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:864pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:66pt;top:864pt;width: 1pt;height:74pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:864pt;width: 1pt;height:74pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:253.50pt;top:939.60pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><b><FONT COLOR="000000"><FONT STYLE="font-size: 9.75pt">Privacy Act Statement</FONT></FONT></b></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:94.50pt;top:960.75pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Furnishing your Social Security Number is voluntary, but encouraged. The information on this form is used by EPA to maintain a record of</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:969.00pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">those persons cleared for access to TSCA Confidential Business Information (CBI) and to maintain the security of TSCA CBI.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:93.50pt;top:984.75pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Disclosure of information from this form may be made to the Office of Pollution Prevention and Toxics (OPPT) contractors in order to carry out</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:993.00pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">functions for EPA compatible with the purpose for which this information is collected; to other Federal agencies when they possess TSCA CBI and</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1001.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">need to verify clearance to EPA and EPA contractor employees for access; to the Department of Justice when related to litigation or anticipated</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1009.50pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">litigation involving the records or the subject matter of the records; to the appropriate Federal, State or local agency charged with enforcing a statute or</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1017.00pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">regulation, violation of which is indicated by a record in this system; where necessary, to a State, Federal or local agency maintaining information</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1025.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">pertinent to hiring, retention, or clearance of an employee, letting of a contract, or issuance of a grant or other magistrate or administrative tribunal; in</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1033.50pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">the course of litigation under TSCA; and to a member of Congress acting on behalf of an individual to whom records in this system pertain.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:66pt;top:939pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:66pt;top:939pt;width:477pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:939pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:66pt;top:939pt;width: 1pt;height:114pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:939pt;width: 1pt;height:114pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:228.00pt;top:1055.10pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><b><FONT COLOR="000000"><FONT STYLE="font-size: 9.75pt">Instructions for Form Completion</FONT></FONT></b></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1054pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1054pt;width:477pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:1054pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1055pt;width: 1pt;height:11pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:1055pt;width: 1pt;height:11pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1067.10pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><b><FONT COLOR="000000"><FONT STYLE="font-size: 9.75pt">Section I – To be completed by all</FONT></FONT></b></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1067.10pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><b><FONT COLOR="000000"><FONT STYLE="font-size: 9.75pt">Section III – To be completed by HQ Federal</FONT></FONT></b></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1078.35pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><b><FONT COLOR="000000"><FONT STYLE="font-size: 9.75pt">and HQ Contractor employees only</FONT></FONT></b></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1066pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1066pt;width:238pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:305pt;top:1066pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:306pt;top:1066pt;width:238pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:1066pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1067pt;width: 1pt;height:22pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:305pt;top:1067pt;width: 1pt;height:22pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:1067pt;width: 1pt;height:22pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1097.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">1. List Full Name</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1104.75pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">2. List 9-Digit ID (e.g., SSN)</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1113.00pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">3. List Telephone number of person in item 1</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1121.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">4. List Full Acronym of Requesting Office (i.e. EPA Office in which the</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1129.50pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">individual works or for contractor employees, the EPA Office with whom</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1137.00pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">the contract is with)</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1145.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">5. List the immediate Document Control Officer for the office in which the</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1153.50pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">individual works</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1161.00pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">6. List the telephone number of the Document Control Officer</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1169.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">7. Check the TSCA Sections for which access is requested or check ALL</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1177.50pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">if applicable</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1185.75pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">8. Circle the appropriate Access Justification Code</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:76.50pt;top:1193.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><b><FONT STYLE="font-size: 6.75pt">A</FONT></b><FONT STYLE="font-size: 6.75pt">. </FONT></FONT><i><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Employee is an EPA employee or EPA contractor employee whose</FONT></FONT></i></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1201.50pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><i><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">work assignments involve the New and/or Existing Chemical Programs of</FONT></FONT></i></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1209.75pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><i><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">TSCA. Hence access to the TSCA sections listed in item 7 of this form is</FONT></FONT></i></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1218.00pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><i><FONT STYLE="font-size: 6.75pt">required in performance of his/her duties</FONT></i><FONT STYLE="font-size: 6.75pt">.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:76.50pt;top:1225.50pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><b><FONT STYLE="font-size: 6.75pt">B</FONT></b><FONT STYLE="font-size: 6.75pt">. </FONT></FONT><i><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Employee is an EPA employee or EPA contractor employee whose</FONT></FONT></i></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1233.75pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><i><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">work entails the administration of computer systems housing TSCA CBI.</FONT></FONT></i></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1242.00pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><i><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Hence access to the TSCA sections listed in</FONT></FONT></i></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1250.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><i><FONT STYLE="font-size: 6.75pt">item 7 of this form is required</FONT></i><FONT STYLE="font-size: 6.75pt">.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:76.50pt;top:1257.75pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><b><FONT STYLE="font-size: 6.75pt">C</FONT></b><FONT STYLE="font-size: 6.75pt">. </FONT></FONT><i><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Employee is an EPA employee or EPA contractor employee whose</FONT></FONT></i></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1266.00pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><i><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">work entails physical security or maintenance for TSCA CBI secure</FONT></FONT></i></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1274.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><i><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">storage areas. Although employee will not actually</FONT></FONT></i></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1281.75pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><i><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">work with any TSCA CBI materials, access to the TSCA sections listed in</FONT></FONT></i></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1290.00pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><i><FONT STYLE="font-size: 6.75pt">item 7 of this form is required</FONT></i><FONT STYLE="font-size: 6.75pt">.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:76.50pt;top:1298.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><b><FONT STYLE="font-size: 6.75pt">D</FONT></b><FONT STYLE="font-size: 6.75pt">. List Justification here</FONT></FONT></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:153pt;top:1305pt;width:129pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:72pt;top:1317pt;width:228pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:72pt;top:1329pt;width:228pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:72pt;top:1340pt;width:228pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:72pt;top:1352pt;width:228pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:72pt;top:1363pt;width:228pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:72pt;top:1374pt;width:228pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1097.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">NOTE: </FONT></FONT><i><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">These procedures apply only to employees requiring access to</FONT></FONT></i></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1104.75pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><i><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">OPPT Secure Storage areas. All others follow standard Agency</FONT></FONT></i></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1113.00pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><i><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">procedures.</FONT></FONT></i></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1121.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">14. Check either box a, b, c or (c&d) for EPA ID badge or Contractor</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1129.50pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Building Pass. If box c is checked, write in badge number.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1137.00pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><b><FONT STYLE="font-size: 6.75pt">a. Yes </FONT></b><FONT STYLE="font-size: 6.75pt">- Check if new employee getting first EPA ID Badge. (New</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1145.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">programmed badge and barcode)</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1153.50pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><b><FONT STYLE="font-size: 6.75pt">b. Need Replacement </FONT></b><FONT STYLE="font-size: 6.75pt">- Check if replacement ID Badge is needed</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1161.00pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">(replacement badge and barcode)</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1169.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><b><FONT STYLE="font-size: 6.75pt">c. No </FONT></b><FONT STYLE="font-size: 6.75pt">- Existing badge needs programming. List ID Badge no.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1177.50pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">15. Check and list OPPT secured areas for which access (via “RUSCO”</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1185.75pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">electronic door control system) is required. List Division acronyms for the</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1193.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">requested areas.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1201.50pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><b><FONT STYLE="font-size: 6.75pt">Home Division </FONT></b><FONT STYLE="font-size: 6.75pt">- List Division in which employee works</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1209.75pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><b><FONT STYLE="font-size: 6.75pt">Other Divisions </FONT></b><FONT STYLE="font-size: 6.75pt">- List other OPPT Divisions for which unrestricted</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1218.00pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">daytime access is requested</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1225.50pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><b><FONT STYLE="font-size: 6.75pt">CBIC Only </FONT></b><FONT STYLE="font-size: 6.75pt">- To be checked for those who only need to access the</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1233.75pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Confidential Business Information Center.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1242.00pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><b><FONT STYLE="font-size: 6.75pt">IMD Areas </FONT></b><FONT STYLE="font-size: 6.75pt">- Employees who need to regularly access the IMD Document</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1250.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Control Office Suite should circle </FONT></FONT><FONT COLOR="000000"><b><FONT STYLE="font-size: 6.75pt">DC0 </FONT></b><FONT STYLE="font-size: 6.75pt">in the fourth block. Only IMD staff</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1257.75pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">and contractors who work in IMD computer rooms should circle </FONT></FONT><b><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">IMD</FONT></FONT></b></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1266.00pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><b><FONT STYLE="font-size: 6.75pt">Computer Rooms</FONT></b><FONT STYLE="font-size: 6.75pt">.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1274.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">16. List OPPT areas by Division and Room numbers for which Alarm</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1281.75pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">Activation/Deactivation authority is requested. Generally, this is</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1290.00pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">employees home Division only.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1089pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1089pt;width:238pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:305pt;top:1089pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:306pt;top:1089pt;width:238pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:1089pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1090pt;width: 1pt;height:300pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:305pt;top:1090pt;width: 1pt;height:300pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:1090pt;width: 1pt;height:300pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1391.10pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><b><FONT COLOR="000000"><FONT STYLE="font-size: 9.75pt">Section II – To be completed by Contractor</FONT></FONT></b></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1402.35pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><b><FONT COLOR="000000"><FONT STYLE="font-size: 9.75pt">Employees only</FONT></FONT></b></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1391.10pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><b><FONT COLOR="000000"><FONT STYLE="font-size: 9.75pt">Section IV – To be completed by all</FONT></FONT></b></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1390pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1390pt;width:238pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:305pt;top:1390pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:306pt;top:1390pt;width:238pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:1390pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1391pt;width: 1pt;height:22pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:305pt;top:1391pt;width: 1pt;height:22pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:1391pt;width: 1pt;height:22pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1413.00pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">17. Employee Signature (must be original)</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1421.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">18. Signature Date</FONT></FONT></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1413pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1413pt;width:238pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:305pt;top:1413pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:1413pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1414pt;width: 1pt;height:15pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:305pt;top:1414pt;width: 1pt;height:15pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:1414pt;width: 1pt;height:15pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1430.85pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><b><FONT COLOR="000000"><FONT STYLE="font-size: 9.75pt">Section V – To be completed by all</FONT></FONT></b></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1430pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:305pt;top:1430pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:306pt;top:1430pt;width:238pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:1430pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1431pt;width: 1pt;height:17pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:305pt;top:1431pt;width: 1pt;height:17pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:1431pt;width: 1pt;height:17pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1447.50pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">19. Enter date employee attended TSCA CBI Security Briefing</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1455.75pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">20. Immediate Supervisor/EPA Project Officers name and sign.</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1463.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">21. Date of signature</FONT></FONT></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1448pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:305pt;top:1448pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:1448pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1449pt;width: 1pt;height:24pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:305pt;top:1449pt;width: 1pt;height:24pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:1449pt;width: 1pt;height:24pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:311.25pt;top:1473.60pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><b><FONT COLOR="000000"><FONT STYLE="font-size: 9.75pt">Section VI – To be completed by OPPT Security</FONT></FONT></b></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1473pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:305pt;top:1473pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:306pt;top:1473pt;width:238pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:1473pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1473pt;width: 1pt;height:16pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:305pt;top:1473pt;width: 1pt;height:16pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:1473pt;width: 1pt;height:16pt;background-color:#000000;"></SPAN><SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1421.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">9. List Employer’s name</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1429.50pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">10a-d. List Employer’s address</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1437.00pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">11. List Contract number</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1445.25pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">12. List EPA Project Officer’s name</FONT></FONT></FONT></SPAN>
<SPAN STYLE="color:#000000;position:absolute;left:72.00pt;top:1453.50pt;z-index:3;"><FONT FACE ="Arial" style = "font-size: 12.00pt"><FONT COLOR="000000"><FONT STYLE="font-size: 6.75pt">13. List EPA Project Officer’s telephone number</FONT></FONT></FONT></SPAN>
<SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1490pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:305pt;top:1490pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:306pt;top:1490pt;width:238pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:1490pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1491pt;width: 1pt;height:24pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1515pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1515pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:66pt;top:1515pt;width:238pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:305pt;top:1491pt;width: 1pt;height:24pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:305pt;top:1515pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:306pt;top:1515pt;width:238pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:1491pt;width: 1pt;height:24pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:1515pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;font-size:0;left:544pt;top:1515pt;width: 1pt;height: 1pt;background-color:#000000;"></SPAN><SPAN STYLE="position:absolute;left:71.76pt;top:1584.00pt"> </SPAN>
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