Form 3520-13 Fuel Additive Manufacturer Notification Report

EPA Form 3520-13 (06-2003) - Fuel Additive Manufacturer Notification

Page 1 of 6

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

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

Fuel Additive Manufacturer Notification
1. Additive (Comercial Name):
2. Company Name:

2a. Company ID:

3. Address:

4. Method of Use (Check as Appropriate):

g Bulk Treatment - Blended into fuel prior to being dispensed into a vehicle.
c
d
e
f
c Aftermarket - Sold in consumer-sized containers for addition to a vehicle's fuel system.
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5. Recommended Usage and Range of Concentration
(Complete as appropriate. If this is an aerosol, only indicate the recommended frequency of use)
Range of Additive Concentration
Bulk Treatment
For Use In
Unleaded Motor
Vehicle Gasoline
Motor Vehicle Diesel
Fuel

(
Highest

Lowest

) Units
Average

Range of Additive Concentration
Aftermarket
For Use In
Unleaded Motor
Vehicle Gasoline
Motor Vehicle Diesel
Fuel

(
Highest

Lowest

) Units
Average

If this is an aerosol, recommended frequency of use:
6. Recommended Purpose-In-Use of the fuel additive named in Item 1 (Check Appropriate Item(s)).
Gas Diesel

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(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
(j)
(k)
(l)
(m)
(n)
(o)
(p)
(q)
(r)
(s)
(t)
(u)
(v)
(v)
(x)
(y)

Purpose-In-Use
Anti-icing agent/moisture absorbent
Antiknock
Antioxidant
Antistall agent
Antistatic agent
Cetane improver
Combustion improver/modifier
Corrosion inhibitor
Deposit modifier/control
Detergent
Dye
Gum solvent
Masking or odorizing agent
Metal deactivator
Pour point depressant
Sediment inhibitor
Stabilizer or dispersant
Upper cylinder lubricant
Octane enhancer
Flow improver
Volume extender
Carburetor and choke cleaner
Algaecide/bactericide/fungicide
Valve lubricant
Demulsifier/dehazer

Gas Diesel

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(ac)
(af)
(an)
(bc)
(bd)
(ca)
(cc)
(cp)
(dc)
(df)
(di)
(ec)
(es)
(fr)
(ia)
(ic)
(iv)
(la)
(mr)
(ox)
(pc)
(ri)
(sf)
(sw)
(tr)

Purpose-In-Use
Additive component
Anti-flamant
Acid neutralizer
Blended component/blend stock
Biodiesel
Carrier
Combustion chamber cleaner
Cloud point depressant
Detergent compound
Defoamer
Dilutent
Emission control
Exhaust system cleaner
Certified detergent
Identifying agent
Fuel injector cleaner
Intake valve cleaner
Lubricity agent
Marker
Oxygenate
Process chemical
Rust inhibitor
Starting Fluid
Sweetener
Tracer

EPA Form 3520-13 (06-2003) - Fuel Additive Manufacturer Notification

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7. Chemical Composition:
(a) Names of Additive Compounds or Components

Component
Percent

Methods of
Analysis

(b) Elemental Breakdown

Elemental
Percent

Methods of
Analysis

Chemical Abstract
Service No.

(c) Information on the chemical process of manufacturer is attached.
c Yes
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c No
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f
g
8. Chemical Structure - Is the chemical structure of all components completely defined by the names given under Item 7(a)?
If "No," attach seperate sheet(s) providing the complete structures of such components, so far as
they are known.
9. Impurities - If greater than 0.1% by weight, to the extent known:

c
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Yes

c
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No

Percent by Weight
Names of Impurities

Highest

Lowest

Average

Method of Analysis

EPA Form 3520-13 (06-2003) - Fuel Additive Manufacturer Notification

Page 3 of 6

10. Do you know of any analytical techniques that can be used to detect the presence of this fuel additive and/or measure its
concentration in gasoline and/or diesel fuel?

c
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g

No

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g

Yes If "Yes," attach separate sheet(s) providing the information.

11. Do you have any information developed by or for you concerning the mechanisms of action of this fuel additive; reactions
between this fuel additive and gasoline and/or diesel fuel; the identification and measurement of the emission products of this
fuel additive when used in gasoline and/or diesel fuel; the effects of this fuel additive on all emissions; the toxicity and any
other public health or welfare effects of the emission products of this fuel additive; and/or the effects of the emission products
on the performance of emission control devices or systems?

c
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No

c
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g

c
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No

c
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Yes If "Yes," attach separate sheet(s) providing summaries and a description of the test
procedures used in obtaining the information.
12. Is this additive a relabel of an additive currently registered under 40 CFR section 79?
Yes If "Yes," enter the name of the additive and its manufacturer.

Name of registered additive:

Manufacturer:

13. Annual Production - What is the estimated annual volume, in gallons, of this additive during the third year of production?

Bulk:

Aftermarket:

14. Market Distribution - To the nearest percent (no decimals), estimated for the third year of production, enter the percent of
sales by Petroleum Administration for Defense District (PADD) for the bulk additive volume and the percent of sales for each
state for the aftermarket additive volume.
Bulk:
PADD1

PADD2

PADD3

PADD4

PADD5

CT

IL

AL

CO

AK

DE

IN

AR

ID

AZ

DC

IA

LA

MT

CA

FL

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UT

HI

GA

KY

NM

WY

NV

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MI

TX

MD

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MA

MO

NY

NE

NH

ND

NJ

OH

NC

OK

PA

SD

RI

TN

SC

WI

Aftermarket:

VT
VA
WV

OR
WA

EPA Form 3520-13 (06-2003) - Fuel Additive Manufacturer Notification

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If you answered "yes" to item 12, skip to item 19.
15. Is this fuel additive derived only from conventional petroleum, heavy oil deposits, coal, tar sands, and/or oil sands?

g Yes
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f

g No
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16. Small Business Provisions - 40 CFR 79.58(d).
A manufacturer of a baseline or nonbaseline additive whose average of the previous three years annual sales revenue is less
than $50 million is exempt from the Tier 1 and Tier 2 health-effects testing requirements. A manufacturer of an atypical
additive whose average of the previous three years annual sales revenue is less than $10 million is exempt from the Tier 2
requirements. If you believe that you qualify for an exemption, enter below your sales revenue for each of the previous three
years and the average.
(Note: In cases where subsidiary, divisional, or other complex business arrangements exist, the business entity to which this
sales level pertains is the parent company with ultimate ownership. The "ultimate" parent is defined as the uppermost
headquarters or topmost company encompassing all related parents, subsidiaries, divisions, branches, or other operating
units. This definition follows that used by the Small Business Administration. It also helps to ensure that a company will not
subdivide merely to become eligible for an exemption.)

Annual sales revenue 3 years ago: $
Annual sales revenue 2 years ago: $
Annual sales revenue 1 year ago: $
Average of above: $
Is the above average for the company named in Item 2?

c
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Yes

c
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No

If "No," complete the following:

Name of the parent company with ultimate ownership:

Address:

Contact Name:

Phone:

Title:

Email:

17. Aerosol - Is this an aerosol additive?

c No g
d
e
f
g
c Yes
d
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f
If "Yes," do you claim applicability of the special provisions for aerosol additives at 40 CFR 79.58(e)?

c No g
d
e
f
g
c Yes If "Yes," attach the information required for an aerosol additive and skip to item 19.
d
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f

EPA Form 3520-13 (06-2003) - Fuel Additive Manufacturer Notification

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18. Grouping Information - Pursuant to 40 CFR section 79.56. If you do not qualify for an aerosol or Tier 1 and Tier 2 small
business exemption, you must be a member of a testing group appropriate for your fuel additive or supply the appropriate
health-effects test information.
This additive is covered by the following testing group:

Group description:
Organizing entity:
Contact person:
Telephone:

Address:
OR
I have attached the appropriate information.

c
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f
g

Yes

c
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No

If "No," attach an explanation.

19. 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 item?

c
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g

c
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Yes

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

Item 5:

c
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Yes

c
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No

Item 10:

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Yes

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No

Item 14:

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Yes

c
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No

Item 7:

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Yes

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No

Item 11:

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Yes

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No

Item 15:

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Yes

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No

Item 8:

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Yes

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No

Item 12:

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Yes

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No

Item 16:

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Yes

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No

Item 9:

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Yes

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No

Item 13:

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Yes

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No

No

20. Attachments - Are attachments included with this notification?

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No

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Yes If "Yes," list below:

EPA Form 3520-13 (06-2003) - Fuel Additive Manufacturer Notification
21. Certification
To the best of my knowledge, the above is complete and correct.
I am authorized by the manufacturer to submit this notification.
As per 40 CFR 79.21(f), the U.S. Environmental Protection Agency would be notified in writing if certain information
in this notification were to change.
This fuel additive manufacturer will not represent, directly or indirectly, in any notice, circular, letter, or other written
communication, or any written, oral, or pictorial notice or other announcement is any publication or by radio or
television, that registration of this fuel additive constitutes endorsement, certification, or approval by any agency of
the United States.
Signature:

Date:

Name of Signer (print):

Title:

Telephone:

Fax:

E-mail:

Comments:

Mail the completed form to:
U.S. Environmental Protection Agency
Attn: Fuel Additive 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 Additive Registration/Suite L -103
Mail Code - 6406J
501 Third Street, NW
Washington, DC 20001

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