Form 3520-12Q Fuel Manufacturer Quarterly Report for Motor Vehicle Gas

EPA Form 3520-12Q (08-2003) - Fuel Manufacturer Quarterly Report for Motor Vehicle Fuel

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

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

Fuel Manufacturer Quarterly Report for
Motor Vehicle Gasoline or Diesel Fuel

Leave Blank

1. Company Name:

1a. Company ID:

2. Address:

3. Fuel ID:
4. Report Year:

5. Quarterly Production Volume:
gal

4. Quarter (check one):
c (a) January through March
d
e
f
g
c (b) April through June
d
e
f
g

g (c) July through September
c
d
e
f
c (d) October through December
d
e
f
g

7. Brand name of the motor vechicle fuel covered by this report:

8. Use during this quarter of additives previously reported for use in this fuel:

(Leave Blank)

(a) Commercial Name of Additive

Range of Additive Concentration
(mg/liter) or (% volume) or (gal/kgal)
(b) High
(c) Low
(d) Average
(e) Unit

EPA Form 3520-12Q (08-2003) - Fuel Manufacturer Quarterly Report for Motor Vehicle Fuel

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8 . Use during this quarter of additives previously reported for use in this fuel:

(Leave Blank)

(a) Commercial Name of Additive

Range of Additive Concentration
(mg/liter) or (% volume) or (gal/kgal)
(b) High
(c) Low
(d) Average
(e) Unit

EPA Form 3520-12Q (08-2003) - Fuel Manufacturer Quarterly Report for Motor Vehicle Fuel

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9. 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 5 and/or 8?

c
d
e
f
g

No

c
d
e
f
g

Yes

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

Item 5:

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

10. Certification
To the best of my knowledge, the above is complete and correct.
I am authorized by the manufacturer to submit this information.
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