Copyright Permission Form

This form is to be completed for ALL figures and tables,
even those that are original and not from another source.

Title:
Author:
Project Number:
WRF Contact:

Figure or Table Number	Short Title	Source: Author-Date Publisher	Permission Required? (Yes or No)	Response Received? (Yes or No)

SAMPLE—SAMPLE—SAMPLE

Copyright Permission Form

This form is to be completed for ALL figures and tables,
even those that are original and not from another source.

Title:	Contaminant Removal Systems for Drinking Water Supplies
Author:	Joe Drago
Project Number:	2658
WRF Contact:	Jim Smith

Figure or Table Number	Short Title	Source: Author-Date Publisher	Permission Required? (Yes or No)	Response Received? (Yes or No)
ES-1	Overview of Monitoring Solutions	Original	No	N/A
Table 1	Operating parameters	Original	No	N/A
Figure 1	Effluent versus influent	Original	No	N/A
Table 2	Average radon levels	Michel 1987 (Plenum)	Yes	Yes
Figure 2	Mechanical surface	Metropolitan Water District	No (participating utility provided figure)	N/A
Table 3	DYIII media	EPA 1999	No (in public domain)	N/A
A-1	Removal system install costs	Original	No	N/A

(delete this page and the section break above to use this form)