Form 5900-575 Service Provider Directory

Service Provider Directory Contact
Information Form (Web Form)
This form should be completed by companies that are interested in being added to the [Voluntary
Program Name] Service Provider Directory.
This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et
seq. (OMB Control No. 2060-0446). Responses to this collection of information are voluntary (42 USC
7403(g)). An agency may not conduct or sponsor, and a person is not required to respond to, a collection
of information unless it displays a currently valid OMB control number. The public reporting and
recordkeeping burden for this collection of information is estimated to be 0.25 hours per response. Send
comments on the Agency’s need for this information, the accuracy of the provided burden estimates and
any suggested methods for minimizing respondent burden to the Regulatory Support Division Director,
U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460.
Include the OMB control number in any correspondence. Do not send the completed form to this address.
Field Name

Data Type

Required

First Name

Single Line of Text

Yes

Last Name

Single Line of Text

Yes

Company/Org Name
Street Address
City
State
Zip/Postal Code
Country
Email Address
Phone Number
Fax Number
Website Address
Services Description
Service Category
Service Category Other

Single Line of Text
Single Line of Text
Single Line of Text
Single Line of Text
Single Line of Text
Dropdown List
Single Line of Text
Single Line of Text
Single Line of Text
Single Line of Text
Multiple Lines of Text
Multiselect
Single Line of Text

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
No

Emission Sources

Multiselect

Yes

Emission Sources Other
Technology
Technology Other
Applicable Sectors
Would You Like to
Receive Email Updates?

Single Line of Text
Multiselect
Single Line of Text
Multiselect

No
No
No
Yes

Yes/No

Yes

Notes
First name of company point of
contact
Last name of company point of
contact

Email address for company contact
Phone number for company contact
Fax number for company contact
Company/org website
Identify applicable service categories
Identify service categories not listed
Equipment/Technology to Mitigate
Methane Emissions From:
Identify emission sources not listed
Identify applicable technologies
Identify technologies not listed
Identify applicable sector(s)
Preference to receive updates from
applicable voluntary program

NOTE: EPA created the Service Provider Directory to share information on service and technology
providers that can facilitate emission reduction activities, not to endorse particular companies or
products. Providing contact information and links to non-EPA websites does not constitute an
endorsement by EPA or any of its employees.
EPA Form Number 5900-575