5900-143 Methyl Bromide Second Party Transformation Annual Report

Protection of Stratospheric Ozone: Request for Applications from Critical Use Exemption for the Phaseout of Methyl Bromide (Renewal)

Transformation MeBr 5900-143

Protection of Stratospheric Ozone: Critical Use Exemption from the Phaseout of Methyl Bromide - Reporting and Periodic Recordkeeping Requirements (transfered from 2060-0564)

OMB: 2060-0482

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OMB Control Number: 2060-0482

Expiration Date: 10/31/14 OMB Control Number: 2060-0482 Expiration Date: 8/31/11

U.S. Environmental Protection Agency


stratospheric ozone protection program

class i controlled substance

methyl bromide

second-party transformation annual report

(40 CFR 82.13)

SECTION 1 COMPANY IDENTIFICATION

1.1 Date of Submission

     

1.2 Year to Which This Report Applies

     


1.3 Original Submittal Re-submittal

1.4 Have you submitted an IRS certificate of intent to transform to the producer or importer (per 40 CFR 82.13)?

Yes No


1.5 Company Information


Company Name      

Street Address      


City      

State      

Zip Code      

1.6 Company Contact Identification

Reporting Company Contact Person

     


Phone Number

     

Fax Number

     

E-mail Address      

1.7 Transformation Total

Second-Party Transformation of Methyl Bromide (kg):      

1.8 Signature of Reporting Company Representative

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      

Date      

SEND COMPLETED FORMS TO:

For U.S. Postal Service:

Tracking System Program Manager

Stratospheric Protection Division

U.S. EPA (6205J)

1200 Pennsylvania Avenue, NW

Washington, DC 20460

For Private Courier:

Tracking System Program Manager

Stratospheric Protection Division

U.S. EPA (6205J)

1310 L Street, NW; 10th Floor

Washington, DC 20005


A company may assert a claim of confidentiality for information submitted in this form 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 1.3 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 # 5900-143, Revised 5/11

File Typeapplication/msword
AuthorMollie Barwis
Last Modified ByEmily Herzog
File Modified2011-04-28
File Created2011-04-26

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