EPA Form 3540-1 with instructions

Print Form
United States Environmental Protection Agency
Form 3540-1

Notice of Arrival of
Pesticides and Devices

Send Completed Form to
Appropriate Regional Office
Listed on the Reverse of this
Form.

Form Approved
OMB No. 2070-0020

Note: Read Instructions on reverse before completing form.
To Be Completed by Importer or Agent
Part I:
1. Name and Complete Address of Broker or Agent
2. Name and Complete Address of Importer or Consignee

Return Form to this Address

Return Form to this Address

4. EPA Registration Number
3. Name and Address of
Shipper

5. EPA Producer Establishment No.

6. Brand name of Product

7. Major Active Ingredients and Percentage of Each
8. Unit Size

9. Quantity

10. Total Net Weight

12. Port of Entry

11. Country of Origin
13. Carrier

14. Entry Number

15. Entry Date

17. Location of Goods for Examination after Importation

16.

I assert that information constituting Confidential Business
Information is shown in the above blocks numbered: (Note:
Blocks 4, 5, 6, 7 are not entitled to CBI treatment–see
Instructions)

18. Remarks

Certification
I certify that the statements I have made on this form and all attachments thereto are true, accurate, and complete.I acknowledge that any
knowingly false or misleading statement may be punishable by fine or imprisonment or both under applicable law.
19. Printed Name of Importer or Agent

Telephone Number

20. Signature of Importer or Agent

Date Signed

Part II: To Be Completed by U.S. Environmental Protection Agency
Action to be taken by U.S. Customs Service
Release Shipment

Detain for Inspection

Release shipment to consigne under bond. Shipment must be held
intact pending inspection.

Other
Remarks

Signature and Title of EPA Official

Date

Part III:
To Be Completed by U.S. Customs Service
The information shown in Part I was compared with the entry papers for this shipment and no discrepancies were noted.
The shipment was handled as instructed by EPA in Part II. Any deviations should be brought to the attention of EPA before releasing shipment and
should also be noted in "Remarks."
Remarks

Signature of District Director of Customs

EPA Form 3540-1 (Rev. 2-00)

Date

Official File Copy

Instructions
Customs Regulations. 19 CFR 12.112 requires an importer desiring to import pesticides or devices into the United Statesto submit EPA Form
3540-1, Notice of Arrival of Pesticides and Devices, to the U.S. Environmental Protection Agencyprior to the arrival of shipment in the United
States. This form will be used by:Importer or Agent. The Importer or his agent must complete Part 1 of the form. It may be necessary to
complete some ofthe items at the time of entry, e.g., entry data, carrier. To expedite the handling of pesticides shipments, submit this formto the
EPA office listed below having jurisdiction over the state/territory in which the Port of Entry is located prior to thearrival of the shipment.EPA.
Part II of this form will be completed by EPA. EPA will retain the EPA Copy for its files and return the other copiesto the importer or agent for
presentation to Customs at the time of entry.Customs . Customs will compare the information shown on this form with the entry documents and
the shipment. Bringany discrepancies to the attention of EPA before the shipment is released and noted in the remarks section. If theimportation
is not handled by Customs in the manner instructed in Part II, this should also be noted in remarks. All dataleft blank by the importer (e.g., entry
date) must be completed at this time. After completion of Part III and signing theform, Customs will return the Official File Copy to EPA and
retain the Custom's Copy.

The following blocks are self explanatory - 1, 2, 8, 9, 10, 12, 14, 15, 18, 19, and 20.
3. Name and Address of Shipper. The name and address of person exporting the pesticide to the United States.
4. EPA Registration No. The product registration number assigned at the time of registration which identifies the
product. If the product is a device, write the word `device' in the block.
5. EPA Producer Establishment No. The producing establishment registration number which identified where
the pesticidal product, active ingredient, or device was produced.
6. Brand Name of Product. Name under which the product is sold or distributed.
7. Major Active Ingredients and Percentage of Each. If block 4 contains registration number, leave blank. If no
registration number, list active ingredients (or two major ingredients and percentage of each).
11. Country of Origin. The country in which the pesticide producer is located.
13. Carrier. E.g., ship's name, airline or trucking company.
16. Confidential Business Information (CBI) designation. Please note that the information provided in blocks 4,
5, 6, and 7 is not entitled to confidential treatment under section 7(d) of FIFRA and under labeling requirements
for pesticides at 40 CFR 156.10. Information provided in those blocks will be made public with no further notice.
17. Location of Goods for Examination after Importation. Enter the EPA establishment number for importing
registered establishment in the case of unregistered product imports between establishments operated by the same
producer.
EPA Regional Offices

States Covered

EPA Region I
1 Congress Street (SEA)
Boston, MA 02114-2023
Dallas, TX 75202-2733

CT MA ME
NH RI VT

EPA Region VI
445 Ross Avenue OK TX
Suite #1200 (6PD-P)

AR LA NM

EPA Region II
MS-500, Bldg #5
2890 Woodbridge Ave.
Edison, NJ 08837-3679

NJ NY
PR VI

EPA Region VII
901 N. 5TH Street (PESTWWPD)
Kansas City, KS 66101

IA KS
MO NE

EPA Region III
1650 Arch Street (3WC32)
Philadelphia, PA 19103-2029
Denver, CO 80202-2466

DE DC
MD PA
VA WV

EPA Region VIII
999 18th Street
Suite #500 (8ENF/TEP)

CO MT
ND SD
UT WY

EPA Region IV
61 Forsyth Street, SW (APT-PS)
Atlanta, GA 30303-8960

AL FL GA
KY MS NC
SC TN

EPA Region IX
75 Hawthorne Street (CMD-4-3)
San Francisco, CA 94105-3901

AZ AS CA
GU HI NV
PI WK

EPA Region V
77 West Jackson Blvd.(DT-8J)
Chicago, IL 60604-3507

IL IN
OH MI
MN WI

EPA Region X
1200 Sixth Avenue (ECO-084)
Seattle, WA 98101-9797

AK ID
OR WA

EPA Form 3540-1 (Rev. 2-00)

EPA Regional Offices

States Covered