5900-155 Distributor of QPS Methyl Bromide Quarterly Report

OMB Control Number: 2060-0170
Expiration Date: 4/30/12

CLASS I CONTROLLED SUBSTANCE

U.S. Environmental Protection Agency

DISTRIBUTOR OF QPS
METHYL BROMIDE QUARTERLY REPORT

STRATOSPHERIC OZONE PROTECTION PROGRAM

(Sec 82.13)

SECTION 1

DISTRIBUTOR IDENTIFICATION

1.1 Date of
Submission

1.3

1.2 Total Quantity of Methyl Bromide
Delivered for Use in Certified QPS
Applications (kg)
1st

1.4 Quarter and Year to Which This Report Applies

Original Submittal
Re-submittal

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 ________________________________________________________________

SEND COMPLETED FORMS TO:

Date

_______________________________________

For U.S. Postal Service:

For Private Courier:

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

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 04/09