5900-139 Certification of Purchase of Critical Use Methyl Bromide

OMB Control Number: 2060-0482

Expiration Date: 6/30/15

U.S. Environmental Protection Agency stratospheric ozone protection program					class i controlled substance methyl bromide certification of purchase of critical use methyl bromide (40 CFR 82.13)
SECTION 1 PURCHASER INDENTIFICATION
1.1 Date of Submission	     
1.2 Total Quantity of New Production Pre-Plant Critical Use Methyl Bromide Purchased (kg)									     
1.3 Total Quantity of New Production Post Harvest Critical Use Methyl Bromide Purchased (kg)									     
1.4 Company Information
Company Name      
Street Address      
City      						State      		Zip Code      
1.5 Company Contact Identification
Reporting Company Contact Person      
E-mail Address      
Phone Number      				Fax Number      
Approved critical use(s) are those uses of methyl bromide listed in Appendix L to Subpart A of 40 CFR Part 82. See www.epa.gov/ozone/mbr/cueuses.html.
1.6 Signature of Reporting Company Representative
I certify, under penalty of law, that the quantities of methyl bromide specified in Section 1.2 and 1.3 of this form, are ordered/purchased and will be sold or used exclusively for an approved critical use (pre-plant or post-harvest) as identified, and not sold/ transferred to another person. I certify that I am an approved critical user and I will use this quantity of methyl bromide for an approved critical use. My action conforms to the requirements associated with the critical use exemption published in 40 CFR part 82. I am aware that any agricultural commodity within a treatment chamber, facility or field I fumigate with critical use methyl bromide cannot subsequently or concurrently be fumigated with non-critical use methyl bromide during the same control period, excepting a QPS treatment or treatment for a different use (e.g., a different crop or commodity). I will not use this quantity of methyl bromide for a treatment chamber, facility, or field that I previously fumigated with non-critical use methyl bromide during the same control period, excepting a QPS treatment or treatments for a different use (e.g., a different crop or commodity), unless a local township limit now prevents me from using methyl bromide alternatives or I have now become an approved critical user as a result of rulemaking. 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:			The Company From Whom the Critical Use Methyl Bromide is Being Purchased

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 # 5900-139, Revised 6/12