5900-143 Methyl Bromide Second-Party Transformation Annual Report

OMB Control Number: 2060-0482

Expiration Date: 8/31/11

U.S. Environmental Protection Agency stratospheric ozone protection program				class i controlled substance methyl bromide second-party transformation annual report (Sec 82.13)
SECTION 1 COMPANY IDENTIFICATION
1.1 Date of Submission	     		1.2 Year To Which This Report Applies				     
1.3 Original Submittal Re-submittal
1.4 Have you submitted an IRS certificate of intent to transform to the producer or importer (per Sec 82.13)?							Yes No
1.5 Company Information
Company Name      
Street Address      
City      		State      			Zip Code      
1.6 Company Contact Identification
Reporting Company Contact Person      		Phone Number      			Fax Number      
E-mail Address      
1.7 Transformation Total
Second-Party Transformation of Methyl Bromide (kg):      
1.8 Signature of Reporting Company Representative
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 18 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 # 5900-143, Revised 6/08