REQUEST FOR CLEARANCE OR CANCELLATION OF A STANDARD OR OPTIONAL FORM INSTRUCTIONS: For all actions to Standard and Optional forms, complete and submit 3 ‘separate set of slearance documents for oach form (o,f one form being cancelled and replaced. with another form, submit’ two eta of Soouments: one set to cancel the ald form and anothor set to establish the hnew form). Then forward along with the hams listed below to: Washington, BC 20405 1, Supporting statement deseribing the situation or problem which maka the iti sion, of eencelation ot this form Vand de irae, 2. Copy of form for all roquosts except cancsllations. This copy shoud be both eectrons nd paper unless composition te being requeste List of potential us 1 agencies and the projected snnusl usage. Proposed implementing of canceling regulaioniditective (for forme) '5. Printing epostications on Standard Fotm 1, of Standard Form 1 propriate. ©. Any other appropriate documentation. orm will be used for public reporting (5 CFR 1320), include a copy ‘of OMB’ Form 83, supporting documentation, ond OMB clearance {eport. If form is ah interagency report, Include copy of the approved ‘Standard Form 360 end one sat of supporting docunvents T_REGUESTING DEPARTMENT OF AGENCY Fa REGUESTING BUREAU OW OFFICE cB DATE REQUEST mateo “ELTYPE OF ACTION (Oheck av wpplcblad IS 1YFE OF FORM Tete pec Beow! {Check one) Fieseuee [7] ime neviseo (creck apaeabe! [7 PRESENT EDITION DATE]S. PROPOSED EDITION — | PRESENT SF OR OF NUMGER ‘Ga. FROMULGATING REGULATION OR DIRECTIVE Wequred for Standard Forme ony) "TON 11, OTHER CLEARANCES [cheak onli appleaba) fom ROMER [EXPIRATION DATE T5- RELATED STANDARD OR OPTIONAL FORRS 7a: OFFICIAL SUBWITTWG REQUEST 15, AGENCY STANDARD AND OPTIOWAL FORMS LIAISON REPRESENTATIVE 3 SIGNATURE [> sionATORE Dane =e Jo Wane TELEPHONE RE SHES a TELERIONE j= DATE SIGHED ‘SRER CODE OWER [aRex cope — Joe "APPROVAL ACTION (GSA ONLYT Tea: SIGNATURE OF CLERAANGE OFFICIAL Tee. DATE SIGNED Tae WANE OF CLEARANCE OFFICIAL ‘Rutyonizep Fon Locat RepmooucTion PREVIOUS EBMION NOT USABLE Tn aesSTOCK EVALUTION (Complete Tor old stock of form revised on this request] (Obtain this Information from GSA's Federal Supply Se EXISTING STOCK ovoiua ie (FSS), Gonoral Products Commodity Genter, Fort Worth, TX and of revision in blocks 25-26. Note that unite are EA (Each), HO (Hundred), BX (Box), and PG. 18. QUANTI (OF UNITS) 20, MONTHLY DEMAND Pat MONTHS OF BTOGE 0121) (OF STOCK (20 x23) ‘STOCK DISPOSITION (Complote for revised or canceled forms.) 2, FORM NUMBER fs. EDION DATE [27. NATIONAL STOCK NOWBER OF FORM TO BE js cooe [. EFFECTIVE DATE 1 Discontinee form immediatly and dispose ‘2 Contin to ene exiting stocks, but do ~ fovlsod or modtad 5 = Order naw dion inmaditly: dapore of swisting forme upon rocaipto evoed {6 = Other Extn in om 41) B= PROCUREMENT AND STOCKING OF NEW OR REVISED FORM [50, NATIONAL STOCK NUMBER 17 wssanod 32, ESTIMATED GOVT-WIDE USAGE Ie Formal fs-FIST YEAR [> SUCCEEDING YEARS USAGE WHE heat [Si STOCKING WSTRUCTIONS (Shack ane Deenstanr Csr thes wastes HS Re te pc Dvjnuaie [ron sats 70 1 ruse By Li accounase nem, recone RE nom 1 SROSEIOI RE Etre ASCNUTARE Sat IF intone be anacwonsa Ds rt or ot Shoo! Lise rene seo Doro 1026s iroinaty Anche IND DESCRIPTION (Chock as applicable] Tomer ispecty below A umn SHNER Ofer ‘CAMERA COPY OTHER (Specify pe PR00s > SAUPLES ator tis Itarmaton on printing req. Lines b and. are Tor Agonay we "7. HUMBER oF ROOFS Ba" WOWSER OF DAVE], SehD SPEGIED NUMBER OF RTE FORM SAMPLES TO Vout on) Proves wnt oe NONE (Camem copy fished LD miiasen ‘speci "STANDARD FORM 152 (nev. 17-2000 BACK