Tire Recycling Facility Sample Collection Agreement

Attachment 4c. Tire Recycling/Crumb Rubber Manufacturing Facility Collection Agreement

(Flesch-Kincaid Reading Level: Grade 9.5)

COLLECTION AGREEMENT

United States Environmental Protection Agency and the Agency for Toxic Substances and Disease Registry

Collections Related to Synthetic Turf Fields with Crumb Rubber Infill

Overview

The Agency for Toxic Substances and Disease Registry (ATSDR) and the United States Environmental Protection Agency (USEPA) invite you to be in a project to measure the amount of chemicals in crumb rubber infill used in synthetic turf fields.

You are being asked to participate in this project. Your participation is voluntary. After you read about the project and before you decide to participate, please ask questions if there is anything that you do not understand.

What is the purpose of this project?

The purpose is to see what chemicals are present in newly manufactured tire crumb rubber infill used in synthetic turf fields.

We will use the results of this project to better understand the most relevant chemicals, exposures to those chemicals, and toxicity information available for those chemicals found in crumb rubber infill used in synthetic turf fields guide actions that will protect people from exposure to contaminants in the environment.

Why are you being asked to be in this project?

You were chosen to participate in this research project because your facility was identified as manufacturing tire crumb rubber used as infill in synthetic turf fields and you completed a survey that indicated you willing to participate. ATSDR and EPA hope to get 9 facilities to participate.

Public reporting burden of this collection of information is estimated to average 5 minutes per response for total participation, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0923-XXXX).

Public reporting burden of this collection of information is estimated to average 5 minutes per response for total participation, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0923-XXXX).

What are we asking you to do?

• We will ask you to provide permission for us to collect samples of the crumb rubber manufactured at your facility. We need samples from three different production batches and/or storage containers from your facility. We will collect about four pounds of crumb rubber from each batch or container.

How long will this take?

It will take us about 90 minutes for us to collect the samples.

What will the field samples be tested for?

We will look for chemicals in the crumb rubber, including

• Metals

• Volatile Organic Compounds

• Semi-Volatile Organic Compounds

We will also characterize particle sizes in the collected material.

We would like your permission for us to store the leftover samples to possibly test for other chemicals in the future.

Are there any risks or discomforts to you if you decide to be in this project?

There are no risks from the sample collection. The facility owners will not incur any costs for the laboratory tests performed by the federal government.

Are there any risks or benefits to you from being in this project?

The facility owners will not incur any costs for the laboratory tests performed by the federal government. There are no direct benefits from being a part of the project.Tire recycling facilities will have the option to request a copy of the laboratory results from the crumb rubber samples collected.

Who will see the information you give the researchers?

All information about your facility will be secure. We keep track of your information using a code number rather than the facility name. We will keep paper records in locked files and electronic records are stored on password protected computers at the USEPA. Only staff working on the project will be allowed to look at the paper and electronic records. Federal policy requires making the data we collect available to the public, but we will not include your name or other identifying information in public release. However, identifying information may be released in the event of a Freedom of Information Act request.

What is the cost to you and what compensation will you get?

The only cost to you for being in our project is your time to take part. We will be collecting about twelve pounds of crumb rubber; however, the collection will occur from three different lots or storage containers (about four pounds per lot or container).

What are your choices about participating?

Your participation in this project is voluntary. You are free to be a part of it or not.

Who should you contact if you have questions later on?

If you have any question about the project or wish to drop out, please contact:

Elizabeth Irvin-Barnwell, ATSDR Project Officer

Jcx0@cdc.gov

770-488-3684

What should you do after reading this information?

If you do not understand what we are asking you to do, please ask questions. After all your questions have been answered to your satisfaction and if you want to be in this project, please sign the consent form on the next page.

United States Environmental Protection Agency and the Agency for Toxic Substances and Disease Registry

Collections Related to Synthetic Turf Fields with Crumb Rubber Infill

Sample Collection Agreement

I have read the above information about the project “Collections Related to Synthetic Turf Fields with Crumb Rubber Infill.” I have been allowed to ask questions and I had all my questions answered.

By signing below, I agree to allow USEPA and ATSDR to collect crumb rubber samples from my manufacturing facility.

_______________________________________________

Participant’s name (Print)

_______________________________________________

Participant's signature / Date

_____________________________________________________________

Organization/Facility Name Participant Position/Title

By signing below, I give USEPA and ATSDR permission to store my leftover field samples to test for other contaminants at a later date.

_______________________________________________

Participant’s name (Print)

_______________________________________________

Participant's signature / Date

By signing below, I am indicating I would like to receive a copy of the laboratory results from the crumb rubber samples collected from my facility.

_______________________________________________

Participant’s name (Print)

_______________________________________________

Participant's signature / Date

______________________________________________________________________________

Mailing Address for results