Form 3520-12 Fuel Manufacturer Notification for Motor Vehicle Fuel

EPA Form 3520-12 (06-2003) - Fuel Manufacturer Notification for Motor Vehicle Fuel

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U.S. Environmental Protection Agency
Office of Transportation and Air Quality

Form Approval
OMB No. 2060 -0150
Approval Expires 01/31/2004

Fuel Manufacturer Notification
for Motor Vehicle Fuel

Leave Blank

1. Brand name(s) of the motor vehicle fuel covered by this notification (list):
2. Company Name:

3. Company ID:

4. Address:

5. Type of Fuel (Check Only One)

g (a) Unleaded Premium Gasoline
c
d
e
f
c (b) Unleaded Regular Gasoline
d
e
f
g
c (c) Unleaded Midgrade Gasoline
d
e
f
g

g (d) Grade 1-Diesel
c
d
e
f
c (e) Grade 2-Diesel
d
e
f
g
c (f) Other (Specify):
d
e
f
g

6. Fuel Properties, to the extent known:
Highest
(a) Aromatics
(b) Olefins
(c) Saturates
(d) Polynuclear Organic Material
(e) Sulfur
(f) Trace Elements

Gasoline:
(g) Reid Vapor Pressure (kPa or psi)
(h) Distillation: 10% Point (°C)
(i) Distillation: End Point (°C)
(j) Research Octane Number
(k) Motor Octane Number
Diesel Fuel:
(I) Distillation: 90% Point (°C)
(m) Distillation: End Point (°C)
(n) Cetane Number or Index

Percent by weight
Lowest
Average

Methods of Analysis
(a) through (f) only

EPA Form 3520-12 (06-2003) - Fuel Manufacturer Notification for Motor Vehicle Fuel

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EPA Form 3520-12 (06-2003) - Fuel Manufacturer Notification for Motor Vehicle Fuel
8.

Do you know of any analytical technique that can be used to detect the presence of any of the reported additives in this fuel
and/or measure their concentration therein?

c
d
e
f
g
9.

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No

c
d
e
f
g

Yes If "Yes," attach separate sheet(s) providing the information.

Do you have any information developed by or for you concerning the mechanisms of action of any of the additives reported;
reactions between the additives and the motor vehicle fuel; the identification and/or measurement of the emission products of
the additives when used in the motor vehicle fuel; the effects of the additives on all emissions; the toxicity and any other public
health or welfare effects of the emission products of the additives; and/or the effects of the emission products of the gasoline
additives on the performance of emission control devices or systems?

c
d
e
f
g

No

c
d
e
f
g

Yes If "Yes," attach separate sheet(s) providing summaries and a description of the test
procedures used in obtaining the information.
10. To the nearest percent, estimated for the third year of production, enter the percent of sales by Petroleum Administration for
Defense District (PADD) for the motor vehicle fuel. See instructions for the states in each PADD.
PADD1

PADD2

PADD3

PADD4

PADD5

11. Is this fuel derived only from conventional petroleum, heavy oil deposits, coal, tar sands, and/or oil sands?

c Yes
d
e
f
g

c No
d
e
f
g

12. Small Business Provisions - 40 CFR 79.58(d). (See instructions)
A manufacturer of a baseline or nonbaseline fuel whose average of the previous three years annual sales revenue is less
than $50 million is exempt from the Tier 1 and Tier 2 health-effects testing requirements. A manufacturer of an atypical fuel
whose average of the previous three years annual sales revenue is less than $10 million is exempt from the Tier 2
requirements. If you believe that you qualify for an exemption, enter below your sales revenue for each of the previous three
years and the average.
(Note: In cases where subsidiary, divisional, or other complex business arrangements exist, the business entity to which this
sales level pertains is the parent company with ultimate ownership. The "ultimate" parent is defined as the uppermost
headquarters or topmost company encompassing all related parents, subsidiaries, divisions, branches, or other operating
units. This definition follows that used by the Small Business Administration. It also helps to ensure that a company will not
subdivide merely to become eligible for an exemption.)

Annual sales revenue 3 years ago: $
Annual sales revenue 2 years ago: $
Annual sales revenue 1 year ago: $
Average of above: $
Is the above average for the company named in Item 2?

c
d
e
f
g

Yes

c
d
e
f
g

No

If "No," complete the following:

Name of the parent company with ultimate ownership:

Address:

Contact Name:

Phone:

Title:

Email:

EPA Form 3520-12 (06-2003) - Fuel Manufacturer Notification for Motor Vehicle Fuel

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13. Grouping Information - If you do not qualify for a small business provision, you must be a member of a testing group
appropriate for your fuel or supply the appropriate health-effects test information.
This fuel is covered by the following testing group:
Group description:
Organizing entity:
Contact person:
Fax:

Telephone:
Email:

Address:
OR
I have attached the appropriate information.

c
d
e
f
g

Yes

c
d
e
f
g

No

If "No," attach an explanation.

14. Confidential Business Information - You may assert a business confidentiality claim for certain items. If no claim is made, the
information may be made available to the public without further notice. All questions of confidentiality will be handled pursuant
to 40 CFR 2.
Do you wish to assert a claim of confidentiality for any of items 6 through 12?

c
d
e
f
g

No

c
d
e
f
g

Yes

If "Yes," indicate "Yes" or "No" for each item below:

Item 6:

c
d
e
f
g

Yes

c
d
e
f
g

No

Item 7:

c
d
e
f
g

Yes

c
d
e
f
g

No

Item 8:

c
d
e
f
g

Yes

c
d
e
f
g

No

Item 9:

c
d
e
f
g

Yes

c
d
e
f
g

No

Item 10:

c
d
e
f
g

Yes

c
d
e
f
g

No

Item 11:

c
d
e
f
g

Yes

c
d
e
f
g

No

Item 12:

c
d
e
f
g

Yes

c
d
e
f
g

No

15. Attached Information - Are attachments included with this notification?

c
d
e
f
g

No

c
d
e
f
g

Yes If "Yes," list below:

EPA Form 3520-12 (06-2003) - Fuel Manufacturer Notification for Motor Vehicle Fuel
16. Certification
To the best of my knowledge, the above is complete and correct.
I am authorized by the manufacturer to submit this notification.
As per 40 CFR 79.11(g), the U.S. Environmental Protection Agency would be notified in writing if certain
information in this notification were to change.
This fuel manufacturer will not represent, directly or indirectly, in any notice, circular, letter, or other written
communication, or any written, oral, or pictorial notice, or other announcement in any publication or by radio or
television, that registration of this fuel constitutes endorsement, certification, or approval by any agency of the
United States.
Signature:

Date:

Name of Signer (print):

Title:

Telephone:

Fax:

E-mail:

Comments:

Mail the completed form to:
U.S. Environmental Protection Agency
Attn: Fuel Registration/Suite L -103
Mail Code - 6406J
1200 Pennsylvania Avenue, NW
Washington, DC 20460- 0001
Telephone (202) 564 -9754
Fax (202) 565 -2153
email: [email protected], [email protected]
This office is operated by a contractor for the EPA.

or, via courier:
U.S. Environmental Protection Agency
Attn: Fuel Registration/Suite L - 103
Mail Code - 6406J
501 Third Street, NW
Washington, DC 20001

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