5900-155 Distributor of QPS Methyl Bromide Quarterly Report

OMB Control Number: 2060-0170

Expiration Date: 12/31/11

U.S. Environmental Protection Agency stratospheric ozone protection program

class i controlled substance distributor of qps methyl bromide quarterly report (Sec 82.13)

SECTION 1

DISTRIBUTOR IDENTIFICATION

1.1 Date of Submission

     

1.2 Total Quantity of Methyl Bromide Delivered for Use in Certified QPS Applications (kg)

     

1.3 Original Submittal Re-submittal

1.4 Quarter and Year to Which This Report Applies

1st

2nd

3rd

4th

Year      

1.5 Distributor Information

Company Name      

Street Address      

City      

State      

Zip Code      

1.6 Distributor Contact Identification

Reporting Distributor Contact Person      

Phone Number      

Fax Number      

E-mail Address      

1.7 Supplier Identification

Supplier Name      

1.8 Signature of Reporting Distributor Representative

I certify that the total quantity of methyl bromide listed in this form was exclusively sold for use in quarantine & preshipment applications, and not sold/ transferred to another person. I certify under penalty of law that I have personally examined and am familiar with the information submitted in this and all attached documents, and that based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the submitted information is true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment.

Name       Title       Signature      

Date      

SEND COMPLETED FORMS TO:

For U.S. Postal Service: Tracking System Program Manager Stratospheric Protection Division U.S. EPA (6205J) 1200 Pennsylvania Avenue, NW Washington, DC 20460

For Private Courier: Tracking System Program Manager Stratospheric Protection Division U.S. EPA – (6205J) 1310 L Street, NW; 10th Floor Washington, DC 20005

Information in reports submitted in compliance with the final rule may be claimed as confidential. A company may assert a claim of confidentiality for information submitted by clearly marking that information as confidential. Such information shall be treated in accordance with EPA’s procedures for information claimed as confidential at 40 CFR Part 2, Subpart B, and will only be disclosed by the means set forth in the subpart. If no claim of confidentiality accompanies the report when it is received by EPA, it may be made public without further notice to the company (40 CFR 2.203).

The public reporting and recordkeeping burden for this collection of information is estimated to average 2.4 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, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 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.

EPA Form # 5900-155, Revised 08/08