Form 3520-13A Fuel Additive Manufacturer Annual Report

EPA Form 3520-13A (08-2003) - Fuel Additive Manufacturer Annual Report

Page 1 of 2
Form Approval
OMB No. 2060-0150
Approval Expires 01/31/2004

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

Leave Blank

Fuel Additive Manufacturer Annual Report
1. Company Name:

1a. Company ID:

2. Report Year:
4.

5.

3. Report Type: (Check Only One)
c Original
d
e
f
g

g Resubmission
c
d
e
f

For any additive below, do you have information, not previously reported, on the levels of impurities greater than 0.1 percent
by weight?
If "Yes," attach separate sheet(s) giving, to the extent known, the highest, lowest, and
c No g
d
e
f
g
c Yes average values of impurities, and the methods of analysis used.
d
e
f
For any additive below, do you have information, not previously reported, concerning the mechanisms of action of the
additive; reactions between the additive and gasoline and/or diesel fuel; the identification and measurement of the emission
products of the additive when used in gasoline and/or diesel fuel; the effects of the additive on all emissions; the toxicity and
any other public health or welfare effects of the emissions products of the additive; and/or the effects of the emission products
of the additive on the performance of emission control devices/systems?

c
d
e
f
g

No

c
d
e
f
g

6. Production Values:
a. Additive ID:

Yes

If "Yes," attach separate sheet(s) providing summaries of such information and a
description of the test procedures used in obtaining the information.

b. Market:
A – Aftermarket
B – Bulk
C – Don't Know

c. Production Volume:

d. Production Units:
gal – Gallons
lb – Pounds
kg – Kilograms

EPA Form 3520-13A (08-2003) - Fuel Additive Manufacturer Annual Report
7.

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 items 4, 5 and/or 6?

c
d
e
f
g

8.

No

c
d
e
f
g

Yes

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

Item 4:

c
d
e
f
g

Yes

c
d
e
f
g

No

Item 5:

c
d
e
f
g

Yes

c
d
e
f
g

No

Item 6:

c
d
e
f
g

Yes

c
d
e
f
g

No

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:

9.

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Are any Supplemental Additive Manufacturer Annual Reports (EPA Form 3520-13B) attached?

c
d
e
f
g

No

c
d
e
f
g

Yes If "Yes," how many?

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