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Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/20xx

Attachment 4d. Tire Recycling Plant Sampling Collection Form

Study ID Number _______________________

Sample Collection Date _______________________

Collector ID _______________________

Production Process Type: Ambient Cryogenic (Circle one)

Crumb Rubber Samples Collection – For Metals and Particles (Plastic Containers)

Sample	Sample Collected
Batch/Lot/Storage Bag 1	Yes No
Batch/Lot/Storage Bag 1	Yes No
Batch/Lot/Storage Bag 1	Yes No
Batch/Lot/Storage Bag 2	Yes No
Batch/Lot/Storage Bag 2	Yes No
Batch/Lot/Storage Bag 2	Yes No
Batch/Lot/Storage Bag 3	Yes No
Batch/Lot/Storage Bag 3	Yes No
Batch/Lot/Storage Bag 3	Yes No

Crumb Rubber Samples Collection – For Organics (Glass Containers)

Sample	Sample Collected
Batch/Lot/Storage Bag 1	Yes No
Batch/Lot/Storage Bag 1	Yes No
Batch/Lot/Storage Bag 2	Yes No
Batch/Lot/Storage Bag 2	Yes No
Batch/Lot/Storage Bag 3	Yes No
Batch/Lot/Storage Bag 3	Yes No

ATSDR estimates the average public reporting burden for this collection of information as 90 minutes per response, 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).

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Zartarian, Valerie
File Modified	0000-00-00
File Created	2021-01-23